U.S. Public Health Service STD Experiments in Guatemala (1946–1948) and Their Aftermath

Kayte Spector-Bagdady, Paul A. Lombardo

Abstract

The U.S. Public Health Service’s sexually transmitted disease (STD) experiments in Guatemala are an important case study not only in human subjects research transgressions but also in the response to serious lapses in research ethics. This case study describes how individuals in the STD experiments were tested, exposed to STDs, and exploited as the source of biological specimens—all without informed consent and often with active deceit. It also explores and evaluates governmental and professional responses that followed the public revelation of these experiments, including by academic institutions, professional organizations, and the U.S. federal government, pushing us to reconsider both how we prevent such lapses in the future and how we respond when they are first revealed.


SpectorBagdady K, Lombardo PA. U.S. Public Health Service STD Experiments in Guatemala (1946–1948) and Their Aftermath. Ethics & Human Research. 2019 Apr; 41(2): 29-34.

Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying

S. Sinmyee V. J. Pandit J. M. Pascual A. Dahan T. Heidegger G. Kreienbühl D. A. Lubarsky J. J. Pandit

Summary

A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used.

However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported.

The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an ‘optimum’ itself has important implications for ethics and the law.


Sinmyee S, Pandit VJ, Pascual JM, Dahan A, Heidegger T, Kreienbühl G, Lubarsky DA, Pandit JJ. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia. 2019 May;74(5): 630-637.

Can conscientious objection lead to eugenic practices against LGBT individuals?

Toni C. Saad, Daniel Rodger

Abstract

In a recent article in this journal, Abram Brummett argues that new and future assisted reproductive technologies will provide challenging ethical questions relating to lesbian, gay, bisexual and transgender (LGBT) persons. Brummett notes that it is likely that some clinicians may wish to conscientiously object to offering assisted reproductive technologies to LGBT couples on moral or religious grounds, and argues that such appeals to conscience should be constrained. We argue that Brummett’s case is unsuccessful because he: does not adequately interact with his opponents’ views; equivocates on the meaning of ‘natural’; fails to show that the practice he opposes is eugenic in any non-trivial sense; and fails to justify and explicate the relevance of the naturalism he proposes. We do not argue that conscience protections should exist for those objecting to providing LGBT people with artificial reproductive technologies, but only show that Brummett’s arguments are insufficient to prove that they should not.


Saad C, Rodger D.  Can conscientious objection lead to eugenic practices against LGBT individuals? Bioethics; 2019 Feb 08

Is there a difference between palliative sedation and euthanasia?

BioEdge

Xavier Symons

One common argument in favour of legalising euthanasia is that several accepted medical practices already involve hastening the death of patients. Some ethicists claim, for example, that we are already hastening patients’ deaths in palliative care contexts through the administration of toxic levels of opioids and sedatives to patients. In palliative sedation — a relatively common procedure in end of life scenarios — doctors administer strong doses of drugs such as midazolam to sedate a patient. Ostensibly this is done to relieve refractory symptoms, yet some suggest that doctors are fully aware that the drugs may bring about a quicker death. In light of this, some ethicists argue that we need not be so concerned about hastening death through euthanasia — this is a mere extension of the already existing practices in palliative care.

There are two common rejoinders to this argument. The first is that palliative sedation does not even hasten death — in fact, studies show that it actually may prolong life. Thus, there is no causal link between the administration of analgesics and barbiturates and the death of the patient.

The second is that the practice of palliative sedation is defensible on the basis of double effect reasoning. The doctrine of double effect is quite difficult to summarise in a sentence, but essentially the claim is that doctors do not intend for the patient’s death to be hastened, even though they foresee that this may be the case.

A new article in the Journal of Medical Ethics attempts to critique these two responses. Doctor Thomas David Riisfeldt of the University of New South Wales argues that empirical evidence on palliative sedation does not in fact provide a reliable indication of whether or not palliative sedation hastens death. In a blog post summarising the article, Riisfeldt writes:

“[the claim that pain killers and sedatives do not hasten death] is not watertight at all.  This is mainly owing to the ethical limitations (more so, the ethical impossibility) of conducting high-quality randomised controlled trials to definitively compare survival times in patients receiving or not receiving palliative opioids and sedatives, along with a number of other practical difficulties.  I conclude that adopting a position of agnosticism on the matter is appropriate”.

In the article, Riisfeldt also suggests that the doctrine of double effect is indefensible, and argues that — in the case of palliative sedation — there is no meaningful distinction between the direct effect of the action (pain relief) and the unintended consequence (death).

So, does Riisfeldt’s critique itself hold water? He makes a series of controversial claims regarding the nature of palliative sedation, and whether it violates the sanctity of life principle (he believes that it does). It seems to this author that his essay would be befitting a robust response from someone familiar with the literature on palliative sedation and also the across the ethics of double effect.


This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees. Some articles on this site are published under different terms.

“Choose, You Lose” Scheme Threatens All Ethical Professionals

Jonathon Imbody

The increasingly aggressive discrimination in recent years against religious and pro-life healthcare professionals and students[1] parallels a concentrated effort by abortion proponents to undermine the rationale for conscience protections in healthcare. Desperate abortion advocates apparently have concluded that the way to counter the medical community’s resistance to abortion is through coercion.

Coercion appeals to some activists because coercion is much quicker than persuasion in effecting change. If abortion activists can eliminate conscience protections, then health professionals can be forced to participate in abortion or else sacrifice their careers. .

American principles protect conscience even at a price

Affordable Care Act architect Dr. Ezekiel Emanuel and University of Pennsylvania professor Ronit Stahl lay the foundation for getting rid of healthcare conscience protections, in a New England Journal of Medicine opinion piece entitled, “Physicians, Not Conscripts — Conscientious Objection in Health Care.”[2]

Their message is simple: Choice is a one-way street. Patients get to choose; doctors don’t—at least not after they enter the medical profession.

Emanuel and Stahl attempt to establish this radical principle by postulating a sharp distinction between conscience accommodations for military draftees and conscience accommodations for physicians.

Emanuel and Stahl write,

Although this [conscience healthcare protection] legislation ostensibly mimics that of military conscientious objection, it diverges considerably. Viewing conscientious objection in health care as analogous to conscientious objection to war mistakes choice for conscription, misconstrues the role of personal values in professional contexts, substitutes cost-free choices for penalized decisions, and cedes professional ethics to political decisions.”[3]

In the United States, a pacifist opposed to the military draft can receive a conscientious exemption from combat duty, even during a time of war when every other able-bodied citizen his age is expected to fight to defend the national interest. The cost to the country is high if counted in terms of fewer soldiers available for active duty.

Yet the authors would countenance no such rights, no such accommodation of cost, to a pro-life physician who cannot on the basis of conscience end the life of a developing baby in an elective abortion. While permitting the pacifist draftee a conscientious objection to killing, the authors contend, government must deny the same objection by a health professional.

Why? According to Emmanuel and Stahl, the reason is that physicians choose their professions, whereas draftees do not choose to join the military. . .[Full text]

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

Lori Seller, Marie Eve-Bouthillier, Veronique Fraser

Journal of Medical Ethics

Abstract

Background Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

Methods A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

Results Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient’s death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

Interpretation We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians’ approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Seller L, Bouthillier M, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. J Med Ethics. 2019;45:106-111 .

Drawing the line on physician-assisted death

Lynn A. Jansen, Steven Wall, Franklin G. Miller

Abstract

Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill.


Jansen LA, Wall S, Miller FG. Drawing the line on physician-assisted death. J Med Ethics. 2019;45:190-197.

3 ethical reasons for vaccinating your children

The Conversation

Joel Michael Reynolds

Across the country, billboards are popping up suggesting that vaccines can kill children, when the science behind vaccination is crystal clear – vaccinations are extremely safe.

Researchers who study the beliefs of anti-vaxxers have found many different reasons, not just religious or political, as to why some parents refuse to get their children vaccinated.

As a bioethicist who investigates how societal values impact medicine, I consider such decisions to be downright indefensible. And here are three reasons why. . . [Full text]

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

Thomas David Riisfeldt

Journal of Medical Ethics

Abstract

Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.


Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. J Med Ethics 2019;45:125-130.

Conscientious objection in reproductive health – ancient prerogative or harmful practice

J.M. Thorp Jr.

Abstract

BJOG

We must return to our Pythagorean roots and not substitute a secular group conscience to replace individual conscience, and thereby protect the rights of all parties. My hope is that our specialty will uphold the right of individual clinicians to practise according to their consciences and we will continue to welcome Hippocratic clinicians into our ranks.


Thorp JM. Conscientious objection in reproductive health – ancient prerogative or harmful practice. BJOG. 2018 Oct;125(11):1357-1358. doi: 10.1111/1471-0528.15226. Epub 2018 May 2.