Canadian ethicists prepare for the worst


 Michael Cook

Conscientious objection seems like the paradigmatic ethical choice between right and wrong. An ethicist, of all people, ought to have this option, just as mathematicians count or sopranos sing.

Not so fast, write two healthcare ethicists at the Centre for Applied Ethics at McGill University Health Centre, in Montreal, in the blog Impact Ethics. Now that the Canadian Supreme Court has declared that euthanasia is a human right, it is time to focus on who is entitled to conscientious objection to participating in euthanasia. And perhaps ethicists are not.

We found ourselves asking the following questions: Should a clinical ethicist have the right to conscientious objection in cases of medical aid in dying? Can the role of the clinical ethicist to provide ethics analysis in matters of moral ambiguity be reconciled with a right to opt-out on the basis of personal convictions?

The nub of the question is this: when an ethicist is asked for advice, is she involved as a human being or is she merely a database of ethical choices? The ethicists write:

On the other hand, there is a growing consensus that clinical ethics expertise is grounded in the competence of the clinical ethicist to facilitate a robust process aimed at ensuring fair and transparent healthcare decisions. The clinical ethicist is expected to adopt a stance of neutrality which allows her to facilitate discussion of competing values without allowing her own beliefs to influence the discussion.

On this view, it is not the “rightness” or “wrongness” of the final outcome by which the clinical ethicist is professionally judged, but rather her skill in guiding various stakeholders through a reasonable process; a clinical ethicist’s personal convictions should not impact on her ability to facilitate this process. In this sense, perhaps the right to conscientious objection is antithetical to the provision of clinical ethics consultation, as it seems to call into question the profession’s ability to remain neutral on morally contentious issues.

There is an urgent need, the authors write, to articulate the rights and duties of healthcare ethicists, as in the wake of Carter v Canada, the euthanasia case, the boundaries will be tested.

It would be interesting indeed if Canadian ethicists who oppose euthanasia are told to pack their bags and look elsewhere for jobs. What do unemployed ethicists do? Work in Starbucks? Become an Uber driver? There are some great ideas at the website of the Unemployed Philsophers Guild — making coffee mugs, finger puppets, and scented soap.

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The nuts and bolts of CIA torture


Michael Cook

Can doctors participate in torture if there is a reasonable expectation of mitigating the harm done? It could be a seductive hope for a military doctor who is under pressure to cooperate.

However, in a book review in the Journal of Medical Ethics, Henry Shue, of Oxford University, explains that the latest CIA techniques of torture make even minimal participation ethically impossible, no matter how low the bar is set.

Contemporary torture is not so much physical as mental. Its goal is to make the person “psychological putty” in the hands of his interrogators.

The goal of the CIA paradigm as used in Guantanamo is to produce at least temporary regression to an infantile state in which the torture victim will become completely compliant (and therefore supposedly tell the torturers what they want to know). Infantile regression is produced by unhinging the structure of the self of the torture victim and alienating him from his own values through methods like sexual humiliation, religious contempt, sleep deprivation and temperature extremes.

An essential element in this is ensuring that no stable human relationship of any kind should develop between the victim and his captors.

… such total control is maintained over the victim that it is difficult for me to imagine how even if a well disposed doctor could manage to have meaningful conferences with a victim, or by some other method somehow discern what she took his genuine interests to be (as a physician attending an unconscious patient might), that the authorities at a torture site like Guantanamo would ever permit a doctor to take action that served the interests of the victim in a manner that was contrary to the demands of its relentless regression regimen.

A doctor needs to establish some bond with a patient and to understand his history in order to help him. But in this regimen, it would be impossible to know anything meaningful about the victim’s real state of mind. So it is quite unlikely that a doctor’s complicity with the torturers will ever succeed in lessening the pain of the victim.

cclicense-some-rightsThis article is published by Michael Cook 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 us for permission and fees. Some articles on this site are published under different terms.


Torture: sometimes a man’s gotta do what a man’s gotta do, say bioethicists

Michael Cook*

Torture is an issue on which the public might expect bioethicists to be moral absolutists. Never again! Never ever! It was somewhat surprising, then, to read in the New York Times that one of the world’s leading animal rights theorists, Oxford’s Jeff McMahan, support torture. . . .   Full Text 

Should governments pay for sex for the disabled?


Michael Cook

Most social work students probably do not imagine that their career might require them to play the pander. But finding prostitutes for disabled clients is sometimes part of the job description, even though both the legality and morality of this practice are disputed. Another voice was added this week to long-simmering debate in the pages of the Journal of Medical Ethics over this issue.

Back in 2009 Dr Jacob M. Appel, a New York psychiatrist with a flair for controversy, argued that “sexual pleasure as a fundamental right that should be available to all”. Hence, if the disabled were unable to experience this, the government should step in and provide subsidised prostitution. “As a society, we also provide food for those who cannot feed themselves—even delivering it to their homes, when required. Sexual pleasure ought not be viewed any differently.”

Dr Appel acknowledged that he supports neonatal euthanasia for severely disabled infants. However, he contends, if society has erred in allowing these children to life, it is a matter of justice to offer them the possibility of sexual pleasure.

In 2011 Dr Ezio Di Nucci, of the University of Duisburg-Essen weighed in. He agreed that severely disabled individuals should be helped to satisfy their sexual interests. But he questioned whether this should happen at the public expense. He proposed instead that “the sexual interests and needs of the severely disabled be met by charitable non-profit organisations, whose members would voluntarily and freely provide sexual pleasure to the severely disabled”. He thinks that this is superior to Appel’s proposal because, amongst other reasons, it would not require the legalisation of prostitution.

A powerful argument against providing the disabled with sexual services is that it assumes a regime of legalised prostitution – which many feel is demeaning and harmful to women. The most recent contributor to the debate, Dr Frej Klem Thomsen, of Roskilde University, in Denmark, tackles this problem. He says that the issue is complex and unclear, but that there seems to be sufficient justification for allowed a legal exception. In other words, prostitutes could service the disabled, but only the disabled.

cclicense-some-rightsThis article is published by and 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 us for permission and fees. Some articles on this site are published under different terms.

What are the issues in post-mortem sperm retrieval?


Michael Cook

In 2010 21-year-old Niklas Evans was assaulted outside a bar in Texas. He ended up in a coma and died after 10 days. His heartbroken mother, Missy Evans, requested the hospital to retrieve her son’s sperm so that she could create a grandchild with a surrogate mother. The case was too controversial for American fertility clinics so she ended up travelling to South Africa.

Did Missy and her doctors act ethically in removing sperm from Niklas’s dead body without his consent? This is the question that Anna Smajdor, of the University of East Anglia, tackles in the Journal of Medical Ethics, based on a discussion of some cases which have occurred in England. Like many other bioethicists, she opposes it.

The dead still have interests. The logic of post-mortem sperm retrieval without explicit consent could be extended to many other issues,  like organ extraction, exhibition of the body, probate law and so on. Legally speaking, much more than a child is at stake.

The validity of inferred consent is a dangerous principle. “In medicine generally, consent for procedure X cannot be inferred from someone’s previous beliefs about situation Y,” she writes. If men knew what was involved in electro-ejaculation, they might well refuse their consent, even if they did express a wish to have children.

Proxy consent for one’s own benefit is a dangerous principle. She writes: 

Relatives can agree to donate a loved one’s tissue, but they cannot demand access to that tissue for themselves. The reasons for this are straightforward. Human tissues and organs are valuable commodities. This means that the bodies of dead and dying patients are vulnerable to exploitation. If the person testifying as to the patient’s wishes and providing proxy consent is alsothe one who stands to gain from the tissue that is made available, there is a clear conflict of interest.

The desire for offspring is not sufficient reason. From a woman’s ardent desire for a child one cannot infer consent. “Couples’ reproductive decisions are not necessarily based on symmetrical and equally held desires … It is risky and unjust to assume that one partner’s reproductive desires can be inferred from those of the other. And if this is the case in the living, it is still more so in the case of the dead or dying, who cannot articulate their dissent.”

Smajdor makes two specific recommendations. First, that the rules for posthumous gamete donation be tightened. Second, that the discretionary authority of the UK’s fertility watchdog, the Human Fertilisation and Embryology Authority, be rescinded so that it cannot permit the export of gametes obtained without consent.

cclicense-some-rightsThis article is published by and 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 us for permission and fees. Some articles on this site are published under different terms.

Stop fretting about 3-parent embryos and get ready for “multiplex parenting”

Michael Cook*

The controversy over three-parent embryos could soon be old hat. Writing in one of the world’s leading journals, one of Britain’s best-known bioethicists has outlined a strategy for creating children with four or more genetic parents. He calls it “multiplex parenting”.

John Harris, of the University of Manchester, and two colleagues, César Palacios-González and Giuseppe Testa contend in the Journal of Medical Ethics (free online) that this is one of many exciting consequences of using stem cells to create synthetic eggs and sperm. (Or as they prefer to call them, in vitro generated gametes (IVG).)

After the discovery of induced pluripotent stem cells in 2007, theoretically any cell in the body can be created from something as simple as a skin cell. Mice have already been born from sperm and eggs created from stem cells. Harris and his colleagues believe that the day is not far off when scientists will be able to do the same with humans. In their paper, they spin an ethical justification for this and outline some possible uses.

First, is it ethical? Of course it is, so long as experiments on mice show that it is safe. After all, they write, this is already a much higher ethical bar than the one used for the first IVF babies. “If impractically high precautionary thresholds were decisive we would not have vaccines, nor IVF, nor any other advance. Nothing is entirely safe.” Besides, any children brought into the world are better off than if they never existed. . . [Full Text]

Conscientious objection to “patriarchal norms”

 Hymen restoration and ‘virginity certificates’ in Sweden


 Michael Cook*

Informed consent and conscientious objection are easy to fulminate about, but tricky to discuss with consistency. Take, for instance, the delicate topic of requests for hymen restorations and virginity certificates. Worldwide, an estimated 5,000 women were victims of honour killings in 2000. If a young woman from a culture which sanctions honour killing approaches a doctor, what should he or she do?

Refusal is not a popular or even, in some jurisdictions, a legal option for doctors who are asked to refer for an abortion or to prescribe contraception. But a request which reinforces “patriarchal norms” is different.
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Complicity after the fact

Moral blindness becomes a virtue and necessity

US scientists were “accomplices after the fact” in Japanese doctors’ war crimes


Michael Cook*

All of contemporary bioethics springs from the Nuremberg Doctors Trial in 1947. Seven Nazi doctors and officials were hanged and nine received severe prison sentences for performing experiments on an estimated 25,000 prisoners in concentration camps without their consent. Only about 1,200 died but many were maimed and psychologically scarred.

So what did the US do to the hundreds of Japanese medical personnel who experimented on Chinese civilians and prisoners of war of many nationalities, including Chinese, Koreans, Russians, Australians, and Americans? They killed an estimated 3,000 people in the infamous Unit 731 in Harbin, in northeastern China before and during World War II – plus tens of thousands of civilians when they field-tested germ warfare. Many of the doctors were academics from Japan’s leading medical schools.
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Conscientious objection: the struggle continues


Reproduced with permission

Michael Cook*

The fight over conscientious objection to abortion has moved from the evening news to the academic journals. In the April issue of the American Journal of Public Health, two defenders of reproductive rights outline strategies to restrict abortion rights. They complain that “unregulated conscientious objection” seems to be growing, especially in countries where opposition to abortion is strong.

In a SSRN paper which is yet to be published, Lachlan De Crespigny, an Australian doctor writing from Oxford, and two academics from Monash University fiercely defend a recent law in the state of Victoria which forces doctors to refer for abortion. “The unregulated use of conscientious objection impedes women’s rights to access safe lawful medical procedures,” they write. “As such, we contend that a physician’s withdrawal from patient care on the basis of conscience must be limited to certain circumstances.”.

They contend that arguments in support of conscientious objection are often a smokescreen for imposing Catholic dogma. But women who conscientiously desire abortions also have rights. “The choice of abortion is in many cases the morally responsible decision that should not be overridden by the imposition of another’s conscience.”

A recent paper in the Journal of Bioethical Inquiry by two Canadians, a doctor and a lawyer, tries to make some philosophical distinctions which make conscientious objection to abortion more plausible. They distinguish between “perfective” and “preservative” freedom of conscience. The former is exercised in the pursuit of a perceived good. This must often be limited. The latter is more fundamental and cannot legitimately be coerced except in the most exceptional circumstances.

“If the state can legitimately limit perfective freedom of conscience by preventing people from doing what they believe to be good, it does not follow that it is equally free to suppress preservative freedom of conscience by forcing them to do what they believe to be wrong. There is a significant difference between preventing someone from doing the good that he/she wishes to do and forcing him/her to do the evil that he/she abhors.”

It could be argued that an ethics committee, or an institution or a government assumes the moral responsibility for a coerced decision. But this does not take into account the well-documented guilt and shame felt by concentration camp survivors who were forced to participate in heinous crimes. “When it is suppressed by coercion, the result is the kind of spiritual rape suffered by those victims of the camps who were forced to do what they believed to be wrong.”