Project Administrator, Author at Protection of Conscience Project Library

Integrity and conscience in medical ethics: A Ciceronian perspective

Jed W Atkins

Abstract
In his work on medical ethics, Lauris Kaldjian identifies conscience with integrity. However, there are competing notions of integrity that may guide the conscience. This paper addresses debates over conscientious refusals by considering Cicero’s account of integrity, a conception previously not discussed in the context of this debate. Cicero offers a framework for understanding integrity and conscience for the physician that is an alternative to Alasdair MacIntyre’s notion of the completely unified life, an idea appropriated by Kaldjian in his argument that there can be no clean distinction between personal, private, practical reasoning and moral decision-making. Cicero’s account rejects the modern-individualist idea of the autonomous self living a wholly compartmentalized life. It agrees with Kaldjian’s stress on flexible decision- making, the internal morality of medicine, the importance of virtues, and the need to accommodate pluralism. However, Ciceronian integrity is better suited than the MacIntyreian account to our present liberal order. It offers a place for the “moral hero” while recognizing that the vast majority of moral agents will be “progressors” who lack the consistency of the moral hero’s fully integrated life. The inclusion of both types of individuals in the medical field may offset the potentially harmful tendencies to which each is prone.

Atkins JW. Integrity and conscience in medical ethics: A Ciceronian perspective. Perspect Biol Med. 2019;62(3):470-488.

Eugenics between Darwin’s Εra and the Holocaust

Dimitra Chousou, Daniela Theodoridou, George Boutlas, Anna Batistatou, Christos Yapijakis, Maria Syrrou

Abstract
Heredity and reproduction have always been matters of concern. Eugenics is a story that began well before the Holocaust, but the Holocaust completely changed the way eugenics was perceived at that time. What began with Galton (1883) as a scientific movement aimed at the improvement of the human race based on the theories and principles of heredity and statistics became by the beginning of the 20th century an international movement that sought to engineer human supremacy. Eugenic ideas, however, trace back to ancient Greek aristocratic ideas exemplified in Plato’s Republic, which played an important role in shaping modern eugenic social practices and government policies. Both positive (encouragement of the propagation of the fit, namely without hereditary afflictions, i.e. socially acceptable) and negative (institutionalization, sterilization, euthanasia) eugenics focused on the encouragement of healthy and discouragement of unhealthy reproduction. All these practices were often based on existing prejudices about race and disability. In this article, we will focus on the rise of eugenics, starting with the publication of Origin of Species to the Holocaust. This examination will be multidisciplinary, utilizing genetics, legal history and bioethical aspects. Through this examination, we will discuss how provisional understandings of genetics influenced eugenics-based legislation. We will also discuss the rise of biopolitics, the change of medical ethos and stance towards negative eugenics policies, and the possible power of bioethical principles to prevent such phenomena.

Chousou D, Theodoridou D, Boutlas G, Batistatou A, Yapijakis C, Syrrou M. Eugenics between Darwin’s Εra and the Holocaust. Conatus J Philosophy; 2019 4(2); 171-204. DOI: https://dx.doi.org/10.12681/cjp.21061.

Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy

James Downar, Sam D. Shemie, Clay Gillrie, Marie-Chantal Fortin, Amber Appleby, Daniel Z. Buchman, Christen Shoesmith, Aviva Goldberg, Vanessa Gruben, Jehan Lalani, Dirk Ysebaert, Lindsay Wilson and Michael D. Sharpe

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Key Points

First-person consent for organ donation after medical assistance in dying (MAiD) or withdrawal of life-sustaining measures (WLSM) should be an option in jurisdictions that allow MAiD or WLSM and donation after circulatory determination of death.
The most important ethical concern — that the decision for MAiD or WLSM is being driven by a desire to donate organs — should be managed by ensuring that any discussion about organ donation takes place only after the decision for MAiD or WLSM is made.
If indications for MAiD change, this guidance for policies and the practice of organ donation after MAiD should be reviewed to ensure that the changes have not created new ethical or practical concerns. . .

Downar J, Shemie SD, Gillrie C, Fortin M-C, Amber Appleby A, Buchman DZ, Shoesmith C, Goldberg A, Gruben V, Lalani J, Ysebaert D, Wilson L, Sharpe MD. Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy. CMAJ. 2019 Jun 3;191(22):E604-E613. doi: 10.1503/cmaj.181648.

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.

The Market View on conscientious objection: Overvalued

Robert F Card

Abstract
Ancell and Sinnott-Armstrong argue that medical providers possess wide freedoms to determine the scope of their practice, and therefore, prohibiting almost any conscientious objections is a bad idea. They maintain that we could create an acceptable system on the whole which even grants accommodations to discriminatory refusals by healthcare professionals. Their argument is premised upon applying a free market mechanism to conscientious objections in medicine, yet I argue their Market View possesses a number of absurd and troubling implications. Furthermore, I demonstrate that the fundamental logic of their main argument is flawed. Thinkers who wish to address the issues raised in this debate in general or by discriminatory conscience objections in particular should avoid the Market View and instead envisage theories that assess the reasons underlying conscientious refusals in medicine.

Card RF. The Market View on conscientious objection: Overvalued. J Med Ethics 2019 Mar;45(3):168-172. doi: 10.1136/medethics-2018-105173

(Editorial) A right to be unconscious

Julian Savulescu, Janet Radcliffe-Richards

Extract
[Referring to Sinmyee et al] This seems to us to be an important, landmark paper. This is because the issues it addresses are important in their own right: how to ensure death without suffering in jurisdictions where assisted dying (including assisted suicide or euthanasia) is allowed, and also, because the technicalities are the same, in cases of capital punishment by lethal injection. Moreover, the paper shows the potential for the use of anaesthesia in contexts beyond surgery. Anaesthesia in its ordinary uses is intended to facilitate surgery designed to restore a patient to improved health and functioning. In assisted dying, however, there is no question of restoring health. The proposition is to use anaesthesia primarily to prevent suffering in a patient who is about to die and, in this sense, places anaesthesia on a new footing as a primary medical intervention, serving a purpose in its own right. . .

Savulescu J, Radcliffe-Richards J. A right to be unconscious. Anaesthesia. 2019 May; 74(5): 557-559

Understanding conscience as integrity: Why some physicians will not refer patients for ethically controversial practices

Lauris Christopher Kaldjian

Abstract
The moral pluralism of Western democratic societies results in ethical differences among citizens and health professionals, due to contrasts between the foundational beliefs and values on which their ethical convictions rest. Some of these differences have challenging implications for the practice of medicine when a patient seeks access to a legal medical service that a conscientiously acting physician believes is unethical. Such disagreements raise pivotal questions about competing ethical values, the moral dynamic of shared decision-making, the meaning of conscience, and the extent to which society will accept ethical differences in professional practice. The act of referral is the focal point of this essay, because it appears to be at the front line of some current debates and legal contests about the extent to which society is willing to accommodate conscientious practice by physicians. Some see referrals as a way to balance respect for physician integrity with promotion of patient autonomy; others see referrals as a mistaken attempt at compromise that misunderstands the meaning of moral responsibility and participation. Understanding conscience as integrity helps explain the moral seriousness of conscientious practice and reinforces the need for professional and legal accommodations that respect it.

Kaldjian LC. Understanding conscience as integrity: Why some physicians will not refer patients for ethically controversial practices. Perspect Biol Med. 2019 Summer;62(3):383-400.

Victoria’s voluntary assisted dying law: clinical implementation as the next challenge

Ben P. White, Lindy Willmott, Eliana Close

Extract
The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act) will become operational on 19 June, 2019. . . . While some have written on the scope of, and reaction to, the VAD legislation, there has been very little commentary on its implementation. Yet, important choices must be made about translating these laws into clinical practice. These choices have major implications for doctors and other health professionals (including those who choose not to facilitate VAD), patients, hospitals and other health providers. This article considers some key challenges in implementing Victoria’s VAD legislation.

White BP, Willmott L, Close E. Victoria’s voluntary assisted dying law: clinical implementation as the next challenge. Med J Australia. 2019 Mar;210(5):207-209.e1

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

Author 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