Ethics Archives - Page 9 of 81 - Protection of Conscience Project Library

Physician-assisted suicide and euthanasia: Emerging issues from a global perspective

Charles L Sprung, Margaret A Somerville, Lukas Radbruch, Nathalie Steiner Collet, Gunnar Duttge, Jefferson P Piva, Massimo Antonelli, Daniel P Sulmasy, Willem Lemmens, E Wesley Ely

Abstract
Medical professional societies have traditionally opposed physician-assisted suicide and euthanasia (PAS-E), but this opposition may be shifting. We present 5 reasons why physicians shouldn’t be involved in PAS-E.

1. Slippery slopes: There is evidence that safeguards in the Netherlands and Belgium are ineffective and violated, including administering lethal drugs without patient consent, absence of terminal illness, untreated psychiatric diagnoses, and nonreporting;

2. Lack of self-determination: Psychological and social motives characterize requests for PAS-E more than physical symptoms or rational choices; many requests disappear with improved symptom control and psychological support;

3. Inadequate palliative care: Better palliative care makes most patients physically comfortable. Many individuals requesting PAS-E don’t want to die but to escape their suffering. Adequate treatment for depression and pain decreases the desire for death;

4. Medical professionalism: PAS-E transgresses the inviolable rule that physicians heal and palliate suffering but never intentionally inflict death;

5. Differences between means and ends: Proeuthanasia advocates look to the ends (the patient’s death) and say the ends justify the means; opponents disagree and believe that killing patients to relieve suffering is different from allowing natural death and is not acceptable.

Conclusions: Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.

Sprung CL, Somerville MA, Radbruch L, Collet NS, Duttge G, Piva JP et al. Physician-assisted suicide and euthanasia: Emerging issues from a global perspective. J Palliat Care. 2018;33(4):197-203.

Public cartels, private conscience

Michael Cholbi

Abstract
Many contributors to debates about professional conscience assume a basic, pre-professional right of conscientious refusal and proceed to address how to ‘balance’ this right against other goods. Here I argue that opponents of a right of conscientious refusal concede too much in assuming such a right, overlooking that the professions in which conscientious refusal is invoked nearly always operate as public cartels, enjoying various economic benefits, including protection from competition, made possible by governments exercising powers of coercion, regulation, and taxation. To acknowledge a right of conscientious refusal is to license professionals to disrespect the profession’s clients, in opposition to liberal ideals of neutrality, and to engage in moral paternalism toward them; to permit them to violate duties of reciprocity they incur by virtue of being members of public cartels; and to compel those clients to provide material support for conceptions of the good they themselves reject. However, so long as (a) a public cartel discharges its obligations to distribute the socially important goods they have are uniquely authorized to provide without undue burden to its clientele, and (b) conscientious refusal has the assent of other members of a profession, individual professionals’ claims of conscience can be accommodated.

Cholbi M. Public cartels, private conscience. Polit Phil Econ. 2018 May 30;17(4):356-377.

Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Valerie Fleming Lucy Frith, Ans Luyben, Beate Ramsayer

Abstract
Background: Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.

Method: We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.

Results: Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n = 58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.

Conclusions: We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.

Fleming V, Frith L, Luyben A, Ramsayer B. Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons. BMC Medical Ethics. 2018;19:31. doi:10.1186/s12910-018-0268-3.

Conscience claims, metaphysics, and avoiding an LGBT eugenic

Abram Brummet

Abstract
Novel assisted reproductive technologies (ART) are poised to present our society with strange new ethical questions, such as whether lesbian, gay, bisexual, and transgender (LGBT) couples should be allowed to produce children biologically related to both parents, or whether trans-women who want to experience childbirth should be allowed to receive uterine transplants. Clinicians opposed to offering such technologies to LGBT couples on moral grounds are likely to seek legal shelter through the conscience clauses enshrined in U.S. law. This paper begins by briefly discussing some novel ART on the horizon and noting that it is unclear whether current conscience clauses will permit fertility clinics to deny such services to LGBT individuals. A compromise approach to conscience is any view that sees the value of respecting conscience claims within limits. I describe and critique the constraints proposed in the recent work of Wicclair, NeJaime and Siegel as ultimately begging the question. My purpose is to strengthen their arguments by suggesting that in the controversial situations that elicit claims of conscience, bioethicists should engage with the metaphysical claims in play. I argue that conscience claims against LGBT individuals ought to be constrained because the underlying metaphysic—that God has decreed the LGBT lifestyle to be sinful—is highly implausible from the perspective of a naturalized metaphysic, which ought to be the lens through which we evaluate conscience claims.

Brummett A. Conscience claims, metaphysics, and avoiding an LGBT eugenic. Bioethics. 2018;00:1–9.

Testing conscientious objection by the norm of medicine

Toni C. Saad, Gregory Jackson

Abstract
Debate persists over the place of conscience in medicine. Some argue for the complete exclusion of conscientious objection, while others claim an absolute right of refusal. This paper proposes that claims of conscientious objection can and should be permitted if they concern kinds of actions which fall outside of the normative standard of medicine, which is the pursuit of health. Medical practice which meets this criterion we call medicine qua medicine. If conscientious refusal concerns something consonant with the health-restoring aims of medicine, it entails a desertion of professional duty. If, however, it relates to something other than medicine qua medicine, it can rightly be refused. It thus becomes possible to test instances of conscientious objection to determine their validity, and thereby conserve both the principle of conscientious objection and define its scope. This test of conscience prevents arbitrary discrimination, and preserves doctors’ agency. It is a theoretical razor rooted in the practical reasoning of medicine whose operation will prompt, if nothing else, reflection on the goals of medicine.

Saad TC, Jackson G. Testing conscientious objection by the norm of medicine. Clinical Ethics 2018 Mar; 13(1); 9-16.

(Editorial) Physicians are not solely responsible for ensuring access to medical assistance in dying

Diane Kelsall

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Patients’ rights to access to medical assistance in dying (MAiD) trumps the religious rights of physicians under the Canadian Charter of Rights and Freedoms – or so says the Ontario Superior Court of Justice. But ensuring equitable access to health care is a societal responsibility and does not rest solely on the individual physician. Surely there is a way forward that ensures access for patients requesting MAiD without trampling on physician rights enshrined in law.

Kelsall D. Physicians are not solely responsible for ensuring access to medical assistance in dying. CMAJ February 20, 2018 190 (7) E181; DOI: https://doi.org/10.1503/cmaj.180153

Hippocrates’ Oath and Asclepius’ Snake:The Birth of the Medical Profession

Thomas A Cavanaugh

Thomas A. Cavanagh. Hippocrates’ Oath and Asclepius’ Snake:The Birth of the Medical Profession. New York: Oxford University Press, 2018. 177 pp.

Publisher’s Description
T. A. Cavanaugh’s Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession articulates the Oath as establishing the medical profession’s unique internal medical ethic – in its most basic and least controvertible form, this ethic mandates that physicians help and not harm the sick. Relying on Greek myth, drama, and medical experience (e.g., homeopathy), the book shows how this medical ethic arose from reflection on the most vexing medical-ethical problem – injury caused by a physician – and argues that deliberate iatrogenic harm, especially the harm of a doctor choosing to kill (physician assisted suicide, euthanasia, abortion, and involvement in capital punishment), amounts to an abandonment of medicine as an exclusively therapeutic profession. The book argues that medicine as a profession necessarily involves stating before others what one stands for: the good one seeks and the bad one seeks to avoid on behalf of the sick, and rejects the view that medicine is purely a technique lacking its own unique internal ethic. It concludes noting that medical promising (as found in the White Coat Ceremony through which U. S. medical students matriculate) implicates medical autonomy which in turn merits respect, including honoring professional conscientious objections.

Euthanasia and Palliative Sedation in Belgium

Raphael Cohen-Almagor, E Wesley Ely

Abstract
The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.

Cohen-Almagor R, Ely EW. Euthanasia and Palliative Sedation in Belgium. BMJ Supportive Palliative Care. 2018 Jan 04;8(3):307-313.

Autonomy in Tension: Reproduction, Technology, and Justice

Louise P King, Rachel L Zacharias, Josephine Johnston

Abstract
Respect for autonomy is a central value in reproductive ethics, but it can be a challenge to fulfill and is sometimes an outright puzzle to understand. If a woman requests the transfer of two, three, or four embryos during fertility treatment, is that request truly autonomous, and do clinicians disrespect her if they question that decision or refuse to carry it out? Add a commitment to justice to the mix, and the challenge can become more complex still. Is it unfair for insurance policies to exclude from coverage the costs of giving fertility to those who lack it or restoring fertility in those who have lost it? What does “just reproduction” look like in the face of multifarious understandings of both justice and autonomy and in light of increasingly complex and costly reproductive technologies? In today’s dialogue about reproduction, medicine, and ethics in the United States, old ethical issues—such as whether women ought to be allowed to access pregnancy termination—are more contested than they have been in decades, while new technologies—like those used to edit the genes of human embryos—suggest that our species could face unprecedented questions about who should exist. As we considered the discussions accompanying these issues and contemplated a special report responding to them, we found ourselves consistently circling back to two ethical commitments: respect for autonomy and the pursuit of justice. As one of the nine essays in this collection asks, why should certain women receive help to establish a pregnancy while others are thrown in jail when they miscarry or their child is stillborn? Respect for autonomy is required where individuals have the ability to make fully informed and voluntary choices. Yet does respecting autonomy require acceding to all the choices of patients or consumers of medical care? We consider these and related questions in this special report from the Hastings Center Report..

King LP, Zacharias RL, Johnston J. Autonomy in Tension: Reproduction, Technology, and Justice. Hastings Cent Rep. 2017 Nov 24;47:S3.

This moral coil: A cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying

Eli Xavier Bator, Bethany Philpott, Andrew Paul Costa

Abstract
Background: In February, 2015, the Supreme Court of Canada struck down the ban on medical assistance in dying (MAiD). In June, 2016, the federal government passed Bill C-14, permitting MAiD. Current medical students will be the first physician cohort to enter a system permissive of MAiD, and may help to ensure equitable access to care. This study assessed medical student views on MAiD, factors influencing these views, and opportunities for medical education.
Methods: An exploratory cross-sectional survey was developed and distributed to medical students across all years of a three-year Canadian undergraduate medical program. The investigators administered the survey to participants during academic sessions from November to December, 2015. Analysis of the results included summary descriptive statistics, Pearson’s chi-square test of independence to identify differences between participants by year of study, logistic regression to identify factors that influence students’ stances on MAiD, and Wilcoxon signed rank test to measure changes in student support for MAiD and comfort discussing MAiD.
Results: There were 405 participants for a response rate of 87%. The majority of students (88%) supported the Supreme Court’s decision, 61% would provide the means for a patient to end their life, and 38% would personally administer a lethal medication. Students who were more willing to provide the means for MAiD found medical education/clinical experience and patient autonomy to be important contributors to their stances on MAiD. Those students who were less willing to provide the means for MAiD found religious/spiritual beliefs and teachings, as well as concern about potential negative consequences, to be important contributors to their stances on MAiD. Educational training desired by participants included medicolegal (91%), communication skills (80%), technical skills (75%), and religious (49%).
Conclusions: Medical students generally supported and would provide the means for MAiD to patients. They also indicated a desire for directed medical education on MAiD.

Bator EX, Philpott B, Costa AP. This moral coil: A cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying. BMC Medical Ethics. 2017;18(1).