Extract Abstract . . . This Article is the first to address whether terminally ill persons with cognitive impairments should be able to access PAID [Physician Aid In Dying] through supported decision-making. If provided with decision-making support, terminally ill persons with cognitive impairments may be able to elect PAID intentionally, voluntarily, and with understanding; that is, despite their impairments, such persons may be capable of autonomous end-of-life decision-making. This Article thus argues that the principle of equality demands that the law not exclude terminally ill supported persons with decisional impairments from PAID. This Article also argues that supported decision-making is a superior means for terminally ill persons with decisional impairments to access this end-of-life option compared to advance directives, which have numerous and well-documented problems. . .
Extract In December 2020, less than a year after severe acute respiratory syndrome coronavirus 2 was identified as the cause of the coronavirus pandemic, an extraordinary collaboration between scientists, the pharmaceutical industry, and government led to 2 highly efficacious, safe vaccines being approved by the US Food and Drug Administration . . .
. . . However . . . A number of leaders in federal, state, and local government, guided by political exigency and recommendations from a small number of physicians and scientists who ignored or dismissed science, refused to promote sensible, effective policies such as mask wearing and social distancing. This contributed to the US having more infections and deaths than other developed nations in proportion to population size . . .
Among the ways in which science-based public health evidence has been dismissed in the US is the replacement of highly experienced experts . . . with persons who appear to have been chosen because of their willingness to support government officials’ desire to discount the significance of the pandemic. . .
. . . History is a potent reminder of tragic circumstances when physicians damaged the public health, from promoting eugenics to participating in the human experiments that took place in Tuskegee to asserting erroneously that vaccines cause autism. It can be difficult to hold physicians accountable, especially when they are acting in policy roles in which malpractice lawsuits will not succeed. Professional self-regulation serves as the primary vehicle for accountability and is critical if trust in science and medicine is to be maintained.
To that end, action from within the medical profession is an important but underused strategy. . .
Abstract Human germline genome editing is increasingly being seen as acceptable provided certain conditions are satisfied. Accordingly, genetic modifications would take place on eggs or sperm (or their precursor cells) as well as very early embryos for the purpose of bringing children into existence with or without particular genetic traits. In this context, a number of already discussed and separate arguments, such as the (1) synecdoche, (2) non-identity (3) inherent equality and (4) expressivist arguments, can be brought together in the new context of examining, from an ethical perspective, some of the possible consequences of such germline genome editing. In so doing, it becomes clear that these novel procedures are incompatible with the concept of equality in value and in worth of all human beings in a genuinely inclusive society. Such equality is expressed in Article 1 of the United Nations’ Universal Declaration of Human Rights which states that: ‘All human beings are born … equal in dignity and rights.’
A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer
BMJ Supportive & Palliative Care
Abstract Background The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.
Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.
Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.
Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.
Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.
Author Extract The market changes sweeping the U.S. health care industry have a distinctive impact on communities that rely on religiously affiliated health care providers. When a sectarian sponsor subsumes multiple providers, its assertion of religious beliefs can preclude the provision of certain health care services to the entire community. In addition, the sectarian provider’s refusal to offer certain services may violate state certificates of need, licensing, Medicaid managed care, or even professional liability law. This situation challenges both the provider and the state: the provider seeks adherence to religious law, and the state seeks compliance with its law and citizens access to health care.
I propose that the state attempt to ameliorate tensions between civil and religious laws through negotiated accommodation. This concept encourages the sectarian institution to reassess its mission in the current market and to identify alternative avenues of health care delivery that will preserve patients’ access to care without excessively diluting religious identity or beliefs.
Abstract Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution.
Räsänen J. Twin pregnancy, fetal reduction and the ‘all or nothing problem’. J Med Ethics. 2020 Dec 21:medethics-2020-106938. doi: 10.1136/medethics-2020-106938. Epub ahead of print. PMID: 33443129.
Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva
World Medical Journal
Extract Since 1948 the Declaration of Geneva (the Declaration) has insisted that physicians must practise medicine “with conscience and dignity.” In 2017 this provision was modified by adding, “and in accordance with good medical practice” [1].
Good medical practice in Canada is said to include providing euthanasia and assisted suicide or arranging for someone else to do so. From this perspective, physicians who cannot in conscience kill their patients or collaborate in killing are not acting “in accordance with good medical practice,” and – some might say – the revised Declaration.
However, this merely literal application of the text cannot be correct, since the WMA later reaffirmed its support for physicians who refuse to provide or refer for euthanasia and assisted suicide even where they are considered good medical practice [2]. A reading informed by the history of the document is necessary and consistent with the care taken in its revision [1]. This yields a rational and coherent account of the relationship of conscience and dignity to medical practice.
Extract The concerns of students opposed to abortion go well beyond simple personal preference, opinion, or even political leaning. Opposition to abortion rests firmly in the realm of one’s most fundamental beliefs and convictions about human life, human dignity and human rights. Together with this fact is the freedom of an individual to hold and manifest such fundamental beliefs and convictions and not be discriminated against as a result. It is well known that neither physicians, medical students, nor residents could ever be compelled to perform or observe abortions against their will. In this article, however, we have considered the closely related question: is it possible to require medical students to learn in detail the methods and procedures of a medical act that conflicts with their most fundamental beliefs and convictions? The answer has to be no. So long as the bona fide beliefs of an individual – explicitly grounded in conscience or religion – can be reasonably accommodated, they must be. We must respect this basic requirement of freedom in our community. Given the nature of the belief that underlies objection to abortion, it is not difficult to see how thin would be the line between performing an abortion and learning learning the procedure in all the detail required of a physician.
Declaration of Geneva (1948), International Code of Medical Ethics (1949)
Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding
World Medical Journal
Extract Practising Medicine “with conscience and dignity” Beginning with the Declaration of Geneva (the Declaration), for over 70 years the World Medical Association (WMA) has maintained that physicians must practise medicine with conscience and dignity [1]. On the Declaration’s 70th anniversary, seven associate WMA members raised serious concerns about their ability to remain in medical practice if they fulfil this obligation by refusing to support or collaborate in the killing of their patients by euthanasia and assisted suicide (EAS)[2].The physicians practise in Canada, where euthanasia and assisted suicide (EAS) are legal, [3,4] recognized as therapeutic medical services by the national medical association [5,6] and provided through a public health care system controlled by the state, which also regulates medical practice and medical ethics. The national government is now poised to make EAS available for any serious and incurable medical condition, vastly increasing the number of patients legally eligible for the service [7].
In these circumstances, it is urgent to reassert that the duty to practise medicine “with conscience and dignity” includes unyielding refusal to do what one believes to be wrong even in the face of overwhelming pressure exerted by the state, the medico-legal establishment and even by medical leaders and colleagues. That the founders of the WMA not only supported but expected such principled obstinacy is evident in the WMA’s early history and the development of the Declaration, all of which remain surprisingly relevant . . .
Franck Mauvais-Jarvis, Noel Bairey Merz, Peter J Barnes, Roberta D Brinton, Juan-Jesus Carrero, Dawn L DeMeo, Geert J De Vries,C Neill Epperson, Ramaswamy Govindan, Sabra L Klein, Amedeo Lonardo, Pauline M Maki, Louise D McCullough, Vera Regitz-Zagrosek,Judith G Regensteiner, Joshua B Rubin, Kathryn Sandberg, Ayako Suzuki,
The Lancet
Author Summary
Clinicians can encounter sex and gender disparities in diagnostic and therapeutic responses. These disparities are noted in epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment. This Review discusses the fundamental influences of sex and gender as modifiers of the major causes of death and morbidity. We articulate how the genetic, epigenetic, and hormonal influences of biological sex influence physiology and disease, and how the social constructs of gender affect the behaviour of the community, clinicians, and patients in the health-care system and interact with pathobiology. We aim to guide clinicians and researchers to consider sex and gender in their approach to diagnosis, prevention, and treatment of diseases as a necessary and fundamental step towards precision medicine, which will benefit men’s and women’s health.
Mauvais-Jarvis F, Bairey Merz N, Barnes PJ, Brinton RD, Carrero J-J, DeMeo DL, De Vries GJ, Epperson CN, Govindan R, Klein SL, Lonardo A, Maki PM, McCullough LD, Regitz-Zagrosek V, Regensteiner JG, Rubin JB, Sandberg K, Suzuki A. Sex and gender: modifiers of health, disease, and medicine. The Lancet; 2020 Aug 22 396(10250): 565-582. DOI:https://doi.org/10.1016/S0140-6736(20)31561-0
