Protection of Conscience Project Library

Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living?

Eva Elizabeth Bolt, Marianne C Snijdewind, Dick L Willems, Agnes van der Heide, Bregje D Onwuteaka-Philipsen

Abstract
Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.

Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.

Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.

Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.

Bolt EE, Snijdewind MC, Willems DL, van der Heide A, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics doi:10.1136/medethics-2014-102150

Why physicians ought not to perform virginity tests

Kevin Gary Behrens

Abstract
In this article I argue that it is not morally justified for physicians to perform virginity tests. First, I contend that, on the basis of the principle of non-maleficence, physicians should not perform virginity tests, because of the potential harms to those who are tested that can result from such tests. Second, I highlight some of the social harms that the practice causes, and argue that physicians ought not to be complicit in causing these harms. Third, I argue that physicians ought not to perform virginity tests on the grounds that testing for virginity is scientifically impossible, and physicians are morally obliged to practise according to scientific principles. Finally, I contend that an ethically sound response to virginity testing requires that the medical profession as a whole should follow the example of the Quebec College of Physicians in declaring this practice by physicians as unethical.

Behrens KG. Why physicians ought not to perform virginity tests. J Med Ethics doi:10.1136/medethics-2014-102344

An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine

Mithya Lewis-Newby, Mark R Wicclair, Thaddeus Mason Pope, Cynda Rushton, Farr A Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D Siegel, Scott D. Halpern, Robert D Truog, Douglas B White

American Journal of Respiratory and Critical Care Medicine

Abstract
Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs.

Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting.

Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law.

Main Results: The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield ” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting.

Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians’ COs in the critical care setting.

Lewis-Newby M, Wicclair MR, Pope TM, Rushton C, Curlin FA, Diekema D et al.. An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med. 2015;191(2):219-227.

Political Justification through Democratic Participation: The Case for Conscientious Objection

Emanuela Ceva

Abstract
On a proceduralist account of democracy, collective decisions derive their justification-at least in part-from the qualities of the process through which they have been made. To fulfill its justificatory function, this process should ensure that citizens have an equal right to political participation as a respectful response to their equal status as agents capable of self-legislation. How should democratic participation be understood if it is to offer such a procedural justification for democratic decisions? I suggest that, in order to overcome the structural procedural disadvantages affecting the actual, effective opportunities that citizens who hold nonmainstream views have to exercise their right to political participation, the enhancement of such opportunities requires securing space for contestation. Against this background, I vindicate the (currently underestimated) role of conscientious objection as a form of political participation.

Ceva E. Political Justification through Democratic Participation: The Case for Conscientious Objection. Social Theory and Practice. 2015 Jan;41(1):26-50

Medical ethics and more: ideal theories, non-ideal theories and conscientious objection

Florencia Luna

Abstract
Doing ‘good medical ethics’ requires acknowledgment that it is often practised in non-ideal circumstances! In this article I present the distinction between ideal theory (IT) and non-ideal theory (NIT). I show how IT may not be the best solution to tackle problems in non-ideal contexts. I sketch a NIT framework as a useful tool for bioethics and medical ethics and explain how NITs can contribute to policy design in non-ideal circumstances. Different NITs can coexist and be evaluated vis-à-vis the IT. Additionally, I address what an individual doctor ought to do in this non-ideal context with the view that knowledge of NITs can facilitate the decision-making process. NITs help conceptualise problems faced in the context of non-compliance and scarcity in a better and more realistic way. Deciding which policy is optimal in such contexts may influence physicians’ decisions regarding their patients. Thus, this analysis-usually identified only with policy making-may also be relevant to medical ethics. Finally, I recognise that this is merely a first step in an unexplored but fundamental theoretical area and that more work needs to be done.

Luna F. Medical ethics and more: ideal theories, non-ideal theories and conscientious objection. J Med Ethics. 2015 Jan;41(1):129-33. doi: 10.1136/medethics-2014-102295. PMID: 25516954.

“Womb Transplant Babies”: A Preliminary Exploration of Recent Biomedical Advances

Paige Comstock Cunningham

Extract
In September 2014, a little boy named Vincent was born prematurely, but healthy. While such a birth would usually attract the attention of family and friends, baby Vincent’s arrival made world news. He is the world’s first “womb transplant baby.” Like Louise Brown, Vincent is marked for history. Weeks after Vincent’s birth, two more women gave birth to boys, this time each mother carrying her child in the same womb in which she herself was gestated. . .

. . . This essay explores some of the research and issues raised by uterus transplantation. As is appropriate for an emerging biomedical technology, we approach these new developments with caution. My conclusions are preliminary. While I address some of the arguments pro and con, I will merely suggest some of the theological and biblical themes. These merit a lengthier treatment and charitable dialogue with others.

Cunningham PC. “Womb Transplant Babies”: A Preliminary Exploration of Recent Biomedical Advances. Dignitas. 2014 Winter;21(4):4-14.

The ambiguous victim: Miklós Nyiszli’s narrative of medical experimentation in Auschwitz-Birkenau

Marius Turda

Extract
While recent scholarship has – for the past two decades – endeavoured to transcend initial reservations about these forms of testimony, the difficulty with some of these memoirs – namely their authors’ implicit complicity in unethical medical research and in the Nazi Holocaust in general – remains however problematic. To address this thorny issue, in this article I consider the memoirs of a Jewish inmate doctor and forensic pathologist who worked with and for SS medical officers in Auschwitz, particularly Josef Mengele. His name was Mikló Nyiszli. . .

Turda M. The ambiguous victim: Miklós Nyiszli’s narrative of medical experimentation in Auschwitz-Birkenau. Historein. 2014; 14(1): 43–58. doi: 10.12681/historein.232

The law and physician-assisted dying

Tom Koch

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
For most Canadians, the arguments that began on Oct. 14, 2014, at the Supreme Court in Ottawa are about medical aid in dying. But what is really at stake in Carter et al v Attorney General of Canada et al is Canadian law itself, the meaning of its guarantees, promises and injunctions.

Koch T. The law and physician-assisted dying. Can Med Assoc J. 2014 Nov 18;186(17):1336.

Abortion in Chile: The practice under a restrictive regime

Lidia Casas, Lieta Vivaldi

Abstract
This article examines, from a human rights perspective, the experience of women, and the practices of health care providers regarding abortion in Chile. Most abortions, as high as 100,000 a year, are obtained surreptitiously and clandestinely, and income and connections play a key role. The illegality of abortion correlates strongly with vulnerability, feelings of guilt and loneliness, fear of prosecution, physical and psychological harm, and social ostracism. Moreover, the absolute legal ban on abortion has a chilling effect on health care providers and endangers women’s lives and health. Although misoprostol use has significantly helped to prevent greater harm and enhance women’s agency, a ban on sales created a black market. Against this backdrop, feminists have taken action in aid of women. For instance, a feminist collective opened a telephone hotline, Linea Aborto Libre (Free Abortion Line), which has been crucial in informing women of the correct and safe use of misoprostol. Chile is at a crossroads. For the first time in 24 years, abortion law reform seems plausible, at least when the woman’s life or health is at risk and in cases of rape and fetal anomalies incompatible with life. The political scenario is unfolding as we write. Congressional approval does not mean automatic enactment of a new law; a constitutional challenge is highly likely and will have to be overcome.

Casas L, Vivaldi L. Abortion in Chile: The practice under a restrictive regime. Reprod Health Matters. 2014 Nov;22(44):70-81.

Conscientious Objection and Civil Disobedience

Kimberley Brownlee

From the chapter introduction

The purpose of this chapter is to consider two types of dissent that are generally described as conscientious, namely, civil disobedience and conscientious objection, both of which raise pressing normative questions not only about the proper parameters of dissenters’ rights and duties within a reasonably good society, but also about both the scope of legitimate toleration of assertions of conscientiousness and the appropriate legal and political responses to conscientious disobedience. In what follows, I begin by outlining the conceptual territory of civil disobedience and conscientious objection. I then offer a qualified endorsement of the moral justifiability of these two practices before examining both the scope and legitimacy of their status as moral rights and their grounds for legal defensibility. Among other things, I challenge the dominant liberal position that, in relation to both moral rights and legal defenses, a more compelling case can be made on behalf of private conscientious objection than on behalf of civil disobedience.

Brownlee K. Conscientious Objection and Civil Disobedience. In: Marmor A editors. The Routledge Companion to the Philosophy of Law. 2012;527-539.