Lauris Christoper Kaldjian. Practicing Medicine and Ethics: Integrating Wisdom, Conscience and Goals of Care. New York: Cambridge University Press, 2014, 296 pp. ISBN 10- 1107012163
Publisher’s Description To practice medicine and ethics, physicians need wisdom and integrity to integrate scientific knowledge, patient preferences, their own moral commitments, and society’s expectations. This work of integration requires a physician to pursue certain goals of care, determine moral priorities, and understand that conscience or integrity require harmony among a person’s beliefs, values, reasoning, actions, and identity. But the moral and religious pluralism of contemporary society makes this integration challenging and uncertain. How physicians treat patients will depend on the particular beliefs and values they and other health professionals bring to each instance of shared decision making. This book offers a framework for practical wisdom in medicine that addresses the need for integrity in the life of each health professional. In doing so, it acknowledges the challenge of moral pluralism and the need for moral dialogue and humility as professionals fulfil their obligations to patients, themselves, and society.
Abstract The issue of conscientious objection to agreed public policy is a vexed one. The clearest example is that of conscientious objection to military service. A free and democratic society has to respect the consciences of those who believe that killing in battle is absolutely wrong. Many disagree with the moral stance being taken, but it has been seen as the mark of a mature and civilised society to respect the conscience of pacifists. The freedom to be able to live by what one thinks most important has been seen as a constituent element in the freedoms that others have fought to preserve.
Respect for the conscience of those medical professionals who feel unable to participate in abortion appears to be in the same category (as would be respect for those who refused to participate in assisted suicide or euthanasia). Issues about the value of human life are at stake. Matters are undoubtedly complicated in the case of abortion by arguments over the supposed ‘humanity’ or ‘personhood’ of a fetus. Even so, some sincerely regard abortion as murder. Mutual respect is easy between people who agree. The problem in a democratic society arises when there is significant disagreement, but it is …
Abstract The law regulating abortion in Italy gives healthcare practitioners the option to make a conscientious objection to activities that are specific and necessary to an abortive intervention. Conscientious objectors among Italian gynaecologists amount to about 70%. This means that only a few doctors are available to perform abortions, and therefore access to abortion is subject to constraints. In 2012 the International Planned Parenthood Federation European Network (IPPF EN) lodged a complaint against Italy to the European Committee of Social Rights, claiming that the inadequate protection of the right to access abortion implies a violation of the right to health. In this paper I will discuss the Italian situation with respect to conscientious objection to abortion and I will suggest possible solutions to the problem.
Three physicians and a lawyer have written an article published in the May issue of the Canadian Medical Association Journal.[1] The lead author, Dr. James Downar, is co-chair of a euthanasia/assisted suicide advocacy group.
Anticipating a change in the law, the authors warn that “well-rehearsed debates” about sanctity of life and personal autonomy “may become obsolete.”
“We need to start to answer some challenging questions in preparation for the possibility that physician-assisted death will be available in Canada soon,” they write.
Among the questions they pose, one raises two particularly sensitive issues:
Will physicians who are conscientious objectors be obliged to present physician-assisted death as an option to patients and facilitate transfers of patients to other physicians or facilities?
As a matter of law and ethics, physicians are expected to advise patients of all reasonable legal options for treatment so that patients can provide informed consent to it. However, many physicians who are strongly opposed to euthanasia and assisted suicide may view the “presentation of an option” for either procedure as inherently abusive of vulnerable patients. This problem does not usually arise with respect to other morally contested procedures, like abortion or contraception.
A requirement to “facilitate transfers” of patients would probably be acceptable if it involved only the kind of cooperation normally involved in the transfer of records when a patient is taken on by a different physician; this is all that is required in Belgium, Oregon and Washington State. However, a demand that objecting physicians refer patients or actively initiate transfers would be resisted by those who would consider such actions to involve unacceptable complicity in killing. The Supreme Court of the Philippines recognized this issue when it struck down a mandatory referral requirement in the country’s Reproductive Health Law as an unconstitutional violation of freedom of conscience.
Abstract Although 65 treatises – either preserved or lost, but quoted by ancient authors like Bacchius (3rd century B.C.), Erotian (1st century A.D.) and Galen (c. 129-199 A.D.) – are ascribed to Hippocrates (c. 469-c. 399 B.C.) and consist of nearly 83 books, nonetheless there is no doubt that none of them was written by Hippocrates himself. This being the fact, we cannot help agreeing with Ulrich von Wilamowitz Möllendorf (1848-1931), who maintained that Hippocrates is a name without writings!
Indeed the most of the treatises of the “Corpus hippocraticum” are not the collection of Hippocrates’ works, but were likely the “library” of the Medical School of Kos. The fact that it contains some treatises that represent the theories of the Medical school of Cnidos (most probably founded by a certain Euryphon, almost contemporary with Hippocrates), with which it seems that Hippocrates entered into a relentless debate, is an absolute evidence.
Moreover, we must confess that, although Celsus (1st century B.C.-1st century A.D.) (De medicina, I, Prooemium) writes that “Hippocrates of Kos…separated this branch of learning (i.e. Medicine) from the study of philosophy”, we have nothing to learn from the hippocratic treatises under the scientific point of view.
However, whatever its origin, the “Oath” is a real landmark in the ethics of medicine and we can say – with Thuchydides (460/455-400 B.C.) (Histories, I, 22, 4) – that it is “an achievement for eternity”.
Suffice it to remember that every graduand in Medicine is generally still bound to take an oath that is a more or less modified and more or less updated text of the “Hippocratic oath” and that even the modern concept of bioethics has its very roots in the Hippocratic medical ethics.
“The art is long; life is short; opportunity fleeting; experiment treacherous; judgment difficult: The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals, ” says the first “Aphorism” and the latest author of “Precepts” (chapter VI) writes: “where there is love of man, there is also love of the art”, and the “art” par excellence is medicine! These precepts go surely back to Hippocrates’s moral teaching.
Nonetheless, the preserved text of the marvellous “Oath” raises many problems. Namely:
1) which is the date of it”?
2) Is it mutilated or interpolated?
3) Who took the oath, i.e. all the practitioners or only those belonging to a guild?
4) What binding force had it beyond its moral sanction”?
5) Last but not least: was it a reality or merely a “counsel of perfection”?
In this article we have gathered and discussed all the available and most important sources, but do not presume to have solved all these problems and confine ourselves to proposing some reasonable hypotheses and letting the readers evaluate the positive and negative points of our proposals.
Abstract As a science and practice transcending metaphysical and ethical disagreements, ‘secular’ medicine should not exist. ‘Secularity’ should be understood in an Augustinian sense, not a secularist one: not as a space that is universally rational because it is religion-free, but as a forum for the negotiation of rival reasonings. Religion deserves a place here, because it is not simply or uniquely irrational. However, in assuming his rightful place, the religious believer commits himself to eschewing sheer appeals to religious authorities, and to adopting reasonable means of persuasion. This can come quite naturally. For example, Christianity (theo)logically obliges liberal manners in negotiating ethical controversies in medicine. It also offers reasoned views of human being and ethics that bear upon medicine and are not universally held – for example, a humanist view of human dignity, the bounding of individual autonomy by social obligation, and a special concern for the weak.
Abstract “Emergency contraception” case law from the state of Washington is reviewed and analyzed. Important legal, social policy, and professional ethical questions are considered with focus on professional and institutional conscientious objection to participating in this therapy.
Abstract There is surprising confusion surrounding the concept of biological totipotency, both within the scientific community and in society at large. Increasingly, ethical objections to scientific research have both practical and political implications. Ethical controversy surrounding an area of research can have a chilling effect on investors and industry, which in turn slows the development of novel medical therapies. In this context, clarifying precisely what is meant by “totipotency” and how it is experimentally determined will both avoid unnecessary controversy and potentially reduce inappropriate barriers to research. Here, the concept of totipotency is discussed, and the confusions surrounding this term in the scientific and nonscientific literature are considered. A new term, “plenipotent,” is proposed to resolve this confusion. The requirement for specific, oocyte-derived cytoplasm as a component of totipotency is outlined. Finally, the implications of twinning for our understanding of totipotency are discussed.
Highlights
Inaccurate use of the term “totipotent” by scientists creates unnecessary ethical controversy.
Public concern over producing embryos by reprogramming reflects confusion over totipotency.
Twinning by blastocyst splitting does not provide scientific evidence for totipotency.
Abstract [ES] La proliferación de los conflictos por motivos de conciencia en el contexto sanitario ha conducido con frecuencia a un tratamiento inadecuado de los mismos. En el caso de los profesionales sanitarios, es posible observar un uso inapropiado de conceptos como el de objeción de conciencia, banalizándolo o sacralizándolo, sin considerar el alcance que la negativa a prestar un tratamiento pueda tener para el resto de personas implicadas; en el caso de los usuarios, es frecuente que sus convicciones tengan un reconocimiento limitado a la hora de tomar decisiones que atañen a su bienestar. A partir de estas premisas, se pretende analizar las tensiones entre intereses, derechos y deberes de las partes implicadas, así como las relaciones de poder que se establecen entre quienes ostentan el conocimiento experto y quienes se encuentran en situación de mayor vulnerabilidad. Este análisis persigue identificar los problemas en los distintos niveles discursivos ¿de intereses, de derechos y deberes y de relaciones de poder- para establecer posteriormente una serie de límites que condicionen el ejercicio de la libertad de conciencia tanto para los profesionales como para los usuarios. Con ello se aspira a ofrecer un marco ético-normativo que pudiera servir como referencia para la resolución de conflictos, basado en una noción de conciencia menos individualista y más relacional-feminista.
[Translation] The proliferation of conflicts for reasons of conscience in the health context has frequently led to their inadequate treatment. In the case of health professionals, it is possible to observe an inappropriate use of concepts such as conscientious objection, trivializing or sacralizing it, without considering the scope that the refusal to provide treatment may have for the rest of the people involved; In the case of users, it is common for their convictions to have limited recognition when making decisions that concern their well-being. Based on these premises, it is intended to analyze the tensions between interests, rights and duties of the parties involved, as well as the power relations that are established between those who hold expert knowledge and those who are in a situation of greater vulnerability. This analysis seeks to identify the problems at the different discursive levels – interests, rights and duties and power relations – to subsequently establish a series of limits that condition the exercise of freedom of conscience for both professionals and users. With this, it aspires to offer an ethical-regulatory framework that could serve as a reference for conflict resolution, based on a less individualist and more relational-feminist notion of conscience.
Abstract Many countries, Sweden among them, lack professional guidelines and established procedures for responding to young females requesting virginity certificates or hymen restoration due to honour-related threats. The purpose of the present survey study was to further examine the attitudes of the Swedish healthcare professionals concerned towards young females requesting virginity certificates or hymen restorations. The study indicates that a small majority of Swedish general practitioners and gynaecologists would accommodate these patients, at least given certain circumstances. But a large minority of physicians would under no circumstances help the young females, regardless of speciality, years of practice within medicine, gender, or experience of the phenomenon. Their responses are similar to other areas where it has been claimed that society should adopt a zero tolerance policy against certain phenomena, for instance drug policy, where it has also been argued that society should never act in ways that express support for the practice in question. However, this argument is questionable. A more pragmatic approach would also allow for follow-ups and evaluation of virginity certificates and hymen restorations, as is demonstrated by the Dutch policy. Hence, there are some obvious advantages to this pragmatic approach compared to the restrictive one espoused by a large minority of Swedish physicians and Swedish policy-makers in this area.
