Guest editorial re: conscience in health care

Special edition of The New Bioethics

Mary Neal, Sara Fovargue & Stephen W. Smith

The New Bioethics

It is probably fair to say that academic interest in the role of conscience in healthcare (and specifically, in the phenomenon of conscientious objection (CO)) has never been more intense, as evidenced by the volume of articles (and indeed, special issues) devoted to the topic in recent years. The three of us have contributed to this burgeoning literature, writing separately and together.

This special issue of The New Bioethics marks the mid-point of a project devised and co-managed by us and funded by the Royal Society of Edinburgh’s Research Networks scheme: the Accommodating Conscience Research Network (ACoRN).  Our aim in developing this multidisciplinary network (including academics from arange of disciplines, practitioners, and representatives of professional bodies) is to carve out intellectual space within which to begin exploring conscience/CO inhealthcare from a broadly supportive perspective. Our sense, as participants in academic debates about conscience, is that although the literature contains many rich insights and fascinating discussions, some of the most interesting questions about conscience are being overshadowed by the loudest and most polarized disagreement over whether there is any legitimate role for CO in healthcare at all. This is despite the fact that it seems to us that most contributors adopt positions that are hospitableto the accommodation of CO, at least to some extent and in some circumstances. . . [Full text]


Neal M, Fovargue S, Smith SW. Guest editorial. The New Bioethics. 2019 Sep;25(3): 203-206, DOI:10.1080/20502877.2019.1659485.

Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion

Bruce Philip Blackshaw, Daniel Rodger

Journal of Medical Ethics

 Abstract

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.


Blackshaw BP, Rodger D. Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion. J Medical Ethics 2019 Aug 31. pii: medethics-2019-105566. doi: 10.1136/medethics-2019-105566. [Epub ahead of print]

Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Julie Allard, Marie-Chantal Fortin

Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Résumé

Depuis décembre 2015, l’aide médicale à mourir, une pratique au centre de nombreux débats éthiques, est légalisée dans la province du Québec, au Canada. Ce nouveau type de décès a créé un tout nouveau contexte pour le don d’organes, soit le don d’organes après l’aide médicale à mourir. Le prélèvement des organes s’effectue alors suivant le protocole habituel du don d’organes après décès cardiocirculatoire contrôlé (catégorie Maastricht III), un protocole qui suscitait déjà de nombreux questionnements médico-éthiques. En outre, l’amalgame des deux pratiques soulève de nouveaux enjeux éthiques qui peuvent se traduire par des objections de conscience chez les médecins directement impliqués dans l’aide médicale à mourir et/ou le don d’organes. Or, une telle objection de conscience peut-elle être acceptable ? Nous tenterons de répondre à cette question en trois temps : d’abord, par un bref historique de l’objection de conscience ; ensuite, par une revue des débats actuels sur ce sujet ; enfin, par l’examen, à l’aide de critères recensés dans la littérature, de cas où les médecins refuseraient de participer au don d’organes après l’aide médicale à mourir.

Summary

Medical assistance in dying, a much debated practice in ethical literature, is practiced since 2015 in the province of Québec, Canada. Its practice has opened the door to organ donation after medical assistance in dying. This type of donation is possible through donation after controlled cardiocirculatory death (Maastricht III category), a procedure that also raises many ethical questions. Combining these two practices raises new ethical issues and could therefore generate conscientious objections from physicians directly involved in medical assistance in dying and/or organ donation. Would conscientious objection be acceptable in this context? To answer this question, we present a brief history of conscientious objection, an overview of the actual debates on conscientious objection and we will examine the case of the physician who would object to participate in organ donation after medical assistance in dying using existing criteria.


Allard J, Forin M.-C. Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec. Éthique & Santé; 2019 Sep; 16(3): 125-132

Physician-Assisted Suicide and the Perils of Empirical Ethical Research

Daniel P. Sulmasy

Journal of the American Medical Association

Al Rabadi et al1 compare statistics on physician-assisted suicide (PAS) available from public databases for the states of Washington and Oregon and find similar profiles and trends, which is unsurprising given the similarity of the laws and demographic characteristics of these states. Among the unanswered questions are what such a study can contribute to medical ethics (about PAS or any other ethical controversy) and what the limits are of such work.

Cautions

First, it should be noted that the medical literature is, in general, favorably disposed toward the empirical and the new. Although this predilection is often advantageous for scientific progress, it introduces a problematic bias when applied to ethical questions. The appeal of the study by Al Rabadi et al1 is that it is empirical, and by comparing data from 2 states for the first time, it can be considered novel. Because there are new reports each year and the practice of PAS is legal in only a few states, descriptive reports about PAS are published frequently. This means, however, that articles defending the ethical status quo (ie, against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artifact of a scientific bias. . . . [Full text]


Sulmasy DP. Physician-Assisted Suicide and the Perils of Empirical Ethical Research. JAMA Netw Open. 2019;2(8):e198628. doi:10.1001/jamanetworkopen.2019.8628

Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium

Nicholas Gilbo, Ina Jochmans, Daniel Jacobs-Tulleneers-Thevissen, Albert Wolthuis, Mauricio Sainz-Barriga, Jacques Pirenne, Diethard Monbaliu

Journal of the American Medical Association

Abstract

Transplantation of organs donated after euthanasia may help alleviate the critical organ shortage.1 However, aside from preliminary data on lung transplantation,2 data on graft and patient survival following transplantation of organs donated after euthanasia are unavailable. Because donation after euthanasia entails a period of detrimental warm ischemia that hampers graft survival, similar to donation after circulatory death,3 results after transplantation of this type of graft need to be carefully evaluated.


Gilbo N, Jochmans I, Jacobs-Tulleneers-Thevissen D, Wolthuis A, Sainz-Barriga M, Pirenne  J, Monbaliu D.  Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium. JAMA. 2019;322(1):78-80. doi:10.1001/jama.2019.6553

Medical Referral for Abortion and Freedom of Conscience in Australian Law

Joanne Howe, Suzanne Le Mire

Journal of Law and Religion

Abstract

This article examines legislative changes related to abortion regulation in Australia that create obligations of medical referral on practitioners who have a conscientious objection to abortion. Despite a significant Australian history of accepting secularized conscience claims, particularly in the field of military conscription, the limitation of conscience claims about abortion can be traced to a failure to appreciate the significant secular arguments that can be made to support such claims. We draw on arguments of plurality and pragmatism as capable of providing a firm foundation for legislative protections of freedom of conscience in the case of medical referral for abortion. These justifications are not dependent on religious grounds, and therefore they have the potential to be relevant and persuasive in a secular society such as Australia. Acceptance of a pluralistic argument in favor of freedom of conscience is a powerful commitment to the creation of a society that values human autonomy and a diversity of opinion. It sits comfortably with the democratic values that are enshrined in the Australian political system and institutions. It avoids the potential damage to the individual that may be wrought when conscience is overridden by state compulsion.


Howe J, Le Mire S.  Medical Referral for Abortion and Freedom of Conscience in Australian Law. J Law and Religion. 2019 Apr;34(1):85-112 DOI: https://doi.org/10.1017/jlr.2019.14 Published online by Cambridge University Press: 01 July 2019

Might there be a medical conscience

Nir Ben-Moshe

Bioethics

Abstract

I defend the feasibility of a medical conscience in the following sense: a medical professional can object to the prevailing medical norms because they are incorrect as medical norms. In other words, I provide an account of conscientious objection that makes use of the idea that the conscience can issue true normative claims, but the claims in question are claims about medical norms rather than about general moral norms. I further argue that in order for this line of reasoning to succeed, there needs to be an internal morality of medicine that determines what medical professionals ought to do qua medical professionals. I utilize a constructivist approach to the internal morality of medicine and argue that medical professionals can conscientiously object to providing treatment X, if providing treatment X is not in accordance with norms that would have been constructed, in light of the end of medicine, by the appropriate agents under the appropriate conditions.


Ben‐Moshe, N. Might there be a medical conscience? Bioethics. 2019; 33: 835– 841. https://doi.org/10.1111/bioe.12611

Responding to religious patients: why physicians have no business doing theology

Jake Greenblum, Ryan K. Hubbard

Journal of Medical Ethics

Abstract: A survey of the recent literature suggests that physicians should engage religious patients on religious grounds when the patient cites religious considerations for a medical decision. We offer two arguments that physicians ought to avoid engaging patients in this manner. The first is the Public Reason Argument. We explain why physicians are relevantly akin to public officials. This suggests that it is not the physician’s proper role to engage in religious deliberation. This is because the public character of a physician’s role binds him/her to public reason, which precludes the use of religious considerations. The second argument is the Fiduciary Argument. We show that the patient-physician relationship is a fiduciary relationship, which suggests that the patient has the clinical expectation that physicians limit themselves to medical considerations. Since engaging in religious deliberations lies outside this set of considerations, such engagement undermines trust and therefore damages the patient-physician relationship.


Greenblum J, Ryan K ubbard RK. Responding to religious patients: why physicians have no business doing theology. J Med Ethics 2019;45:705-710. Published Online First: 20 Jun 2019. doi: 10.1136/medethics-2019-105452

Eugenics between Darwin’s Εra and the Holocaust

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

Eugenics between Darwin’s Εra and the Holocaust

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

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. . .
  • [Full text]

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.