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Abstract The U.S. Public Health Service’s sexually transmitted disease (STD) experiments in Guatemala are an important case study not only in human subjects research transgressions but also in the response to serious lapses in research ethics. This case study describes how individuals in the STD experiments were tested, exposed to STDs, and exploited as the source of biological specimens—all without informed consent and often with active deceit. It also explores and evaluates governmental and professional responses that followed the public revelation of these experiments, including by academic institutions, professional organizations, and the U.S. federal government, pushing us to reconsider both how we prevent such lapses in the future and how we respond when they are first revealed.
Abstract Ancell and Sinnott-Armstrong argue that medical providers possess wide freedoms to determine the scope of their practice, and therefore, prohibiting almost any conscientious objections is a bad idea. They maintain that we could create an acceptable system on the whole which even grants accommodations to discriminatory refusals by healthcare professionals. Their argument is premised upon applying a free market mechanism to conscientious objections in medicine, yet I argue their Market View possesses a number of absurd and troubling implications. Furthermore, I demonstrate that the fundamental logic of their main argument is flawed. Thinkers who wish to address the issues raised in this debate in general or by discriminatory conscience objections in particular should avoid the Market View and instead envisage theories that assess the reasons underlying conscientious refusals in medicine.
Extract [Referring to Sinmyee et al] This seems to us to be an important, landmark paper. This is because the issues it addresses are important in their own right: how to ensure death without suffering in jurisdictions where assisted dying (including assisted suicide or euthanasia) is allowed, and also, because the technicalities are the same, in cases of capital punishment by lethal injection. Moreover, the paper shows the potential for the use of anaesthesia in contexts beyond surgery. Anaesthesia in its ordinary uses is intended to facilitate surgery designed to restore a patient to improved health and functioning. In assisted dying, however, there is no question of restoring health. The proposition is to use anaesthesia primarily to prevent suffering in a patient who is about to die and, in this sense, places anaesthesia on a new footing as a primary medical intervention, serving a purpose in its own right. . .
Abstract The moral pluralism of Western democratic societies results in ethical differences among citizens and health professionals, due to contrasts between the foundational beliefs and values on which their ethical convictions rest. Some of these differences have challenging implications for the practice of medicine when a patient seeks access to a legal medical service that a conscientiously acting physician believes is unethical. Such disagreements raise pivotal questions about competing ethical values, the moral dynamic of shared decision-making, the meaning of conscience, and the extent to which society will accept ethical differences in professional practice. The act of referral is the focal point of this essay, because it appears to be at the front line of some current debates and legal contests about the extent to which society is willing to accommodate conscientious practice by physicians. Some see referrals as a way to balance respect for physician integrity with promotion of patient autonomy; others see referrals as a mistaken attempt at compromise that misunderstands the meaning of moral responsibility and participation. Understanding conscience as integrity helps explain the moral seriousness of conscientious practice and reinforces the need for professional and legal accommodations that respect it.
Extract The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act) will become operational on 19 June, 2019. . . . While some have written on the scope of, and reaction to, the VAD legislation, there has been very little commentary on its implementation. Yet, important choices must be made about translating these laws into clinical practice. These choices have major implications for doctors and other health professionals (including those who choose not to facilitate VAD), patients, hospitals and other health providers. This article considers some key challenges in implementing Victoria’s VAD legislation.
S. Sinmyee V. J. Pandit J. M. Pascual A. Dahan T. Heidegger G. Kreienbühl D. A. Lubarsky J. J. Pandit
Anaesthesia
Author Summary A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used.
However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported.
The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an ‘optimum’ itself has important implications for ethics and the law.
Abstract In a recent article in this journal, Abram Brummett argues that new and future assisted reproductive technologies will provide challenging ethical questions relating to lesbian, gay, bisexual and transgender (LGBT) persons. Brummett notes that it is likely that some clinicians may wish to conscientiously object to offering assisted reproductive technologies to LGBT couples on moral or religious grounds, and argues that such appeals to conscience should be constrained. We argue that Brummett’s case is unsuccessful because he: does not adequately interact with his opponents’ views; equivocates on the meaning of ‘natural’; fails to show that the practice he opposes is eugenic in any non-trivial sense; and fails to justify and explicate the relevance of the naturalism he proposes. We do not argue that conscience protections should exist for those objecting to providing LGBT people with artificial reproductive technologies, but only show that Brummett’s arguments are insufficient to prove that they should not.
Responding to articles by CMA officials (BMJ 2019; 364)
Sean Murphy
British Medical Journal
Extract It is disconcerting to find that the CMA’s President-Elect thinks that Canadian law “does not compel any physician to be involved in an act or procedure that would violate their values or faith.” The state medical regulator in Canada’s largest province has enacted policies that do just that, requiring physicians who refuse to kill their patients to find a colleague who will. These policies do have the force of law, and objecting physicians were forced to launch an expensive constitutional challenge to defend themselves. The Protection of Conscience Project and others have intervened in the case to support them; the CMA has not.
Further, the Canadian Medical Association’s assertion that it has successfully adopted a “neutral” position on euthanasia and assisted suicide (EAS) is challenged in a World Medical Journal article by seven Canadian physicians. “For refusing to collaborate in killing our patients,” they write, “many of us now risk discipline and expulsion from the medical profession,” are accused of human rights violations and “even called bigots.” . . .
Louise Anne Keogh, Lynn Gillam, Marie Bismark, Kathleen McNamee, Amy Webster, Christine Bayly, Danielle Newton
BMC Medical Ethics
Abstract Background: In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria.
Methods: Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically.
Results: The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported.
Conclusion: Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.
Louise Anne Keogh, Lynn Gillam, Marie Bismark, Kathleen McNamee, Amy Webster, Christine Bayly, Danielle Newton
BMC Medical Ethics
Abstract Background: In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria.
Methods: Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically.
Results: The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported.
Conclusion: Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.
