The Tale of the Ethical Neonatologist – And Why There Shouldn’t Be a Legal Right of Conscientious Objection
Doctors have values. These are sometimes described as their conscience. Those values can conflict with what has evolved to be medical practice. Where that practice is consistent with principles, concept and norms of medical ethics, their values should not compromise patient care. The place for doctors to express their values and seek to revise the practice of medicine is at the level of policy and law, not at the bedside. Because conscientious objection can compromise patient care, there should be no legal right to conscientious objection to medical practice that is consistent with medical ethics. Personal values (“conscience”) can be accommodated by employers under standard labour law as occurs in Sweden and Finland, or candidates selected for medical specialties who have values consistent with ethical medicine, or new professions developed to provide those services.
Doctors may have very defensible values. But just because their values are reasonable does not imply they should be accommodated by medicine. Consider the Conscientious Neonatologist.
The Conscientious Neonatologist
Peter is a thoughtful, reflective specialist caring for premature babies in intensive care. He is a vegetarian for 20 years. He became deeply concerned about the welfare of animals during his university years. He believes in “animal liberation”. Neither he nor his family consume meat or use animal products for clothing.
In his job, he must prescribe “surfactant” – a substance to help the lungs of premature babies function better. The standard, and most effective form is derived from the lungs of pigs. However there is a new artificial form. He considers this a more “ethical” product and considers using it in his medical practice. However, it is not currently used in the newborn intensive care unit because it is more expensive than standard treatment, and there is not clear evidence about its effectiveness.
Peter conscientiously objects to the use of animals in medicine and medical research. How should his personal values influence his professional practice?
Abortion remains a crime in Queensland and NSW in Australia. Queensland Parliament has just decided against decriminalising abortion. However, laws are obsolete and unclear, dating back over 100 years. Around 100,000 abortions are performed around Australia every year. In practice, early abortion is available on demand.
Abortion should be decriminalised. Early abortion should be freely and easily available on request. Late abortion should be freely and easily available at least for those who have a valid justification: significant fetal abnormality, threat to woman’s health or serious social reason, for example child pregnancy or rape. Family planning, including safe, free and open abortion services, is an essential part of a civilized society.
Failure to regulate abortion properly results in women being denied safe, effective abortion services, affecting their mental health and social welfare, as well as those of their family and society. It is stigmatising to women and health professionals to allow abortion to occur, while retaining it as a criminal offence. It is also moral hypocrisy.
Originally posted in The Conversation
The audience vote is a resounding yes, all Russian track and field athletes should be banned from competing. But is the International Olympic Committee (IOC) justified in giving individual sports federations the right to decide whether athletes can participate in Rio 2016?
In the run-up to the IOC’s decision, anti-doping leaders from 14 countries signed an open letter demanding the Russians’ exclusion. A petition calling for the whole team to be banned was closing in on its aim of 10,000 signatures, while another arguing against a blanket ban had just managed eight.
The IOC decided to face the mob and take a more nuanced approach; it will allow each sporting federation to decide whether the evidence is sufficient to ban athletes in their discipline. Tennis players, who are regularly tested around the world, are in the clear, for instance, with cyclists set to follow.
But athletes in track and field are banned as a group, although individuals may compete as neutral athletes. Is this kind of “collective responsibility” – or “collective punishment” as Mikhail Gorbachev described it – fair?
Standards of evidence
There’s a genuine dilemma here and the situation is not nearly as clear everyone appears to think – and as the World Anti-Doping Agency (WADA) pretends.
In the job market being attractive is advantageous. According to economist Daniel Hamermesh, an attractive man can earn, over a life time, $230,000 more than an unattractive one. Attractive solicitors raise more money for charities. Very attractive individuals are less likely to engage in criminal activities, whereas unattractive ones have higher propensity for crime. Attractive criminals are punished less severely than unattractive ones.
Both children and adults judge attractive people to be more helpful, more intelligent, and more friendly than their unattractive counterparts.
Adults have higher expectations of attractive kids compared to non attractive ones and mothers of attractive infants tend to be more affectionate, playful, and attentive when interacting with their children than mothers of less attractive infants. Teachers expect better performances from attractive students. Transgressions of unattractive children are judged more negatively than transgressions of attractive ones.
One response to unfairness is to get people to stop discriminating unfairly. This might work for some domains, such as employment where interviews could be conducted blind. But it won’t be possible to counteract all the potential downsides.
We can’t require people to like or fall in love with people they find unattractive. There are at least two possible responses:
- Assist people to find attractive what they currently find unattractive
- Assist people to be more attractive to those who currently find them unattractive
Both of these are reasonable solutions. The second is cosmetic enhancement.
US scientists are creating novel life forms: “human pig chimeras”. These are a blend of human and pig characteristics. They are like mules who will provide organs to us. A mule is the offspring of a male donkey (jack) and a female horse (mare). Horses and donkeys are different species, with different numbers of chromosomes but they can breed together.
In this case, they take a skin cell from a person and turn it back in time to make stem cells capable of producing any cell or tissue in the body, “induced pluripotent stem cells.” They then inject this into a pig embryo. This makes a pig human chimera.
However they do a modification to the pig embryo first. They use gene editing, or CRISPR, to knock out the pig’s genes which produce an organ, say the pancreas. The human stem cells for the pancreas then make an almost entirely human pancreas in the pig human chimera. It functions like an organ mule. (The blood vessels are still porcine.)
In this way, your skin cell could grow a new liver, heart, pancreas, or lung.
This is a technique with wider possibilities: other US teams are working on a chimera –based treatment, this time for Parkinson’s disease which will use chimeras to create human neurones.
CRISPR is also credited with enhancing the safety of this technique, with the BBC reporting that a Harvard team were able to use the new and revolutionary technique to remove copies of a pig retrovirus.
Safety is always a major concern when science crosses new boundaries. But even if a sufficient guarantee of safety could be reached, are there ethical problems?
You are on holiday with your partner of several years. Your relationship is going pretty well, but you wonder if it could be better. It’s Valentine’s Day and you find a bottle on the beach. You rub it. A love genie appears. He (or she) will grant you three special Valentine wishes. Here are some of your choices:
- to have more or less sexual desire (lust);
- to remain always as “in love” as you were when you first fell in love (romantic attraction);
- to be more or less bonded to your partner emotionally (attachment);
- to be (happily) monogamous or polygamous.
What would you choose? What should you choose? What would your partner choose? Would you choose together, if you could? What would you choose for your partner?
Professor Julian Savulescu further discusses this subject at The Conversation
Maria Sharapova has been caught taking the banned performance enhancing drug Mildonium (Mildronate). It was added to the ever growing list of banned substances by WADA in January 2016. She claims to have not read the information sent via email informing athletes of the change of rules and says that she had been taking the drug since 2006 for a magnesium deficiency, an irregular EKG, and her family’s history of diabetes. Mildronate is marketed by the company as a performance enhancer (alongside other uses) and is one of Latvia’s biggest medical exports, accounting for up to 0.7% of its total exports.
Should we feel sorry for her?
Every professional athlete nowadays knows:
- Strict liability obtains – that is, they are responsible for everything they put into their bodies. Ignorance is no excuse.
- If you are taking any potentially, even vaguely performance enhancing substance you have to watch the WADA banned list like a hawk. It is added to on a regular basis. Indeed, substances may not even be specifically named but fall under a generic category of effect, such as accelerating tissue healing.
- If you are taking a banned substance for medical reasons, you need to get a therapeutic use exemption. These are very common: there were at least 550 in cycling from 2008-2014. For example, a cyclist with a diagnosis of asthma can take the beta stimulant, salbutamol. In 2011, 8% of baseballers had a diagnosis attention deficit disorder (and so are allowed to take ritalin, related to amphetamine). Of course, the distinction between health and disease is fuzzy, but that is another story. It is very possible that Sharapova would have been granted a therapeutic use exemption, if she had applied.
Sharapova is a professional. Even if her medical need for what is widely advertised as a performance enhancer is justified, she should have known how to handle the administrative burden around it. Strict liability obtains. She broke the rules and will face the consequences.
The more interesting question is: why was Mildonium placed on the banned list?
The following is a transcript of an interview conducted by Jim Brown from Canadian Broad Casting Corporation’s program, The 180, on 3 December between Margaret Somerville and Julian Savulescu
Margaret Somerville is the Founding Director of the Centre for Medicine, Ethics and Law, the Samuel Gale Chair in Law and Professor in the Faculty of Medicine at McGill University, Montreal. She’s also the author of the new book ‘Bird on an Ethics Wire: Battles about Values in the Culture Wars’.
Julian Savulescu is Uehiro Chair in Practical Ethics and Director of the Oxford Uehiro Centre for Practical Ethics at the University of Oxford.
JB: Julian Savulescu, if I could begin with you. You argue that there is a moral imperative for us to pursue gene editing research. Briefly, why do you think it’s so important for us to embrace this technology?
JS: Genetic engineering has been around for about 30 years, widely used in medical research, and also in agriculture, but gene editing is a new version of genetic engineering that is highly accurate, specific, and is able to modify genomes without causing side effects or damage. It’s already been used to create malaria-fighting mosquitoes, drought-resistant wheat, and in other areas of agriculture. But what’s currently being proposed is the genetic modification of human embryos, and this has caused widespread resistance. I think there’s a moral obligation to do this kind of research in the following way. This could be used to create human embryos with very precise genetic modifications, to understand how we develop, why development goes wrong, why genetic disorders occur. It could also be used to create embryonic stem cells with precise changes that might make subsequent stem cells, cancer-fighting stem cells, or even stem cells that fight aging. It could also be used to create tissue with say, changes to understand the origins of Parkinson’s disease or Alzheimer’s disease and develop drugs for the treatment of those diseases. This is what I’d call therapeutic gene editing, and because it stands to benefit millions of people who die every year of painful and debilitating conditions, we actually have a moral imperative to do it. What we ought to show more concern for and perhaps ban, is what might be called reproductive gene editing – editing embryos to create live-born babies that are free of genetic disease or perhaps more resistant to common, late-onset diseases or even enhanced in various ways. If we’re concerned about those sorts of changes in society, we can ban reproductive gene editing, yet also engage in the very beneficial research using genetically modified human embryos to study disease.
JB: And Margaret Somerville, what concerns you about this technology?
MS: Well, I’m interested in the division that Julian makes between the reproductive gene editing and what he calls the therapeutic gene editing. I’m a little surprised that he might not agree with the reproductive gene editing – that is, you would alter the embryo’s germline, so that it wouldn’t be only altered for that embryo, but all the descendants of that embryo would be changed in the same way. And up until – actually, up until this year, there was almost universal agreement, including in some important international documents, that that was wrong, that was ethically wrong, it was a line that we must never step across, that humans have a right to come into existence with their own unique genetic heritage and other humans have no right to alter them, to design them. Julian uses the term genetic engineering – to make them, to manufacture them. Where we would disagree completely is with the setting up of what can be called human embryo manufacturing plants, that is, you would create human embryos in order to use them to make products that would benefit other people, you would use them for experimentation, for research. And Julian’s right, we could do a great deal of good doing that – but there’s a huge danger in looking only at the good that we do. And what we’re doing there is we’re using human life as a product. We’re transmitting human life with the intention of killing it by using it as a product, and I believe that’s wrong. I think that human embryos have moral status that deserves respect, which means they shouldn’t be treated just as products.
Written by Dr Chris Gyngell, Dr Tom Douglas and Professor Julian Savulescu
A crucial international summit on gene editing continues today in Washington DC. Organised by the US National Academy of Sciences, National Academy of Medicine, the Chinese Academy of Sciences, and the U.K.’s Royal Society, the summit promises to be a pivotal point in the history of the gene editing technologies.
Gene editing (GE) is a truly revolutionary technology, potentially allowing the genetic bases of life to be manipulated at will. It has already been used to create malaria-fighting mosquitoes, drought resistant wheat, hornless cows and cancer killing immune cells. All this despite the fact GE only become widely used in the past few years. The potential applications of GE in a decade are difficult to imagine. It may transform the food we eat, the animals we farm, and the way we battle disease. Continue reading
A stunning report from a WADA Commission, led by former head of WADA Dick Pound has made a series of allegations against Russian athletes and authorities, including that 1400 samples were deliberately destroyed ahead of a visit by WADA. It recommends the suspension of all Russian athletes over the period including the Rio Olympics, and lifetime bans for five individual athletes and five coaches. It says the London Olympics was “sabotaged”, not only by the Russian authorities, but also by the inaction of the IAAF.
While this report focuses on Russia, early independent analyses of leaked blood profiles estimated at least 1/3 of medals involve doping or raised suspicions of doping. So the problem extends way beyond Russia. Arson Wenger, Arsenal Football Club’s manager, recently claimed doping was widespread in football, a sport which has so far had few scandals.
Back in 2012, there was more confidence in the ability to enforce the rules: speaking ahead of the Olympics, the UK Minister for Sport and the Olympics Hugh Robertson said:
“We cannot absolutely guarantee that these will be a drug-free games,” he said.
“But we can guarantee that we have got the very best system possible to try and catch anybody who even thinks of cheating.””
Mr Robertson may have been correct that it was the best system possible. But today’s report, and earlier analyses of leaked blood data show that doping is likely to have nevertheless been widespread, amongst both Russian athletes and those of other nations.
I have argued that in the light of the proven inability to enforce a zero tolerance approach to sport, we should instead take a pragmatic approach. As a very brief and incomplete overview, I argue that we should allow doping within safe, measurable physiological parameters. For example, if an athlete’s haematocrit is under say 50%, we should not worry about whether she reached that level by altitude training, hypoxic tent use, genetic good luck, or EPO. We should focus resources on drugs which are unreasonably risky for athletes, or which are against the spirit of the individual sport (by which I mean they substantially remove the human component of a given sport). The doping we allow should be supervised by a medical professional, within prescribed safe ranges, and tested by independent accredited and monitored laboratories. You can read in more detail here or throughout this blog in the Sport category.
This position remains controversial. But its opponents imagine an Eldorado where sport is mainly clean, and that the few athletes who do dope are likely to get their comeuppance. They argue that allowing doping would be unfair to clean athletes who would not be able to compete. They argue that it would push young athletes into doping. But we now know that doping is not a rare aberration. It was not rare in the 90s for cycling, and it is not rare, 20 years later for athletics.