Decision Making

Economic arguments and assisted dying.

by Dominic Wilkinson (@NeonatalEthics)

Lord Falconer’s assisted dying bill is being debated today in the House of Lords. In the past week or two there has discussion in the media of many of the familiar arguments for and against such a proposal. As Roger Crisp noted in yesterday’s post, there have been relatively few new arguments. Supporters of the bill refer to compassion for the terminally ill, the difficulty of adequately relieving suffering, and patients’ right to make fundamental choices about the last stage of their lives. Opponents of the bill express their compassion for the terminally ill and those with disabilities, fear about coercion, and the omnipresent slippery slope.

One concern that has been raised about the assisted dying bill is the fear of abuse in the setting of an overstretched public health system. For example, Penny Pepper, writing in the Guardian notes that “Cuts to social care are monstrous…How would the enactment of the Falconer bill work if brought to our harassed NHS?”

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Would Legal Assisted Suicide be the Final Triumph of Market Capitalism?

Tomorrow  in the House of Lords Lord Falconer’s bill on assisted dying will be debated. The bill would allow those who are terminally ill and likely to die within six months to request life-ending drugs from their doctor for the patients to use as and when they see fit.

As might have been expected, there has been huge discussion over the bill, but most of the arguments presented so far are not new, and the same will probably be true tomorrow. But there is one I haven’t seen before, put forward recently by Giles Fraser: that assisted suicide is the ‘final triumph of market capitalism’. Continue reading

Sex with corpses might be philosophically cool. But it’s still not a good idea.

It is reported that Jimmy Savile crept at night into the mortuary at Leeds General Infirmary and committed sex acts on corpses.1

So what?

Well, for a start, assuming the acts involved penetration, he had committed a serious criminal offence.2

But shouldn’t we grow up? Shouldn’t we let live, and let the live love the dead? Who was hurt? Isn’t this legislation anachronistic? Doesn’t it stem from superannuated and probably, at root, theological ideas about the sanctity of life – irrationally extended to the sanctity of the dead human body?

If the acts gave Savile pleasure, then what’s the problem? Or, if we grant that the outraged relatives might suffer some distress (because they’ve not read enough philosophy), doesn’t the problem lie only in the fact that the relatives heard about what had happened, rather than in the acts themselves? In which case the real villains are the investigators and the media.

We have strong intuitions about many things. So strong, in fact, that they are often immune to the best arguments of the lawyers and philosophers. Continue reading

Do Not Attempt Resuscitation orders: should you discuss with the patient?

The Court of Appeal has stated that a statement in a capacitous patient’s medical notes that resuscitation should not be attempted (a ‘Do Not Attempt Resuscitation’ Order – DNAR), should usually only be inserted after consultation with the patient: see R (Tracey) v Cambridge University Hospitals NHS Foundation Trust and others [2014] EWCA Civ 822 (17 June 2014).

The facts have been widely aired in the media: see, for example, here.

Mrs. Tracey had terminal lung cancer. Her clinicians indicated in the notes that no attempts at resuscitation should be made. Her family found out about this, and were outraged, saying that the DNAR order should not have been made without consultation with Mrs. Tracey. Their quarrel was not with the medical appropriateness of the determination that resuscitation would not be in Mrs. Tracey’s best interests, but with the procedure  - the failure to consult.  This, they said, violated Mrs. Tracey’s rights under Article 8 of the ECHR.

The Resuscitation Council, intervening, said that a requirement to consult with the patient would interfere with clinicians’ ability to deliver individual and compassionate care. A patient might, for instance, be very distressed by a discussion about a possible DNAR order.

The outcome can be briefly stated:

  • Mrs. Tracey’s Article 8 rights were engaged by recording the DNAR in the notes. This followed from, inter alia, Pretty v UK (2002) 35 EHRR 1.
  • Her Article 8(1) rights were violated by failing to involve her in the process
  • Article 8(2) required the policy adopted by a Trust in relation to DNAR orders to be sufficiently clear and accessible: see Purdy v DPP [2009] UKHL 45; [2010] 1 AC 345.
  • The absence of a mandatory national DNAR policy was not a violation of Article 8. Local policies would, if properly formulated, satisfy the demands of Article 8(2)
  • The concerns of the Resuscitation Council were real, but could be met by an important caveat: there should be consultation with the patient unless the clinician ‘thinks that the patient will be distressed by being consulted and that distress might cause the patient harm.’ Continue reading

Telling porkies

by Dominic Wilkinson (@Neonatalethics)

 

One of my registrars asked an interesting question this morning. A commonly used life-saving medicine in newborn intensive care is derived from animal products; should parents be told?

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Two Tales of Marshmallows and their Implications for Free Will

Patricia Churchland, a prominent Neurophilosopher, just published a book on neuroscience and its ethical implications which led to a rather nasty exchange in the New York Review of Books with fellow philosopher Colin McGinn.  His pointed, to put it mildly, criticism of her work was based on philosophical considerations about the implications neuroscience has, or, as he argues, lacks, for the philosophy of mind. This criticism evoked two sentiments in me. First, I felt a strong sense of hopelessness for a world in which not even two philosophers can engage in a sober, respectful argument about something they disagree on; not even under the tutelage of the editors of the New York Review of Books, one of the so-called sanctuaries of intellectualism. Good luck Palestine and Israel! Thereafter, I remembered the unease I at times felt as a psychologist when hearing or reading about Churchland’s work.

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The Right to Forget the Stock Market’s blemished Past

One of the great pleasures of studying human behaviour is to see that what we find in our experiments, what we theorize in our papers and textbooks – as unlikely and counterintuitive it appears to be – actually predicts what happens in so-called real life. Take, for instance, the current build-up of a stock-market bubble in the UK, happening even more dramatically in the US. In the UK, the FTSE 100 is on its way to surpass the record set during the high times of the dotcom bubble and already surpassed the levels reached during the 2008 financial bubble; in the US the Dow Jones has already reached new record highs. Despite having recently experienced the devastating consequences of a stock market bubble bursting, banks and investors return a few years later to the same hyperbolic forecasts and predictions, and start to build up another bubble. It is as if the past did not exist. Compare this behaviour with the following anecdote, which most business school students probably know.

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Food packaging matters more than informed consent to treatment

Packets of cigarettes carry pictures showing purchasers what their lungs or their arteries will look like if they carry on smoking. Consumers International and the World Obesity Federation are now suggesting that some foods should bear similar images.

Assume for the sake of argument that the practice would be effective in discouraging the purchase of health-truncating foods. If the images work by telling consumers something about what they are buying that they would not otherwise know, surely there can be no coherent objection to them. Knowledge of that sort is always good – assuming that the consumer has a real choice as to whether to buy the bad product or a better one.

If they work by pushing to the forefronts of consumers’ minds information that their grosser appetites conveniently suppress when they are wandering down the mall, there may be an argument against them. This would presumably be on the broad basis that the images manipulate the person away from being what they authentically are (a fructose-guzzling cardiac-cripple-in-waiting) towards something else. This argument would assert that there’s a sort of ethical imperialism at work: that those would stamp pictures of limbless diabetics on junk sweet packs are tyrannously seeking to impose an arbitrary normative idea of the good life.

I have little sympathy with this second view. If anyone says in a normative voice that it’s good to be diabetic, they’re insane. If anyone says in an empirical voice that it’s better to be diabetic than non-diabetic, they’re misinformed. If anyone says in the voice of a hedonistic utilitarian that the overall pleasure gained by the consumption of lard outweighs the detriments, I’d invite them to get thin, do all the Munros, and then revisit their original judgment. If anyone thinks that they’re more authentically themselves by being ill might have a point once their illness is long-standing and has truly become a defining characteristic. But before the illness is triggered, aren’t they more themselves without clogged arteries or the need to inject insulin five times a day?

If the packaging proposal is adopted, some interesting questions arise. Should good foods be branded with pictures of the condition you’ll be in or the advantages you’ll have if you eat them? Aphrodisiac oysters would display the beaming visages of satisfied sexual partners. Green tea would show lean centenarians on trampolines. Or perhaps those good foods should show the things that they’ll spare you: prostate-preserving tinned tomatoes might show an unoccupied midnight toilet.

Perhaps other, wider concerns should feature. Tins of palm oil should show dead orangutans. Milk should show the mournful face of a calf-less cow alongside the pictures of healthy, non-osteoporotic bone-scans.

While it’s easy to multiply absurdities, the proposal is basically a very good thing. It’s a good thing for at least some of the reasons that the notion of informed consent to medical treatment is endorsed. If you’re keen on informed consent to treatment, a fortiori you’ll be keen on food package images. In fact, I suggest, you should be more keen on those images. They’re more important. Continue reading

On the Ethics of Tipping

At lunch-time, I will often venture out of the office for lunch to a sandwich shop with a friend. In my sandwich shop of choice, the staff have placed a small jar labelled ‘tips’ on the counter.  Now, in the UK at least, sandwich shop staff seem to fall into something of a ‘grey area’ with regards to tipping convention. Whilst we normally tip waiters and waitresses in restaurants, and bartenders (amongst others), we don’t tend to tip people who serve us in other ways. For example, I don’t feel it incumbent upon me to tip my butcher, who arguably does a lot more work in an individual transaction than someone serving me a sandwich. However, this discrepancy is perhaps not surprising; a great deal of research suggests that tipping decisions are influenced by various social norms;[1] tipping waiters and waitresses is simply ‘the done thing’, whilst tipping butchers is not. Perhaps we just lack a clear social norm in the case of sandwich shops. Continue reading

Complicity and Contraception: Rethinking Hobby Lobby’s Claim of ‘Substantial Burden on the Exercise of Religion’

Within the next month, the United States Supreme Court will decide whether for-profit corporations shall receive an exemption from providing certain types of contraceptives that are otherwise mandated for healthcare coverage by federal law to employees on the basis of the religious objections of the corporations’ owners.  The two cases considered in tandem by the Supreme Court, Sebelius v Hobby Lobby Stores, Inc., and Conestoga Wood Specialties Corporation v Sebelius (Hobby Lobby from here on out), feature a Christian-owned arts and crafts chain and a Mennonite Christian-owned furniture manufacturer, the owners of which object to four specific forms of birth control that they claim cause abortions.

In making their argument for an exemption, the claimants rely mainly on the Religious Freedom Restoration Act (RFRA) passed by Congress in 1993. The RFRA states, “Government shall not substantially burden a person’s exercise of religion…” unless “that application of the burden to the person – 1) is furtherance of a compelling governmental interest; and 2) is the least restrictive means of furthering that compelling governmental interest.” This sets up three tests for judging the permissibility of a government act: the substantial burden test, the compelling interest test, and the least restrictive means test. For the claimants in Hobby Lobby to be successful under the RFRA, the Supreme Court would need to decide first that the government’s ‘contraception mandate’ is indeed a ‘substantial burden’ and second that the provision of contraception is both a compelling government interest and that employer based health insurance is the least restrictive method for securing that interest.

Scholars and journalists have taken various approaches in responding to the range of questions related to these three tests. However, I argue here that Hobby Lobby’s exemption claim can be denied without diving into this spectrum by showing that it fails to meet the first test: the government does not place a substantial burden on the exercise of religion by Hobby Lobby and Conestoga Wood in its ‘contraception mandate.’ Continue reading

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