Medical ethics

Review: Beyond The Abortion Wars, by Charles C. Camosy

 

@JimACEverett

 www.jimaceverett.com

I was recently lucky enough to receive an advance copy of Charles Camosy’s forthcoming book to review – ‘Beyond the abortion wars: a way forward for a new generation’. In this book, Camosy masterfully traverses the ‘battleground’ between the ‘pro-life’ and ‘pro-choice’1 camps in order to show that this battleground is in fact no such thing. In fact, as Camosy notes, the majority of the American public actually agree on a middle-ground position on abortion. Despite what one might think from reading certain media outlets and Twitter wars, there is actually a large consensus in the public regarding abortion. This insight is deceptively powerful. By demonstrating the areas of agreement, Camosy is able to help guide us beyond the abortion wars to allow a way forward for a new generation.

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Aboriginal rights and refusal of treatment in Canada

Consider:

An 11 year-old girl, J.J., is diagnosed with high-risk acute lymphoblastic leukemia, a type of cancer that arises in the bone marrow. She is put on a 32-day course of chemotherapy with an estimated success rate of over 90%. Her doctors don’t know of anyone who has survived this illness without such a course of treatment. However, after just 10 days, her mother withdraws her consent to J.J.’s chemotherapy in order to pursue alternative, non-western remedies. J.J. doesn’t object, but both of her doctors believe that J.J. doesn’t understand either her illness or the importance of the treatment she is on. In all matters, she defers to her mother who is also her surrogate decision maker. The hospital in which J.J. is a patient appeals to Child Services, stating that by ceasing treatment J.J.’s mother has put J.J. into the position of a child in need of protection. Such a status would permit the hospital to continue treatment despite disagreement from J.J’s mother (in her capacity as surrogate decision maker). The case goes to trial, and a ruling is made in favour of J.J.’s mother. J.J. is taken out of the hospital in order to pursue non-western treatment alternatives. It is very likely that J.J. will die. Continue reading

What are the ethics of using brain stimulation technologies for ‘enhancement’ in children?

New open access publication: announcement:

In a recently published article, Hannah Maslen, Roi Cohen Kadosh, Julian Savulescu and I present an argument about the permissible (and not-so-permissible) uses of non-invasive brain stimulation technology in children. We consider both children who may be suffering from a specific neurological disorder, for whom the stimulation is intended as a ‘treatment’, and those who are otherwise healthy, for whom the stimulation is intended as ‘enhancement’. For the full article and citation, see here:

Maslen, H., Earp, B. D., Cohen Kadosh, R., & Savulescu, J. (2014). Brain stimulation for treatment and enhancement in children: An ethical analysisFrontiers in Human Neuroscience, Vol. 8, Article 953, 1-5. Continue reading

“Ravines and Sugar Pills: Defending Deceptive Placebo Use” – New Open Access Publication

A placebo can be understood as a medical intervention that lacks direct specific therapeutic effects on the condition for which it has been prescribed, but which can nonetheless help to ameliorate a patient’s condition. In March 2013, a study by Howick et al. suggested that the vast majority of UK general practitioners (GPs) have prescribed a placebo at some point in their career. This finding was somewhat controversial and received national media coverage in the UK (here and here). Part of the reason for this controversy is that the use of placebos in clinical practice is often deemed to be morally problematic, in so far as it often involves the intentional deception of the patient. Continue reading

The ethics of DocAdvisor: Is accountability always a good thing?

Dominic Wilkinson @NeonatalEthics

 

In the news this morning, the NHS has released data on individual surgeons’ performance, so called “surgeon report cards”. This represents the latest move towards increased transparency and accountability in the National Health Service. Elsewhere in the media today, there are numerous reports of the UK couple who were apparently charged £100 after posting a negative hotel review on an online website.

These parallel stories highlight one concern about certain types of health accountability: sensitivity to the negative impact of reviews (or poor performance figures) could lead to harmful changes in behaviour. For surgeon report cards, one frequently cited concern is that publishing report cards could lead surgeons to avoid high-risk cases. If surgeons choose patients with lower risk of dying, they will potentially end up with a better report card. However, then the results would be misleading (it would be the equivalent of someone getting a higher mark by choosing to sit an easier test). More worrying, it may mean that some high-risk patients are unable to access surgery.

Should we be worried about the negative effect of report cards on surgeons behaviour? Continue reading

Equality and the Clinical Trial Dating Agency

The first advert for the sale of a clinical trial place offers, for $2 million, the chance to participate as a patient in a trial investigating the Farmington virus (FARV) and its potential efficacy in treating certain forms of brain tumours. Meanwhile, Alexander Masters has written convincingly about his idea for a clinical trial dating agency: matching wealthy but sick donors with scientists who have an idea for a cure but no money for a trial (shorter version also available). In Masters’ idea as in the real life case, the proposal is that the wealthy donor will pay not just for himself or herself, but enough for the trial to go ahead with a full complement of those who could not otherwise afford it, recruited on the same basis as any trial.

Predictably, ethical concerns have been raised, perhaps the main one being equality: “In the UK, the principles in participating in clinical trials include open and equal access for those who chose to participate” (Kate Law, director of clinical and population research at Cancer Research UK, quoted in The Telegraph ).

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Facebook and Apple – Increasing choice and control or creating biased solutions?

Reproductive technologies were in the headlines when Facebook and Apple announced they would offer female employees a $20,000 benefit to freeze their eggs. According to the report, this enables women to delay child bearing for different reasons and gives women more control. The announcement states that egg freezing is a pricey but increasingly popular option for women: The procedure typically costs up to $10,000, with an additional $500 for storage each year. After freezing eggs, in vitro fertilisation (IVF) can be used afterwards.

I wish to start with a disclaimer: I’m totally for increasing control and flexibility with reproductive technologies, I think the possibility as such is great, I cheer if some women genuinely wish to use this option, and I totally recognize that Facebook and Apple are just giving an option. However, there is room for questions. First, individual-level solutions are suggested where the actual issue is likely to be socially constructed, and secondly, IVF is seen merely as a handy option. These two are discussed in the following. Continue reading

Relaxed about dying?

“Now we must wait, wait. These hours…. The gurgling starts again — but how slowly a man dies! …By noon I am groping on the outer limits of reason. …every gasp lays my heart bare.” Erich Maria Remarque, All Quiet on the Western Front

In Remarque’s novel, the agony of the German soldier, witnessing the slow death of an enemy combatant, is heightened by his own guilt (the narrator had stabbed another soldier in self defense). However, his powerful evocation of distress (and guilt) at witnessing a slow dying is very close to the expressed concerns of parents and clinicians who are watching the death of a child.

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The Humane and the Ethical in Animal Research

A recent article by Marc Bekoff, written for the website The Dodo, asks whether it might be true that researchers who currently test on animals are less humane than their predecessors. Bekoff thinks it is. His reasons for that belief seem to be something like the following: We know considerably more about the cognitive and emotional faculties of animals now than we did in the past. That is, we know that even smaller mammals and birds can be quite cognitively sophisticated and emotionally developed. In the face of this knowledge, our continued use of those animals for the purpose of conducting research is less humane than it was at a time when we believed animals to not possess any such faculties. Bekoff uses this belief to cast doubt on the ethical status of continued research on animals. If we are being less humane in our research now than we used to be, then we are also being less ethical. It’s not clear to me that this inference is correct. Continue reading

Iterated in vitro reproduction and genetic orphans

In an article soon to be published in the Journal of Medical Ethics, Rob Sparrow imagines a procedure via which multiple generations of human embryos might be created in the laboratory. Egg and sperm cells would first be generated from existing or new human pluripotent stem cell lines. The resulting eggs would be fertilised using the sperm to create zygotes and ultimately embryos. Embryonic stem cells would then be harvested from these embryos and used to create new egg and sperm cells, which would in turn be used to fertilise one another to create further embryos. This process could be iterated, in principle indefinitely.

Let’s call this procedure ‘iterated in vitro reproduction’ (Sparrow calls it ‘in vitro eugenics’). Iterated in vitro reproduction is not yet possible, but, citing recent developments in the science of stem cell-derived gametes, Sparrow argues that it may well become so, though he acknowledges are number of significant hurdles to its development. He also discusses a number of possible applications of the technology and calls for an ethical debate on these. The most controversial application would be in the creation of designer children. Consider the following case, which is a variant on one of the scenarios imagined by Sparrow:

Jack and Jill present to a fertility clinic. Jack provides a sperm sample, and fertility doctors harvest a number of eggs from Jill. These eggs are fertilized with Jack’s sperm to create embryos, from which embryonic stem cells are derived. These stem cells are then induced to develop into eggs or sperm which are used to fertilise one another, and so on. The process is iterated numerous times, and at each stage, the embryos are genetically screened via pre-implantation genetic diagnosis. This screening is used to inform a process of selective crossing, so that, over several generations, the population of embryos evolves towards certain genetic dispositions desired by Jack and Jill (a disposition towards longevity, say). This process is aided by adding small amounts of genetic material from stem cell lines derived from other individuals. Eventually, doctors identify an embryo with almost exactly the desired combination of genes, and this embryo is implanted into Jill’s womb and carried to term. A child, Jarvis, is born.

Cases like this raise numerous ethical issues, some of which are discussed by Sparrow and the seven commentators on his paper. However, they also raise an interesting conceptual question: would the users of such a technology be the genetic parents of the resulting offspring? Would Jack and Jill be the genetic parents of Jarvis?

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