Tag: Michael Cook

Are tribunals the solution to disruptive conscientious objectors?

Michael Cook*

While some bioethicists believe that conscientious objection has no place in modern medicine, others feel that they could be accommodated by setting up tribunals. Here are three proposed this year in the Journal of Medical Ethics.

In times of conscription, military tribunals assess whether a pleas of conscientious objection in legitimate or not. Why not follow this model for healthcare workers, asks Steve Clarke. . .

Robert Card . . . argues in the JME that doctors need to give “public reasons” for conscientious objection. . .This leads him to propose review boards staffed by medical professionals, bioethicists and lawyers.

. . .Jonathan A. Hughes . . . proposed the establishment of Conscientious Objection Tribunals . . . No conscientious objection would be allowed without a licence. . .
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Everybody’s a winner when euthanasia combines with organ donation, say doctors

BioEdge

Michael Cook

Several Dutch and Belgian doctors have proposed legal reforms to increase the popularity of combining euthanasia and organ donation in the Netherlands and Belgium.

Writing in the Journal of Medical Ethics, they report valuable unpublished information about the prevalence of the procedure. So far, it has been performed only about 40 times in the two countries. However, there is “a persisting discrepancy between the number of organ donors and the number of patients on the waiting lists for transplantation” – which euthanasia patients could help to balance.

The authors stress that euthanasia is not a cure-all for the organ shortage. Most euthanasia patients suffer from cancer, which is a contraindication for organ transplantation. However, 25 to 30% of them do not, so there is obviously a real possibility of expanding the supply.

Furthermore, the authors say, public perception of this formerly abhorrent practice is increasingly positive:

. . . transplant coordinators in Belgium and the Netherlands notice a contemporary trend towards an increasing willingness and motivation to undergo euthanasia and to subsequently donate organs as well, supported by the increasing number of publications in popular media on this topic.

Ethically, the procedure is basically uncontroversial as long as the patient is not pressured to donate, they contend.

In the context of organ donation after euthanasia, the right of self-determination is a paramount ethical and legal aspect. It is the patient’s wish and right to die in a dignified way, and likewise his wish to donate his organs is expressed. Organ donation after euthanasia enables those who do not wish to remain alive to prolong the lives of those who do, and also—compared with ‘classical’ donation after circulatory death—allows many more people to fulfil their wish to donate organs after death.

However, there are some legal hitches in both countries. In the Netherlands, unlike Belgium, euthanasia is regarded as an “unnatural death” which has to be reported to the public prosecutor. This could delay donations. If the law were changed to allow the cause of death to be reported as the underlying condition, the procedure would be more expeditious. And “In Belgium, the current policy of determination of death by three independent physicians could be abandoned, facilitating a more lean procedure with only one physician.”

Public perceptions need to be managed as well. At the moment, it is necessary to maintain a strict separation between the request for euthanasia and the need for the organ. Partly this is needed to ensure that the donor is not being pressured. But the public also needs to have confidence that physicians will give objective advice.

Finally, there is the tradition of the dead donor rule “that donation should not cause or hasten death”. The authors imply that this could be scrapped for euthanasia volunteers:

Since a patient undergoing euthanasia has chosen to die, it is worth arguing that the no-touch time (depending on the protocol) could be skipped, limiting the warm ischaemia time and contributing to the quality of the transplanted organs. It is even possible to extend this argument to a ‘heart-beating organ donation euthanasia’ where a patient is sedated, after which his organs are being removed, causing death.

The article’s proposals were not received with great enthusiasm in the UK where there is a simmering debate on assisted dying. Tory MP Fiona Bruce told the Daily Mail: “The paper confirms the worst fears expressed by Parliament when the House of Commons conclusively voted to stop the legalisation of assisted suicide in this country. The possibility of euthanasia achieved through live organ donation, such as by removing a patient’s beating heart, as posited in this paper is shocking and chilling.”

And Lord Carlile of Berriew, a Liberal Democrat peer who is a leading lawyer, said: “I have extreme concerns about the ghoulish nature of the combined euthanasia and organ donation systems in the Netherlands and Belgium. Both can result in unbearable and irresistible pressure on an individual to die, and on a doctor to encourage death.”

cclicense-some-rightsThis article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact us for permission and fees. Some articles on this site are published under different terms.

 

The unsettled status of conscientious objection in the UK

BioEdge

Michael Cook

What are the rights of doctors who have a conscientious objection to certain procedures in the United Kingdom? The slightly confusing status quo is the subject of an article in the Journal of Medical Ethics by a Cambridge University academic, John Adenitire.

Dr Adenitire sketches a gradation of hostility towards conscientious objection.

1. At the very top there are Julian Savulescu and others who have argued that conscientious objection is “a door to a Pandora’s box of idiosyncratic, bigoted, discriminatory medicine” and has little place in modern medical practice. This is not a widely shared view.

2. Then there is the British Medical Association (BMA), the profession’s “trade union”, which defends conscientious objection only in three specific scenarios. It “should ordinarily be limited to those procedures where statute recognises their right (abortion and fertility treatment) and to withdrawing life-prolonging treatment from patients who lack capacity, where other doctors are in a position to take over the care.”

3. And then there is the General Medical Council (GMC), the profession’s regulator in the UK, which allows conscientious objection, albeit with a number of caveats. According to its 2013 policy statement, Personal beliefs and medical practice: “You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. This means you must not refuse to treat a particular patient or group of patients because of your personal beliefs or views about them.‡ And you must not refuse to treat the health consequences of lifestyle choices to which you object because of your beliefs.”

4. Most accommodating of all is a ruling of the European Court of Human Rights (ECtHR) in the British case of Eweida in 2013. It applied Article 9 of the European Convention on Human Rights to several cases of discrimination in the UK. Article 9 guarantees “the right to freedom of thought, conscience and religion”, “subject only to such limitations as are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others”.

It is Dr Adenitire’s contention that the Eweida ruling “effectively provides that medical professionals have the right to conscientiously object to providing certain healthcare services well beyond the scope endorsed by the BMA”.

This implies that “Given the unsettled nature of the law on the topic, [National Health Service] employers will have to proceed very cautiously as it will not always be clear whether denying a request will be considered lawful by a court. This entails that NHS bodies may be at risk of expensive legal challenges by medical professionals whose requests have been denied.”

Dr Adenitire therefore believes that the BMA’s policy should be changed to align more closely to the Eweida ruling.

However, the law is still unsettled and Dr Adenitire is not necessarily hostile to proposals for legalised assisted dying which are currently being debated in the UK. In an unpublished paper he goes on to argue that in certain circumstances doctors already have a “conscience-based right to provide assistance in dying”.

cclicense-some-rightsThis article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees. Some articles on this site are published under different terms.

Canadian ethicists prepare for the worst

Bioedge

 Michael Cook

Conscientious objection seems like the paradigmatic ethical choice between right and wrong. An ethicist, of all people, ought to have this option, just as mathematicians count or sopranos sing.

Not so fast, write two healthcare ethicists at the Centre for Applied Ethics at McGill University Health Centre, in Montreal, in the blog Impact Ethics. Now that the Canadian Supreme Court has declared that euthanasia is a human right, it is time to focus on who is entitled to conscientious objection to participating in euthanasia. And perhaps ethicists are not.

We found ourselves asking the following questions: Should a clinical ethicist have the right to conscientious objection in cases of medical aid in dying? Can the role of the clinical ethicist to provide ethics analysis in matters of moral ambiguity be reconciled with a right to opt-out on the basis of personal convictions?

The nub of the question is this: when an ethicist is asked for advice, is she involved as a human being or is she merely a database of ethical choices? The ethicists write:

On the other hand, there is a growing consensus that clinical ethics expertise is grounded in the competence of the clinical ethicist to facilitate a robust process aimed at ensuring fair and transparent healthcare decisions. The clinical ethicist is expected to adopt a stance of neutrality which allows her to facilitate discussion of competing values without allowing her own beliefs to influence the discussion.

On this view, it is not the “rightness” or “wrongness” of the final outcome by which the clinical ethicist is professionally judged, but rather her skill in guiding various stakeholders through a reasonable process; a clinical ethicist’s personal convictions should not impact on her ability to facilitate this process. In this sense, perhaps the right to conscientious objection is antithetical to the provision of clinical ethics consultation, as it seems to call into question the profession’s ability to remain neutral on morally contentious issues.

There is an urgent need, the authors write, to articulate the rights and duties of healthcare ethicists, as in the wake of Carter v Canada, the euthanasia case, the boundaries will be tested.

It would be interesting indeed if Canadian ethicists who oppose euthanasia are told to pack their bags and look elsewhere for jobs. What do unemployed ethicists do? Work in Starbucks? Become an Uber driver? There are some great ideas at the website of the Unemployed Philsophers Guild — making coffee mugs, finger puppets, and scented soap.

cclicense-some-rightsThis article is published under a Creative Commons licence. You may republish it or translate it free of charge with attribution  to Michael Cook and BioEdge  for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to Bioedge. Commercial media must contact Bioedge for permission and fees.

 

The nuts and bolts of CIA torture

BioEdge

Michael Cook

Can doctors participate in torture if there is a reasonable expectation of mitigating the harm done? It could be a seductive hope for a military doctor who is under pressure to cooperate.

However, in a book review in the Journal of Medical Ethics, Henry Shue, of Oxford University, explains that the latest CIA techniques of torture make even minimal participation ethically impossible, no matter how low the bar is set.

Contemporary torture is not so much physical as mental. Its goal is to make the person “psychological putty” in the hands of his interrogators.

The goal of the CIA paradigm as used in Guantanamo is to produce at least temporary regression to an infantile state in which the torture victim will become completely compliant (and therefore supposedly tell the torturers what they want to know). Infantile regression is produced by unhinging the structure of the self of the torture victim and alienating him from his own values through methods like sexual humiliation, religious contempt, sleep deprivation and temperature extremes.

An essential element in this is ensuring that no stable human relationship of any kind should develop between the victim and his captors.

… such total control is maintained over the victim that it is difficult for me to imagine how even if a well disposed doctor could manage to have meaningful conferences with a victim, or by some other method somehow discern what she took his genuine interests to be (as a physician attending an unconscious patient might), that the authorities at a torture site like Guantanamo would ever permit a doctor to take action that served the interests of the victim in a manner that was contrary to the demands of its relentless regression regimen.

A doctor needs to establish some bond with a patient and to understand his history in order to help him. But in this regimen, it would be impossible to know anything meaningful about the victim’s real state of mind. So it is quite unlikely that a doctor’s complicity with the torturers will ever succeed in lessening the pain of the victim.

cclicense-some-rightsThis article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact us for permission and fees. Some articles on this site are published under different terms.