Graso and colleagues offer a breath of fresh air in the disturbingly dank, highly politicized world of COVID-19 [1]. The authors explore scapegoating of the unvaccinated by those with an imprecise understanding of the risks of COVID-19 infection and an imbalanced comprehension of risk versus benefit of vaccination. This careful consideration is unfortunately in the minority and is in direct contradistinction from other recent manuscripts published in other journals.
Instead of focusing on unprecedented advances in personalized medicine, cellular therapy, and the existential crisis/opportunity of generative Artificial Intelligence (AI), clinicians/researchers are allowing social scientists to drag our profession back into the highly politicized world of Orwellian information wars. Recently, van der Linden and Roozenbeek dangerously misappropriated the term “inoculation” in discussing nebulous concepts of misinformation (disinformation has quietly metamorphosized to misinformation by political leaders/cultural censors) [2]. Much of society is already (arguably, rightfully) concerned with perceived disinformation/misinformation sown by worldwide agencies concerning vaccination; using a metaphor encouraging psychological “inoculation” threatens to reinforce the public’s mistrust of governments and our noble profession.
The COVID-19 pandemic has clearly contributed to advances in understanding the origins of autoimmunity, while encouraging focus/interest in oft-i...
Graso and colleagues offer a breath of fresh air in the disturbingly dank, highly politicized world of COVID-19 [1]. The authors explore scapegoating of the unvaccinated by those with an imprecise understanding of the risks of COVID-19 infection and an imbalanced comprehension of risk versus benefit of vaccination. This careful consideration is unfortunately in the minority and is in direct contradistinction from other recent manuscripts published in other journals.
Instead of focusing on unprecedented advances in personalized medicine, cellular therapy, and the existential crisis/opportunity of generative Artificial Intelligence (AI), clinicians/researchers are allowing social scientists to drag our profession back into the highly politicized world of Orwellian information wars. Recently, van der Linden and Roozenbeek dangerously misappropriated the term “inoculation” in discussing nebulous concepts of misinformation (disinformation has quietly metamorphosized to misinformation by political leaders/cultural censors) [2]. Much of society is already (arguably, rightfully) concerned with perceived disinformation/misinformation sown by worldwide agencies concerning vaccination; using a metaphor encouraging psychological “inoculation” threatens to reinforce the public’s mistrust of governments and our noble profession.
The COVID-19 pandemic has clearly contributed to advances in understanding the origins of autoimmunity, while encouraging focus/interest in oft-ignored diagnoses, e.g., myalgic encephalomyelitis/chronic fatigue syndrome; politicization of medical claims/treatments/preventives has the unintended consequence of encouraging vaccine skepticism of truly essential vaccines (which were previously not doubted by most mainstream members of society). A potential solution is avoiding the dangerous mislabeling of “inoculations” as “vaccines/vaccinations.” It is thus, even more surprising/ironic, that those authors continue the comparison with the precise medical intervention/information being questioned.
In a recent New England Journal of Medicine Perspective, Lerner captures many of the reasons why Americans have become increasingly mistrustful of the medical establishment [3], yet despite his exploration of the multifaceted reasons for the decline in trust, even he falls prey to the Siren call to enter the highly politicized information wars by gratuitously making reference to “conservative radio.” His explanation that “criticisms reflected ignorance of the scientific process, which has always relied on falsifiable” is inconsistent with the heavy-handed way partisans pledged to “follow the science,” while not being open to divergent perspectives. Lerner is commended on his attempt to have physicians reflect on our own complicity in the public’s mistrust, but only by opening this dialogue with the public can we hope to reverse (understandable) erosion in trust. The research by Graso and colleagues should be widely distributed to help balance Medicine’s complicity in scapegoating those with whom we may not fully agree with.
Questioning prior “knowledge” and challenging the status quo are exactly what have led to major advances in Medicine, such as the replacement of Galen’s theories with Harvey’s, the recognition by Hooke and van Leeuwenhoek of an unseen world and the 2023 discovery of histones in bacteria [4] Instead of engaging in cultural wars using provocative language, physicians should avoid dogma and continue our long history of out-of-the-box discoveries, such as the Nobel prize winning isolation of H. pylori from ulcers [5].
Sisti et al (2024) [1] embrace some arguments about Medical Assistance in Dying. An argument that rages across the continents - especially where one looks at enabling it for conditions that are not terminal. However it ignores the broader physician assisted dying debate. Their argument that in a mood disorder '[Choosing MAiD] this decision marks another significant difference with medical MAID and psychiatric MAID. The former is a decision about how a patient wishes to die because of a terminal or irremediable condition, while the latter raises the question of whether a person wants to live at all.’ is a 'selective abstraction’, in that conditions other than depression may be irremediable. Nor do they consider Benelux legal concepts of ‘unbearable suffering’. The very identification of treatment resistance and lifelong illness patterns speaks to the challenges of improving outcomes for patients with mental illness. Challenges about identifying or the meaning of treatment resistant/irremediable are well explored [2]
People with depressed mood can suffer from serious cognitive errors, but not all will. The Dutch experience suggests that fears of a wave of death are exaggerated, when few requests for PAD are approved on mental health grounds [3]
Putting this to one side, arguing for parity of mental and physical health but excluding access to PAD/MAiD ignores the great strides taken for civil rights embodied in the UNCRPD [4], which would requir...
Sisti et al (2024) [1] embrace some arguments about Medical Assistance in Dying. An argument that rages across the continents - especially where one looks at enabling it for conditions that are not terminal. However it ignores the broader physician assisted dying debate. Their argument that in a mood disorder '[Choosing MAiD] this decision marks another significant difference with medical MAID and psychiatric MAID. The former is a decision about how a patient wishes to die because of a terminal or irremediable condition, while the latter raises the question of whether a person wants to live at all.’ is a 'selective abstraction’, in that conditions other than depression may be irremediable. Nor do they consider Benelux legal concepts of ‘unbearable suffering’. The very identification of treatment resistance and lifelong illness patterns speaks to the challenges of improving outcomes for patients with mental illness. Challenges about identifying or the meaning of treatment resistant/irremediable are well explored [2]
People with depressed mood can suffer from serious cognitive errors, but not all will. The Dutch experience suggests that fears of a wave of death are exaggerated, when few requests for PAD are approved on mental health grounds [3]
Putting this to one side, arguing for parity of mental and physical health but excluding access to PAD/MAiD ignores the great strides taken for civil rights embodied in the UNCRPD [4], which would require member states to avoid discriminating against mental illness. The very argument that the ill may not make decisions for themselves ignores the lived experience movement, and is ‘ableist'
The focus might better look at whether a decision is capacitous or not, rather than whether one agrees with the choice. Societal positions on assisted conception, termination of pregnancy, or gender issues, have changed dramatically over a half-century; plus ca change!
Of course societies may decide that PAD/MAiD is not acceptable for conditions for which there is no prospect of relief. A problem that has been around for Millenia - are we prolonging live or protracting death? In either event whilst we may all agree that those whose decision making is impaired should not be allowed to make this decision, there is not universal agreement on whether capacitous individuals who do not wish to continue living should be allowed to end their existence, with or without humane assistance.
1 https://doi.org/10.1136/jme-2023-109522
2 McIntyre RS, Alsuwaidan M, Baune BT et al. World Psychiatry 2023;22:394-412.
3 Snijdewind M, Willems D, Deliens L et al. JAMA Intern Med 2015;175:1633-40.
4 UN Department of Economic and Social Affairs. Convention on the rights of persons with disabilities (CRPD). https://social.desa.un.org.
Brain death remains a much discussed and perhaps even a controversial topic since its inception in 1968. It is good to see an addition to this debate in the form of an article on “Consent to testing for brain death” (1). The authors of this article note lack of uniformity of this construct across different jurisdictions which, despite reasonably strict codes of practice and different legal frameworks, implies that brain death is perhaps as much social or legal as biological concept. The elephant in the room however, as far as this article is concerned, is the lack of consent when admitting to ICU in the first place. There is an overarching duty to protect life even though prior values are not known at the outset of treatment. Consent in the UK can only be provided by an adult with capacity. Otherwise, treatment is provided based on the best interests framework. Consent on someone’s behalf is not possible in this jurisdiction. The authors repeatedly point out the invasiveness of brain death testing and distress of apnoea testing omitting to highlight the invasiveness of ICU care and distress associated with ventilatory or other interventions. Furthermore, the argument being made about moral distress misses the point: the distress is about ongoing interventions in the face of catastrophic brain injury to which formal diagnosis of death puts an end. Religious and conceptual barriers to withholding critical care interventions can be overcome even in most d...
Brain death remains a much discussed and perhaps even a controversial topic since its inception in 1968. It is good to see an addition to this debate in the form of an article on “Consent to testing for brain death” (1). The authors of this article note lack of uniformity of this construct across different jurisdictions which, despite reasonably strict codes of practice and different legal frameworks, implies that brain death is perhaps as much social or legal as biological concept. The elephant in the room however, as far as this article is concerned, is the lack of consent when admitting to ICU in the first place. There is an overarching duty to protect life even though prior values are not known at the outset of treatment. Consent in the UK can only be provided by an adult with capacity. Otherwise, treatment is provided based on the best interests framework. Consent on someone’s behalf is not possible in this jurisdiction. The authors repeatedly point out the invasiveness of brain death testing and distress of apnoea testing omitting to highlight the invasiveness of ICU care and distress associated with ventilatory or other interventions. Furthermore, the argument being made about moral distress misses the point: the distress is about ongoing interventions in the face of catastrophic brain injury to which formal diagnosis of death puts an end. Religious and conceptual barriers to withholding critical care interventions can be overcome even in most difficult circumstances (2). A common misconception about critical care medicine is that it offers a cure. It does not. It offers a discrete episode of organ support during which either cure is effected - by interventions targeting pathology that led to organ dysfunction - or those interventions fail to offer the cure, at which point that episode is or should be over. This is one of the reasons why Harvard Criteria arose (3). In the circumstances compatible with profound brain dysfunction as encountered in the context of what we term neurological brain death, ongoing treatment is not just inappropriate or distressing, it is dishonest. Based on the current medical understanding of brain function at a point of brain death, which is accepted by the society by being written into our laws, the clinician can and should use this knowledge to arrive at a decision that terminates the episode of critical care support regardless of the views offered by the next of kin. This of course should be done in the most empathetic and caring way with conflict avoidance in mind, but the decision to test for brain death should not be ceded or shared with non-medical actors. This should only change if society at large decides that the concept of brain death is no longer valid, in which case discussion would change to withdrawal or continuation of treatment.
1. Lyons B, Donnelly M. Consent to testing for brain death. J Med Ethics Epub ahead of print. Doi:10.1136/jme-2023-1099425. [Accessed 05.11.2023].
2. Ravitsky V. Timers on ventilators. BMJ 2005;330:415-417.
3. Ad hoc committee of the Harvard Medical School. A definition of irreversible coma. JAMA 1968;205:85-88.
In a recent article two Canadian ethicist/philosophers argued the appropriateness of granting early medical termination (MAiD) to those requesting it because of poverty or a lack of socioeconomic or institutional resources. These are those who would prefer to live but only with unavailable support services ranging from housing to social or rehabilitative and housing resources.
That the ethical focus should be on the a lack of resources so severe as to make life seem intolerable is not considered by these authors or most other ethicist/philosophers. They assume limited resources are fixed and institutionalized. This ignores the long history of medical and social activism begun in the mid-1800s--Rudolph Virchow being the most famous example--that focused on the failure of social support rather than the inevitable deaths that resulted. If one were to take ethics seriously, the issue would not be permissiveness but activist arguments in that earlier tradition for the care required by the fragile and vulnerable. It is thus that was lost--what Jane Adams called the 'guardianship function' when bioethicists sought successfully to disparage the ethical engagement of physicians involved in patient care.
Alas, an ethics of 'least harm' that accepts the status quo driving individuals to seek an early death is really no ethic at all. It's simply an acceptance of an unacceptable status quo that in ethics, should be the focus.
Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”
To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.
It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significa...
Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”
To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.
It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significant disability and chronic pain. He was no longer able to work or access his home, and the required mobility supports were initially denied. In this context, the patient requested MAiD, citing the unjust and ableist nature of the system as his sole motivation. He was clear that his ‘higher’ desire was to live; his request to die would be retracted if his circumstances changed. His request for MAiD was not the choosing of a preferred option. He requested MAiD because, in his unjust context, it seemed to be his only choice. He felt as if he had no choice. His circumstances were straightforwardly coercive.
Wiebe and Mullin have said, in this kind of situation, that a physician like myself can (and should) both try to remedy the underlying injustice and also end the life of a patient who, regardless of any autonomy determination, has a higher desire to live. In a particular case, I cannot do both. In this case, his care team chose to advocate for him. He is alive today, grateful to a team that ‘paternalistically’ valued his higher desire and intrinsic value, over a desperate request driven by unjust circumstances. Would Wiebe and Mullin suggest that they harmed him by doing so?
Finally, it is important to address the underlying assumptions that lie beneath Wiebe and Mullin’s understanding of autonomy and harm. Which understanding of anthropology suggests that it is less harmful to end a person’s life rather than to deny a request that is motivated by remediable social injustice? Certainly not the anthropology of Kant or Mill, who are originators of the modern idea of autonomy. Certainly not that of Beauchamp and Childress, who were the first to formulate ‘The Principle of Respect for Personal Autonomy’ as a “prima facie” principle of biomedical ethics (more on this here: https://academic.oup.com/jmp/article/46/3/330/6265006). Certainly not the classical medical view of the person, which defines harm in terms of health. I empathize with the discouragement that the authors express regarding the availability of equitable medical care in Canada. But I do not agree that such a context should lead us to hopelessness, abandoning vulnerable individuals who feel like they have no choice but to die. An ethical society would pursue the good for these individuals. Good medicine would pursue their health.
Philosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin [1] in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.
In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison [2], for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ [3].
Philosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin [1] in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.
In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison [2], for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ [3].
These are not new arguments.
Thirty years ago, the American murderer Dr MJ ‘Jack’ Kevorkian [4], a euthanasia and assisted suicide advocate and illicit provider, expressed cruder versions of the same positions, claiming that ‘autonomy always, always should be respected, even if it is absolutely contrary, the decision is contrary to best medical advice and what the physician wants…’ and that a mere request for death is justification alone for provision, regardless of circumstance [5]. He rationalised this idea through an instrumental view of life, arguing like Patrick Henry in the American Revolution [6], that death is an acceptable solution to any perceived loss of personal liberty (i.e., oppression).
‘Listen, when you take my liberty away, you've taken away more-something more precious than life. I mean, what good is a life without liberty? Huh? None.’ [7]
‘If you don't have liberty and self-determination, you've got nothing, that's what this is what this country is built on. And this is the ultimate self-determination, when you determine how and when you're going to die when you're suffering.’ [8]
It is also worth noting that Kevorkian disproportionately killed or assisted death for women, many of whom may not have had any physical illness [9] and claimed ‘that only medical men should decide’ on MAiD [7]. Aside from his blatant misogyny, his statements highlight a central but unacknowledged problem in Wiebe and Mullin’s and similar individualised formulations of MAiD: the tension between the patient's autonomy, the clinician's autonomy, and society.
Dying with Dignity, Canada's 43-year-old MAiD lobby group is organised around an autonomy rationale [10,11]. Autonomy likewise appears in the final report of the Canadian parliamentary joint committee on MAiD as part of the package of justifications and recommendations [12]. Current Canadian MAiD providers also frequently cite autonomy rationales that echo Kevorkian, Wiebe and Mullin, and others, suggesting that together with reported cases [13], some assessors and providers may already operationalise such arguments, including senior members of the Canadian Association of MAiD Assessors and Providers [14], who make statements such as:
‘My job is to help them have a good life and a good death by their standards, not by mine or anybody else’s’[15]
‘I believe very, very strongly in patient autonomy, what we call patient centred care…’[16]
Importantly, in Canada, MAiD is 99.9 % euthanasia. Still, the autonomy of the clinicians who decide how to present MAiD to the patient, how to assess the request, and finally, whether to still proceed with lethal injection (or issuing lethal doses of pharmaceuticals for the sporadic self-administration cases) after asking the patient for their final consent, are ignored by Wiebe and Mullin. By enlisting euthanasia, patients might be better said to be surrendering, not embracing, much of their autonomy, indeed their lives, to their assessors and providers. Certainly, there are already published accounts of shackled and guarded prisoners being assessed and euthanised by paired MAID assessors and providers, yet apparently still considered to have enough coercion-free autonomy for death [17].
Providers are not Kevorkian’s Thanatron death machine [18], but human ‘agents ‘ themselves who must have the same autonomy as their patients, albeit with wealth, health, privilege, and decision-making power, including a legal exemption to criminal culpability for murder, that leaves them in a much more advantageous ‘welfare condition’ than Wiebe and Mullin’s impoverished or oppressed requestors. Wiebe and Mullin, however, call it ‘paternalistic’ to prevent people from accessing MAiD but make no comment on the brutal paternalism of a privileged and empowered actor representing the state who judges someone’s eligibility for death and then may kill them. Why is clinician autonomy discounted? The privilege and power of assessors and providers is a major persistently unaddressed flaw in the reasoning of these kinds of patient autonomy-based arguments.
Wiebe and Mullin also attempt to criticise ‘relational autonomy’ perspectives, arguing that restricted options do not limit a person’s autonomy because they can still exercise,
‘the ability to understand, appreciate the consequences of their choice, the capacity to value, the ability to reflect on the values guiding their decision, as well as the attitudes of engaged hope, self-worth and self-trust.’[1]
However, their definition of autonomy appears to be a repackaging of the obsolete ‘homo economicus’ model human actor from neoclassical economic theory, where people are understood to be ‘unswervingly rational, completely selfish, and can effortlessly solve even the most difficult optimization problem’ [19]. However, research in neuroscience, biology, psychology, public health, sociology, and other disciplines has long since established that our relative autonomy and agency are products of myriad internal and external biophysical and social experiences, relationships, circumstances, and systems. None of us exists in hermetic vacuums of rational reason.
Among these relationships are loved ones, friends, and others impacted by a MAiD death, who might also be sources of support otherwise unknown to the assessor. No consideration is given to them, yet it is well established that suicide and homicide (euthanasia is a form of the latter), in addition to MAiD, can lead to diagnosed prolonged grief disorder, trauma, and other health problems in those who knew the deceased or witnessed the death [20–22]. MAiD clinicians, however, are not legally required to seek information from such people (including other healthcare providers) or enlist them to help identify supports that might relieve oppression and improve conditions. Nor are they required to facilitate grief support, even when the patient does not ban them from contacting others. In fact, the recently released but optional Model Practice Standard for MAiD strongly advises assessors to take every step to seek ‘collateral information’ from other sources [23], suggesting this is not routinely happening. However, suppose a MAiD assessor strongly believes in the individual rather than relational autonomy. In that case, they have no ideological reason to seek such information from others or mitigate harm to them through engagement and grief support.
By voiding a person’s relational context, the impact of their death on others, and the autonomy of the people who must assess and approve death from consideration, Wiebe and Mullin and their ideological colleagues idealise patient autonomy. Like Kevorkian, they construct euthanasia or assisted suicide (non-culpable homicide and suicide assistance under Canadian MAiD law [24]) as virtuous though ‘tragic’ expressions of self-determination and ‘harm reduction’. Do they consider the harm to others from MAiD deaths as illegitimate or irrelevant? There is a prospect, for example, of an otherwise healthy person grieving or traumatised by a MAiD death and diagnosed with PTSD or a grief disorder receiving MAiD for such mental illnesses in 2024 when this becomes available. Would such begotten MAiD also be a tragic but laudable act of ‘harm reduction’ because grief is suffering, regardless of its origin?
Finally, Wiebe and Mullin claim that the cases they describe ‘will be few relative to the proportion of patients who can and will access MAiD due to Bill C-7’ (MAiD for disabled people who are not dying). However, according to federal reporting, there were 221 C-7 deaths in 2021 after Bill C-7 became law [25], which is not a ‘few’. Note here that Health Canada reporting obscures this number in a mixed format of a percentage of a fraction (2.2 %/10 064 deaths), so the reader must convert that percentage to get the number of C-7 deaths [25]. Given the significant yearly increases in MAiD deaths, there will likely be more than 221 for 2022 when data become available. Those 221 people were real people with names and authentic lives (not merely dehumanised ‘agents’) and will likely amount to thousands of deaths in a very short time, given the annual increases in deaths we have already seen [25].
Societies that find intellectual ‘reasons’ to euthanise or kill the poor, sick, disabled, or socially oppressed groups commit atrocities. A former MAiD provider has even sounded this alarm in the wake of eligibility expansions [26]. Despite claims that a lack of support for people is a ‘deep injustice’, the vision of society painted by Wiebe and Mullins is dystopian, where injustice may be morally permitted to flourish so long as others with greater autonomy judge oppressed people to have enough autonomy and ‘engaged hope’ to kill themselves or have themselves killed. Indeed, they seem to argue that medically provided suicide-for-oppression is a suitable and just response ‘to a world that currently does not exist and is unlikely to emerge in the near future’. Thus, in addition to MAiD for both chronic and terminal physical illness and disability, and official consideration or arguments for mental illness [27], children (‘mature minors’) [12] and infants [28], we now see Kevorkian’s old argument re-emerge as a new slip on the expansionist slope as an argument for MAiD for people whose sole condition is the experience of forms of deprived liberty. Wiebe and Mullin’s and allied proposals, perhaps unwittingly, thus serve the construction of an intellectual foundation for eliminating rather than emancipating the poor and oppressed by an empowered (medical) elite. MAiD, in this way, is ultimately a political, not a medical, project. We have seen versions of this before and we know how it ends.
References
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21 Tal Young I, Iglewicz A, Glorioso D, et al. Suicide bereavement and complicated grief. Dialogues Clin Neurosci 2012;14:177–86. doi:10.31887/DCNS.2012.14.2/iyoung
22 Yan H, Bytautas J, Isenberg SR, et al. Grief and bereavement of family and friends around medical assistance in dying: scoping review. BMJ Support Palliat Care Published Online First: 13 September 2022. doi:10.1136/spcare-2022-003715
23 MAID Practice Standards Task Group. Model Practice Standard for Medical Assistance in Dying (MAID): Regulatory authority for [Physicians/Nurses] of [jurisdiction] Standard of Practice Medical Assistance in Dying (MAID). Health Canada 2023. https://www.canada.ca/en/health-canada/services/medical-assistance-dying...
24 Criminal Code. 1985.
25 Health Canada. Third annual report on Medical Assistance in Dying, 2021. Ottawa: : Government of Canada 2022. https://www.canada.ca/en/health-canada/services/medical-assistance-dying...
26 Gaind KS. Nothing, nowhere, all at once: Canada’s courtship with assisted death. 2023.https://umanitoba.yuja.com/V/Video?v=847548&node=4129787&a=22215896&auto... (accessed 12 May 2023).
27 Health Canada. Final Report of the expert panel on MAiD and mental illness. Ottawa: : Government of Canada 2022.
28 Cullen C, Zabjek A. Federal minister says she’s ‘shocked’ by suggestion of assisted deaths for some babies. CBC News. 2022.https://www.cbc.ca/news/politics/assisted-dying-carla-qualtrough-1.6625412 (accessed 11 Apr 2023).
I agree that personal autonomy does not of itself invalidate medical mandates.
I note that I do not conclude that vaccine mandates are wrong just because they violate body autonomy of vaccine refusers. Rather, ‘mandatory vaccination, immunity passports, or any other form of discrimination on the basis of the vaccination status are defeasible not because they limit basic freedoms and rights but because they discriminate against (and thus devalue) the innate constitution of all human beings.’ Moreover, the premise that vaccine mandates are justified by the value of human autonomy is logically inconsistent: ‘We must, first of all, value our kind ’as it is’ in order to bestow worth on what we ‘ought to become’, and to pursue any ontological transformation by devaluing the innate constitution of other members of the kind would, paradoxically, negate the value of our own judgement.’ https://blogs.bmj.com/medical-ethics/2021/03/01/discrimination-on-the-ba...
It seems the authors interpret the healthy, innate human constitution that includes our immune system - an act of nature that determines our objective identity - as an act of socia...
I agree that personal autonomy does not of itself invalidate medical mandates.
I note that I do not conclude that vaccine mandates are wrong just because they violate body autonomy of vaccine refusers. Rather, ‘mandatory vaccination, immunity passports, or any other form of discrimination on the basis of the vaccination status are defeasible not because they limit basic freedoms and rights but because they discriminate against (and thus devalue) the innate constitution of all human beings.’ Moreover, the premise that vaccine mandates are justified by the value of human autonomy is logically inconsistent: ‘We must, first of all, value our kind ’as it is’ in order to bestow worth on what we ‘ought to become’, and to pursue any ontological transformation by devaluing the innate constitution of other members of the kind would, paradoxically, negate the value of our own judgement.’ https://blogs.bmj.com/medical-ethics/2021/03/01/discrimination-on-the-ba...
It seems the authors interpret the healthy, innate human constitution that includes our immune system - an act of nature that determines our objective identity - as an act of social coercion, which I contend is a category mistake.
For the sake of clarity, I summarise the three strongest arguments against the ethical permissibility of vaccine mandates:
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow our unrestricted participation in society, which amounts to discrimination on the basis of healthy, innate characteristics of the human race. This devaluation of the innate human constitution is not only universally dehumanising, but it perverts the very concept of human rights; discrimination against the unvaccinated implies that being born human is no longer a guarantee of full human rights.
2. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no guaranteed rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not only from ourselves but from our children and from future generations, and we do not have the moral right to do this. Acquiescence to medical coercion is therefore always unethical, even if the mandated intervention were a placebo.
3. Vaccines are known to occasionally cause deaths of healthy people. When an employee is required to receive vaccination as a condition of employment, that employee is economically coerced to participate in an activity where a percentage of employees are expected to die ‘in the course of employment’ as a direct result of the mandated activity. It may be objected that infectious pathogens also kill people, but these two categories of deaths are not ethically equivalent. Infection with a pathogen is not mandated, whereas deaths resulting from mandatory vaccination are mandated deaths, a legalised killing of some people for the prospective benefit of the majority. Critically, any discrimination against the unvaccinated amounts to a violation of the right to life, because a small percentage of the targeted population are expected to die as a result of this coercive treatment. By refusing to acquiesce to mandated vaccines we take an ethical stance in defence of the right to life.
While I do understand why some people may have strong sentiments towards this published article, I do find it interesting how most of them are not morally backed. This is a philosophical discussion and I believe that in order to make your point known you should be able to use moral principles to respond to the article.
In order to discuss this question we must separate whether we should do something and whether something is morally wrong. For example, we should not speed on a highway, yet it is not morally wrong provided that we do not harm others' interest. At the same time, killing animals for meat is morally wrong, yet we still do it for various reasons. Here, I argue for the author that there is no moral difference between a fetus and a infant in moral status, yet we should not be allowed to kill an infant because it will inevitably lead to multiple complications that our society and legal system may not be ready to face. One of such issue is that it is hard to draw the line between a baby with personhood and a baby without, since it is a continuous process. The legalization of this may also lead to other issues such as the permissibility of killing severely mentally impaired adults (as they do not have a personhood either).
There seems to be a disconnect between Dr. Pennings and the decades of reporting of actual experiences of parents, donors and donor-conceived people.
The first argument is that there is no evidence that a change in age will increase the total well-being of donor offspring as a group.
There is plenty of published research and years of anecdotal evidence. We invite Dr. Pennings to read not only the research, (https://indd.adobe.com/view/ac2a0b99-f67a-4768-bf8c-c48af5aeebaf) but also the reported experiences of more than 86,000 over the past 22 years on the www.DonorSiblingRegistry.com website. Many thousands of these donor-conceived people (DCP) have connected with their biological parent (donor) long before the age of 18. Many more DCP have made their stories public in hopes of shining a light on the innate human desire to know who and where we come from. Many formerly anonymous egg and sperm donors who have connected with donor children have participated in research and have also made their stories public. Additionally, several dozen egg clinics, agencies, and lawyers have been writing the Donor Sibling Registry into their parent-donor agreements for many years, connecting donors and parents right from pregnancy/birth. This is an extremely popular and successful program empowering donors and parents to decide the depth, breadth,...
There seems to be a disconnect between Dr. Pennings and the decades of reporting of actual experiences of parents, donors and donor-conceived people.
The first argument is that there is no evidence that a change in age will increase the total well-being of donor offspring as a group.
There is plenty of published research and years of anecdotal evidence. We invite Dr. Pennings to read not only the research, (https://indd.adobe.com/view/ac2a0b99-f67a-4768-bf8c-c48af5aeebaf) but also the reported experiences of more than 86,000 over the past 22 years on the www.DonorSiblingRegistry.com website. Many thousands of these donor-conceived people (DCP) have connected with their biological parent (donor) long before the age of 18. Many more DCP have made their stories public in hopes of shining a light on the innate human desire to know who and where we come from. Many formerly anonymous egg and sperm donors who have connected with donor children have participated in research and have also made their stories public. Additionally, several dozen egg clinics, agencies, and lawyers have been writing the Donor Sibling Registry into their parent-donor agreements for many years, connecting donors and parents right from pregnancy/birth. This is an extremely popular and successful program empowering donors and parents to decide the depth, breadth, and timing of their own relationships. Openness, honesty, and transparency is the future of the gamete donation industry.
Several hundred experiences of donor-conceived people connecting with half-siblings and biological parents can be read on the Success Story page: https://donorsiblingregistry.com/success_stories
Nowhere on the planet, or at any time in history has it been medically or psychologically accepted practice to deliberately keep a person from their ancestry, medical family history, or close genetic relatives for the first 5, 10, or 18 years of life.
The second argument stresses that the rights language used for the donor-conceived child isolates the child from his or her family and this is unlikely to be in the best interest of the child.
Completely false. Connecting with one’s donor relatives in no way isolates them from the family they’ve grown up with. Connecting with donor family: half-siblings or biological parents is expanding family. It is an "adding to", not a "taking away" or diminishing one's current family system. More than 24,000 donor-conceived people have made these connections on the Donor Sibling Registry.
Finally, lowering the age limit reintroduces the genetic father in the family and expresses the bionormative ideology that contradicts gamete donation as a practice.
Gamete donation is utilized because of the importance of biology. Parents want, and acknowledge the importance of that genetic link, usually with one parent. You can not acknowledge the importance of the genetic connection of one biological parent while denying the importance of knowing the other genetic parent, ancestry, and medical family history. DNA is not the only way to make a family, but the adoption world and now the world of donor conception have taught us that it is certainly one way to define family. Many thousands of adopted people and donor-conceived people feel very strongly about knowing their DNA relatives. Tho them, it's isn't just a "donated cell" or a "piece of genetic material". It's one half of their identity.
Anonymity has not been possible for 18 years. Why continue to have conversations around mandated anonymity when it's been an antiquated idea and practice since 2005? Why not listen to us, the donor families? Why not ride the horse in the direction it's going?
Wendy Kramer wendy@donorsiblingregistry.com
Parent to a donor-conceived son
Director and Co-founder, the Donor Sibling Registry
S.P.E.R.M. The Society for the Promotion of Ethics in Reproductive Medicine
I thank Dr. Pennings for his thoughtful work. There are, however, further critical points to be considered when designating any arbitrary age by which a donor conceived person (DCP) can learn the identity of his/her donor. Although I agree that outcome research needs to be conducted on DCP stratified by the age at which they specifically learn their donors identities, the existing research on adoption, which parallels many of the ethical and humanistic aspects of donor conception, largely supports the idea of open adoption, where all parties are knowledgeable of the others at birth. According to one recent review, contact with the birth family results in substantially more positive outcomes for adoptees (Smith et al, 2020). Research has also shown significantly greater benefit for the adoptive parents and birth mothers in terms of satisfaction with the adoption process and post-partum adjustment in open adoption (Ge et al, 2008). This study also indicates positive experience in the new kinds of relationships created through open adoption, and the authors extend the implications of their findings to reproductive technologies such as donor conception as well.
The practicalities of enforcement of a designated age where DCPs might be permitted to learn their donor's identities also must be addressed. DCPs learning the identity of their donor through commercial DNA testing prior to the designated age is only one consideration. A second ethical dilemma would b...
I thank Dr. Pennings for his thoughtful work. There are, however, further critical points to be considered when designating any arbitrary age by which a donor conceived person (DCP) can learn the identity of his/her donor. Although I agree that outcome research needs to be conducted on DCP stratified by the age at which they specifically learn their donors identities, the existing research on adoption, which parallels many of the ethical and humanistic aspects of donor conception, largely supports the idea of open adoption, where all parties are knowledgeable of the others at birth. According to one recent review, contact with the birth family results in substantially more positive outcomes for adoptees (Smith et al, 2020). Research has also shown significantly greater benefit for the adoptive parents and birth mothers in terms of satisfaction with the adoption process and post-partum adjustment in open adoption (Ge et al, 2008). This study also indicates positive experience in the new kinds of relationships created through open adoption, and the authors extend the implications of their findings to reproductive technologies such as donor conception as well.
The practicalities of enforcement of a designated age where DCPs might be permitted to learn their donor's identities also must be addressed. DCPs learning the identity of their donor through commercial DNA testing prior to the designated age is only one consideration. A second ethical dilemma would be that in groups of donor siblings with large age ranges, the older members would inevitably have the "right" to learn the donor identity first, and the expectation that they will then withhold this information from the younger siblings, sometimes for many years or decades, cannot be regulated.
As has been the trend in adoption, the existing empirical and anecdotal knowledge base, the growing recognition of the need for research on donor identity and related topics in donor conception, and available tools such as DNA testing are unquestionably leading the field of third party reproduction towards one of uniform openness. As both a psychologist and a DCP, it is my hope and expectation that the openness will substantially enhance the process and outcomes for all individuals associated with donor families as we have seen in open adoption.
References
Ge, X., Natsuaki, M. N., Martin, D. M., Leve, L. D., Neiderhiser, J. M., Shaw, D. S., Villareal, G., Scaramella, L., Reid, J. B., & Reiss, D. (2008). Bridging the divide: Openness in adoption and postadoption psychosocial adjustment among birth and adoptive parents. Journal of Family Psychology, 22(4), 529- 540. https://doi.org/10.1037/a0012817
Smith, M., Gonzalez-Pasarin, L., Salas, M. D. & Bernedo, I. M. (2020). Review of benefits and risks for children in open adoption arrangements. Child & Family Social Work, 25, 761-774, doi: 10.1111/cfs.12753
Graso and colleagues offer a breath of fresh air in the disturbingly dank, highly politicized world of COVID-19 [1]. The authors explore scapegoating of the unvaccinated by those with an imprecise understanding of the risks of COVID-19 infection and an imbalanced comprehension of risk versus benefit of vaccination. This careful consideration is unfortunately in the minority and is in direct contradistinction from other recent manuscripts published in other journals.
Instead of focusing on unprecedented advances in personalized medicine, cellular therapy, and the existential crisis/opportunity of generative Artificial Intelligence (AI), clinicians/researchers are allowing social scientists to drag our profession back into the highly politicized world of Orwellian information wars. Recently, van der Linden and Roozenbeek dangerously misappropriated the term “inoculation” in discussing nebulous concepts of misinformation (disinformation has quietly metamorphosized to misinformation by political leaders/cultural censors) [2]. Much of society is already (arguably, rightfully) concerned with perceived disinformation/misinformation sown by worldwide agencies concerning vaccination; using a metaphor encouraging psychological “inoculation” threatens to reinforce the public’s mistrust of governments and our noble profession.
The COVID-19 pandemic has clearly contributed to advances in understanding the origins of autoimmunity, while encouraging focus/interest in oft-i...
Show MoreSisti et al (2024) [1] embrace some arguments about Medical Assistance in Dying. An argument that rages across the continents - especially where one looks at enabling it for conditions that are not terminal. However it ignores the broader physician assisted dying debate. Their argument that in a mood disorder '[Choosing MAiD] this decision marks another significant difference with medical MAID and psychiatric MAID. The former is a decision about how a patient wishes to die because of a terminal or irremediable condition, while the latter raises the question of whether a person wants to live at all.’ is a 'selective abstraction’, in that conditions other than depression may be irremediable. Nor do they consider Benelux legal concepts of ‘unbearable suffering’. The very identification of treatment resistance and lifelong illness patterns speaks to the challenges of improving outcomes for patients with mental illness. Challenges about identifying or the meaning of treatment resistant/irremediable are well explored [2]
People with depressed mood can suffer from serious cognitive errors, but not all will. The Dutch experience suggests that fears of a wave of death are exaggerated, when few requests for PAD are approved on mental health grounds [3]
Putting this to one side, arguing for parity of mental and physical health but excluding access to PAD/MAiD ignores the great strides taken for civil rights embodied in the UNCRPD [4], which would requir...
Show MoreDear Editor,
Brain death remains a much discussed and perhaps even a controversial topic since its inception in 1968. It is good to see an addition to this debate in the form of an article on “Consent to testing for brain death” (1). The authors of this article note lack of uniformity of this construct across different jurisdictions which, despite reasonably strict codes of practice and different legal frameworks, implies that brain death is perhaps as much social or legal as biological concept. The elephant in the room however, as far as this article is concerned, is the lack of consent when admitting to ICU in the first place. There is an overarching duty to protect life even though prior values are not known at the outset of treatment. Consent in the UK can only be provided by an adult with capacity. Otherwise, treatment is provided based on the best interests framework. Consent on someone’s behalf is not possible in this jurisdiction. The authors repeatedly point out the invasiveness of brain death testing and distress of apnoea testing omitting to highlight the invasiveness of ICU care and distress associated with ventilatory or other interventions. Furthermore, the argument being made about moral distress misses the point: the distress is about ongoing interventions in the face of catastrophic brain injury to which formal diagnosis of death puts an end. Religious and conceptual barriers to withholding critical care interventions can be overcome even in most d...
Show MoreIn a recent article two Canadian ethicist/philosophers argued the appropriateness of granting early medical termination (MAiD) to those requesting it because of poverty or a lack of socioeconomic or institutional resources. These are those who would prefer to live but only with unavailable support services ranging from housing to social or rehabilitative and housing resources.
That the ethical focus should be on the a lack of resources so severe as to make life seem intolerable is not considered by these authors or most other ethicist/philosophers. They assume limited resources are fixed and institutionalized. This ignores the long history of medical and social activism begun in the mid-1800s--Rudolph Virchow being the most famous example--that focused on the failure of social support rather than the inevitable deaths that resulted. If one were to take ethics seriously, the issue would not be permissiveness but activist arguments in that earlier tradition for the care required by the fragile and vulnerable. It is thus that was lost--what Jane Adams called the 'guardianship function' when bioethicists sought successfully to disparage the ethical engagement of physicians involved in patient care.
Alas, an ethics of 'least harm' that accepts the status quo driving individuals to seek an early death is really no ethic at all. It's simply an acceptance of an unacceptable status quo that in ethics, should be the focus.
Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”
To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.
It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significa...
Show MorePhilosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin [1] in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.
In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison [2], for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ [3].
These are not new arguments.
Thirty year...
Show MoreI thank the authors for critically engaging with my paper “Ethics of vaccine refusal”. http://dx.doi.org/10.1136/medethics-2020-107026
I agree that personal autonomy does not of itself invalidate medical mandates.
I note that I do not conclude that vaccine mandates are wrong just because they violate body autonomy of vaccine refusers. Rather, ‘mandatory vaccination, immunity passports, or any other form of discrimination on the basis of the vaccination status are defeasible not because they limit basic freedoms and rights but because they discriminate against (and thus devalue) the innate constitution of all human beings.’ Moreover, the premise that vaccine mandates are justified by the value of human autonomy is logically inconsistent: ‘We must, first of all, value our kind ’as it is’ in order to bestow worth on what we ‘ought to become’, and to pursue any ontological transformation by devaluing the innate constitution of other members of the kind would, paradoxically, negate the value of our own judgement.’ https://blogs.bmj.com/medical-ethics/2021/03/01/discrimination-on-the-ba...
It seems the authors interpret the healthy, innate human constitution that includes our immune system - an act of nature that determines our objective identity - as an act of socia...
Show MoreWhile I do understand why some people may have strong sentiments towards this published article, I do find it interesting how most of them are not morally backed. This is a philosophical discussion and I believe that in order to make your point known you should be able to use moral principles to respond to the article.
In order to discuss this question we must separate whether we should do something and whether something is morally wrong. For example, we should not speed on a highway, yet it is not morally wrong provided that we do not harm others' interest. At the same time, killing animals for meat is morally wrong, yet we still do it for various reasons. Here, I argue for the author that there is no moral difference between a fetus and a infant in moral status, yet we should not be allowed to kill an infant because it will inevitably lead to multiple complications that our society and legal system may not be ready to face. One of such issue is that it is hard to draw the line between a baby with personhood and a baby without, since it is a continuous process. The legalization of this may also lead to other issues such as the permissibility of killing severely mentally impaired adults (as they do not have a personhood either).
There seems to be a disconnect between Dr. Pennings and the decades of reporting of actual experiences of parents, donors and donor-conceived people.
The first argument is that there is no evidence that a change in age will increase the total well-being of donor offspring as a group.
There is plenty of published research and years of anecdotal evidence. We invite Dr. Pennings to read not only the research, (https://indd.adobe.com/view/ac2a0b99-f67a-4768-bf8c-c48af5aeebaf) but also the reported experiences of more than 86,000 over the past 22 years on the www.DonorSiblingRegistry.com website. Many thousands of these donor-conceived people (DCP) have connected with their biological parent (donor) long before the age of 18. Many more DCP have made their stories public in hopes of shining a light on the innate human desire to know who and where we come from. Many formerly anonymous egg and sperm donors who have connected with donor children have participated in research and have also made their stories public. Additionally, several dozen egg clinics, agencies, and lawyers have been writing the Donor Sibling Registry into their parent-donor agreements for many years, connecting donors and parents right from pregnancy/birth. This is an extremely popular and successful program empowering donors and parents to decide the depth, breadth,...
Show MoreI thank Dr. Pennings for his thoughtful work. There are, however, further critical points to be considered when designating any arbitrary age by which a donor conceived person (DCP) can learn the identity of his/her donor. Although I agree that outcome research needs to be conducted on DCP stratified by the age at which they specifically learn their donors identities, the existing research on adoption, which parallels many of the ethical and humanistic aspects of donor conception, largely supports the idea of open adoption, where all parties are knowledgeable of the others at birth. According to one recent review, contact with the birth family results in substantially more positive outcomes for adoptees (Smith et al, 2020). Research has also shown significantly greater benefit for the adoptive parents and birth mothers in terms of satisfaction with the adoption process and post-partum adjustment in open adoption (Ge et al, 2008). This study also indicates positive experience in the new kinds of relationships created through open adoption, and the authors extend the implications of their findings to reproductive technologies such as donor conception as well.
The practicalities of enforcement of a designated age where DCPs might be permitted to learn their donor's identities also must be addressed. DCPs learning the identity of their donor through commercial DNA testing prior to the designated age is only one consideration. A second ethical dilemma would b...
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