494 e-Letters

  • Author’s Response

    I 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...

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  • Feedback & request for correction

    I read with interest the article titled “Ethics of college vaccine mandates, using reasonable comparisons” by Lam LL and Nichols T1, published on Mar 30, 2023, in the Journal of Medical Ethics.

    I would like to comment on statements that the above authors made that COVID-19 vaccine-caused myocarditis cases are “generally mild” and “over 90% of the hospitalized vaccine-caused myocarditis cases fully recovered within days”, and that “approximately 10% of the hospitalised cases … may have some long-term consequences”.

    Among individuals with COVID-19 vaccine-associated myocarditis, the majority develop cardiac MRI abnormalities including fibrosis, which persist on follow-up, as shown below2-4. The authors’ statements that vaccine-caused myocarditis is ‘mild’ and ‘fully recovered in 90% of cases’ with only ‘10% having long-term consequences’ are misleading, since development of myocardial fibrosis in most patients with vaccine-caused myocarditis refutes these statements. Consequently, any conclusions that the authors make relying on these inaccurate statements are not supported. To promote accuracy, a correction should be issued to the above authors’ statements.

    Schauer J2 et al found that at 3-8 months’ follow-up, repeat cardiac MRI showed persistent late gadolinium enhancement, an indicator of cardiac injury and fibrosis, in 68.8% (11/15) of adolescents aged 12-17 years with COVID-19 vaccine–associated myocarditis.

    Cavalcante JL et al3 found that at...

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  • Access to Genetic Identity from Birth Is in the Best Interest of a Child and is Not "Bionormative"

    In the U.S. a parent has a fundamental right to raise their child as they see fit, but this not an absolute right. Parents must act in the best interest of their child. The right to know your genetic identity is supported by ethical principles and existing legal frameworks. Denying individuals access to their genetic information violates their autonomy, privacy, and dignity. Lack of access to genetic identity information from birth also significantly increases the likelihood of physical and mental health issues.

    Medical history and genetic makeup play an essential role in identifying health risk factors. An accurate medical history provides relevant information to the genetic information stored in our DNA. Family health history is a significant factor in determining the likelihood of developing certain diseases we carry in our DNA. Family medical history includes the types of health conditions family members have been diagnosed with, age of diagnosis, and relevant environmental or lifestyle factors. Common health conditions often included in a family medical history are heart disease, cancer, stroke, diabetes, high blood pressure, and mental health disorders.

    A thorough understanding of medical history can help identify early signs of conditions that may otherwise go undetected. People base their health habits on their parents’ medical history which could, if incorrect, lead to medical conditions that might have been prevented, delays in diagnosis, or unnece...

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  • Why an Age Restriction Doesn't Work

    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...

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  • Ride the horse in the direction its going.

    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,...

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  • Kevorkian’s ghost: A response to Wiebe and Mullin’s argument for MAiD for the oppressed

    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 year...

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  • Hopeless hope, autonomy, and anthropology: a response to Wiebe and Mullin

    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...

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  • "harm reduction" for harmful ethics.

    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.

  • Mandating Uncertainty

    "The will of the people shall be the basis of the authority of government".Article 21 of the United Nations' 1948 Universal Declaration of Human Rights
    The most recent feature article by Bardosh et al opposes policies requiring vaccination with SARS Cov-2 mRNA vaccines in order to matriculate at universities in the United States (1). While the exposition put forward is thorough and cogent, the article raises a much larger question dealing with forced vaccination to prevent illness in our population. Vaccination has been enormously successful in dealing with a host of human diseases (2-4). One cannot overstate the huge benefits to humanity accruing from prevention of viral diseases including smallpox, rabies, yellow fever, measles, mumps, rubella, varicella and, of course, paralytic polio. Recently developed vaccines protect against hepatitis A and B. Human papilloma virus vaccine may succeed in reducing the cancer burden in women and also in men. Typhoid, tetanus, diphtheria, pertussis, hemophilus, meningococcus, and pneumococcus vaccines have been highly successful in dealing with these bacterial pathogens (5).
    All states require children to be vaccinated against certain communicable diseases as a condition for school attendance
    That is understandable since school brings together a large number of individuals in very close proximity. Certainly colleges with the inevitable crowded living conditions in dormitories promote a 24 hour expo...

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  • Expanded terminal sedation in end-of-life care (Gilbertson et al. doi:10.1136/jme-2022-108511)

    As a retired palliative care physician, I am puzzled by several aspects of this article. First, authors’ choice of terminology: ‘terminal sedation’ and ‘expanded terminal sedation’. It is more than 20 years since the use of the former began to be discouraged because of perceived ambiguity, and replaced by ‘palliative sedation’ (PS)[1] – as reflected in current professional guidelines.[2] And despite dissenting voices,[3] most clinicians would probably consider ‘expanded terminal sedation’ to be ‘slow euthanasia’.
    PS was used to describe a deliberate switch from escalation of symptom management to a deliberate reduction in a patient’s level of consciousness in order to ease otherwise intolerable refractory suffering in ‘imminently dying’ patients. The sedation varied from light to deep depending on individual need. Some guidelines refer to ‘intermittent’ as well as ‘continuous’ sedation. Recently, because of the lack of clarity in many reports, there’s been a trend towards limiting discussion to ‘deep continuous sedation until death’ (CDSUD) – the most contentious aspect of sedation near the end of life.
    Second, it may be correct that ‘the Doctrine of Double Effect (DDE) continues to shape much of the ethical and legal literature concerning end-of-life care’ (EOLC), but what about the medical literature? Would it surprise the authors if I say that, when a practicing clinician, I never agonized about ‘double effect’? As they noted, DDE was originally formulate...

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