eLetters

501 e-Letters

  • Life-Course Comparison as a justification for voluntary euthanasia and physician-assisted suicide – A response to Panayiotou

    In a recent article in JME, Panayiotou argues that Voluntary Euthanasia (VE) and Physician Assisted Suicide (PAS) cannot be justified on the basis of actualising a comparatively better life for the patient.1 Panayiotou questions how to differentiate between VE/PAS and other acts, such as teaching a patient chess, that may also improve a patient’s life but are not considered clinically appropriate. However, this argument conflates the concepts of beneficence, ethical justifiability with clinical appropriateness.
    Panayiotou assumes that proponents of the Life-Course Comparison framework must accept that all actions which actualise a comparatively better life are automatically a physician’s duty. However, Panayiotou overlooks a key step in the argument. The Life-Course Comparison framework establishes an act as ethically justified by first determining that it is beneficial to the patient. Once an action is determined to be beneficial, additional criteria must be applied to assess its clinical appropriateness. While both chess and VE/PAS may actualise a comparatively better life and thus be considered beneficial and ethically justified, this does not mean they are equally clinically appropriate. The framework does not impose an obligation to actualise a better life but rather uses this as a prerequisite for determining beneficence. Only after VE/PAS are recognised as beneficial within this framework can their clinical appropriateness be evaluated.
    This distinction...

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  • Ethicists to the Rescue

    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...

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  • Tautology: A wish to die is suicidality?

    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...

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  • Decision to test is a medical one

    Dear 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...

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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.

  • 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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  • 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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  • 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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  • A general response to the rapid response section

    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).

  • 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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