The paper by Hooper & Spicer and some of the responses to it raise an important debate about the hazards of safety legislation. It is wrong to assume that safety legislation will cause no harm and in line with principles of medical ethics public health professionals are obliged to take such harm into account.
The first level of harm may arise when the legislation actually mandates an unsafe act because all the consequences of...
The paper by Hooper & Spicer and some of the responses to it raise an important debate about the hazards of safety legislation. It is wrong to assume that safety legislation will cause no harm and in line with principles of medical ethics public health professionals are obliged to take such harm into account.
The first level of harm may arise when the legislation actually mandates an unsafe act because all the consequences of the act have not been taken into account. Although it is self evidently true that cycle helmets have a protective function in certain accidents the benefit that would be expected from the physics of the situation has not been demonstrated in population studies. What is offsetting it? Is it an increased risk of neck injuries? Is it that car drivers drive closer to cyclists who look less vulnerable? We need to know this before legislation could be regarded as ethical.
The second level of harm may arise when the legislation creates a false sense of security resulting in risk compensation. Cycle helmets do not offer anything like the degree of protection that is sometimes assumed so this is a serious potential problem. It is unethical to mislead.
The third level of harm may arise when people act in a dangerous or unhealthy way in response to legislation. This is an issue with cycle helmets because the evidence shows that the introduction of legislation will lead to a fall in cycling rates resulting in deaths from diabetes, heart disease, osteoporosis and mental illness. Excessive rail safety requirements can have the effect of reducing rail travel and substituting less safe road travel. For young men, who are safer cycling than driving, this issue arises with cycle helmets as well. It is unethical to create a situation which leads people to harmn themselves.
The fourth level of harm arises when we lose a sense of proportion in safety legislation so that people lose the capacity to weigh risks. In the Paddington rail disaster a large number of people were killed in a head on collision between two trains one of which had passed a signal at danger. This signal was badly sited and had been passed at danger a number of times previously but nothing was done. Nobody had convened a meeting of the Signal Sighting Committee. At this time the rail network was engaged in a major campaign to reduce deaths to zero and as part of this was developing safety cases about risks like passengers falling off the edge of station platforms. THSG asks a simple question - in the course of this process did the system lose sight of what is important, lose the capacity to prioritise and as a consequence of that neglect a major risk. The case for cycle helmets is weaker than the case for helmets when playing football and on a par with the case for helmets when driving. The added risks of cycling rather than driving on a local journey for a middle aged adult are comparable to the added risks of taking the car instead of the train or driving on an all purpose road instead of a motorway. If society attempts legislative control of risks of this order it will fail, and in doing so its failure will impact on much more significant issues as well. It is unethical to set up systems which will fail in such a way as to damage lifesaving activities.
The fifth level of harm comes when the legislation conveys a false message and as a result people make poor decisions. Cycling is a safe activity which benefits health. Yet the commonest reason given for not cycling is safety. If we compel cyclists to wear helmets we give out the message that it is on a par with riding a motorcycle or with working on a building site. It is unethical to mislead people into making harmful choices.
We must understand that safety legislation is not a free good. We can only handle so much of it and we must prioritise. We must reach out for a safe society, in which people who climb mountains use the right equipment, check the weather and tell people what route they are taking, not a risk averse society where people do not climb mountains. A morbid preoccupation with the dangers of normal safe activities limits lives and can kill people.
STEPHEN J. WATKINS
Chair, Transport and Health Study Group.
Conflict of Interest:
THSG has a policy of opposition to compulsory cycle helmets based on its understanding of the scientific evidence
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinio...
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinion, he wrote:
"This case, of course, is not one in which any harm to the physical or mental health of the child or to the public safety, peace, order, or welfare has been demonstrated or may be properly inferred."2
The court reaffirmed the earlier case of
Prince v. Massachusetts (1944) as the controlling case in situations in which a child is put at risk in the name of religion: 3
"To be sure, the power of the parent, even when linked to a free exercise claim, may be subject to limitation under Prince if it appears that parental decisions will jeopardize the health or safety of the child, or have a potential for significant social burdens."2
In the case of Prince v. Massachusetts, Justice Rutledge delivered the opinion of the court. The court said:
"The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death. People v. Pierson, 176 N.Y. 201, 68 N.E. 243. The catalogue need not be lengthened. It is sufficient to show what indeed appellant hardly disputes, that the state has a wide range of power for limiting parental freedom and authority in things affecting the child's welfare, and that this includes, to some extent, matters of conscience and religious conviction."4
The court then famously stated:
"Other harmful possibilities could be stated, of emotional excitement and psychological or physical injury. Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves."4
Therefore, the free exercise clause of the First Amendment to the United States Constitution cannot be used to support putting a child at risk in the name of religion.
Free exercise of religion is not only an adult right. Children also have a right to freely exercise their religious views when they reach "the age of reason."3 With particular application to the physical injury of circumcision, the child may make that decision for himself when he reaches the age of legal capacity, however neither the free exercise clause nor Yoder offers any support whatsoever for any alleged parental "right to circumcise."
References
Merkel R, Putze H. After Cologne: male circumcision and the law. Parental right, religious liberty or criminal assault? J Med Ethics Published Online First 22 May 2013. doi: 10:1136/medethics-2012-11284.
Wisconsin v. Yoder, 406 U.S. 205 (1972).
Adler PW. Is circumcision legal. 16 Rich. J.L. & Pub. Int. 2013;16: 439. Available at http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf Accessed 9 June 2013.
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."1
The evidence of injury to the child's sexual func...
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."1
The evidence of injury to the child's sexual function is now conclusive. Podnar has demonstrated the adverse effect of circumcision upon the penilo-cavernosus reflex.2 Furthermore, several international studies demonstrate the injury of male circumcision to the sexual relations of both male and female.3-5
Benetar relies on "three major studies" as evidence of the efficacy of male circumcision in reducing HIV infection; however, those studies have been sharply questioned and even debunked.6-8
Therefore, the evidence against circumcision is conclusive, while the alleged evidence for circumcision has collapsed.
By Benetar's own standards, circumcision is not a benefit, but instead is a malefit; thus the circumcision of male children is an unethical operation.
References
Benetar D. Evaluations of circumcision should be circumscribed by the evidence. J Med Eth. 2013; published online first 31 May 2013.
Podnar S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men.BJU Int. 2011;209:582-5. doi:10.1111/j.1464-410X.2011.10364.x
Solinis I, Yiannaki A. Does circumcision improve couple's sex life? J Mens Health Gend. 2007;4(3):361.
Frisch M, Lindholm, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 2011;40(5):1367-81.
Bronselaer GA, Schober JM, Meyer-Bahlburg HFL, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):820-27. doi:10.1111/j.1464-410X.2012.11761.x
Van Howe, Storms MS. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4
Ncayiyana DJ. The illusive promise of circumcision to prevent female-to-male HIV infection - not the way to go for South Africa. SAMJ 2011;101(11):775-6.
Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med (Melbourne) 2011;19:316-34.
We read with great interest Daoust and Racine's contribution to the
ongoing debate about brain death and its ethical and medical implications
[1]. The authors argue that little is known about how the public
understands the concept of death determined by neurological criteria
(DNC). They set out to trace common sources of public confusion about DNC
and seek to "better define the relationship between expert and lay views...
We read with great interest Daoust and Racine's contribution to the
ongoing debate about brain death and its ethical and medical implications
[1]. The authors argue that little is known about how the public
understands the concept of death determined by neurological criteria
(DNC). They set out to trace common sources of public confusion about DNC
and seek to "better define the relationship between expert and lay views
of death". We wish to comment on the issue of whether or not public
confusion "reflects public confusion in the media or perhaps a more
profound insight into the nature of academic debates among experts".
Although the authors recognize that "recent critiques have made any clear
meaning of DNC more challenging and even counterintuitive", they position
themselves, with no further explanation, on one side of the debate by
stating that "landmark contributions and guidelines of professional
societies have brought clarity and credence to the standard definition of
DNC". With that, they imply that current determination of death and organ
transplantation practices are rigorous and that media coverage distorts
the actual process of declaring a person dead based on neurological
criteria.
The two premises-- that the standard of DNC has clarity and credence
and that producing a clear meaning of DNC is both challenging and
counterintuitive-- are logically irreconcilable. The authors,
nevertheless, conclude that all discussions in the media and with patient-
families should "reinforce the genuine nature of neurological
determination of death as a criterion to establish death...". Either (a)
the philosophical rationale proposed in the President's Council on
Bioethics "White Paper" [2] seeking to validate the concept of DNC, and
the criteria and tests for determining DNC outlined in the guidelines by
professional societies, definitively settled the issue, or (b) the critics
have been raising legitimate concerns and have successfully challenged the
validity of this concept. Regarding the President's Council of Bioethics'
philosophical validation of DNC, the debate is ongoing and indeed has
intensified [3-5]. In regard to professional societies' guidelines, the
American Academy of Neurology has assigned level "U" (i.e., unknown,
conflicting or insufficient evidence) to several recommendations in the
DNC [6]. Generally, for clinical practice guidelines to be trustworthy,
the Institute of Medicine requires the recommendations to be supported by
a much higher level of evidence than "U" [7].
The authors also mention that some articles refer to the brain-dead
patient as being "kept alive" by artificial methods rather than as being
dead. Yet this brings out the fact that it is odd to declare an individual
with functioning circulation and respiration (in the sense of cellular
exchange of oxygen and carbon dioxide-- ventilator-dependence is
irrelevant to the issue of whether a person is alive or dead) dead as is
done in brain-dead patients. Even though the authors ostensibly
acknowledge the academic debate about the validity of brain-death
criteria, de facto they ignore it, claiming (though not arguing) that both
discussions between the patient's family (note the use of the word
"patient," which does not make sense if the patient is dead) and
information shared with the general public should reflect the view that
brain death criteria are "genuine". Therefore, Daoust and Racine's
recommendation to reinforce the genuine nature of neurological
determination of death is not only premature but, if followed through,
would deprive the public of informed decision making about organ donation
following DNC. More importantly, merely repeating the claim that brain-
death criteria are "genuine" does not make them so.
Maintaining the professional integrity of medicine and public trust
is a responsibility shared by the global medical community. This
responsibility demands honesty, truthfulness and transparency with the
general public regarding healthcare issues (e.g., organ donation at the
end of life). Daoust and Racine report that critics of DNC have argued
that DNC "merely represents a convenient 'redefinition' of death solely
for the purpose of transplant medicine." Many in the medical community
would agree with the critics. After several decades, the cumulative
clinical experience with many kinds of brain-dead patients over decades,
combined with logic has disproved the neurologic criterion of death.
Persistent denial of caveats that donors are not certainly dead may be
leading to grievously unethical medical practice namely: (1) the lack of
truly informed consent in the donation process, (2) the strategic campaign
of rhetoric, partial information, and misinformation designed to induce
people to check the donor box on drivers licenses and to induce families
to authorize donation from a "brain-dead" loved one, (3) the nondisclosure
of financial conflict of interest on the part of organ procurement
representatives whose job is to convince grieving families to donate.
The media have been fulfilling their primary duties of disclosing to
the general public scientific, ethical and cultural controversies about
neurologic criteria [8,9]. The conclusion of Daoust and Racine that
"public discussions should reinforce the genuine nature of neurological
determination of death as a criterion to establish death" and "scholarly
debates need to be contextualized to avoid undue collateral damage to
public confidence in DNC and organ donation practices" can also be
construed as a call for censorship of media and suppression of scholarly
debates. Costas-Lombardia and Castiel have criticized the control of
information in Spain by the transplantation industry: "disinformation of
society is an indispensable condition for the success of the 'Spanish
Model'" [10]. Organ procurement and transplantation practice generate
billions of dollars in a commodified US health care system annually [11].
The call for control of media and scholarly debates to avoid collateral
damage to organ transplantation practice may indeed violate public trust
in the medical profession and the First Amendment of the United States
Constitution.
Michael Potts, Ph.D., Department of Philosophy, Methodist University,
Fayetteville, North Carolina, USA
Joseph L. Verheijde, PhD, MBA, PT, Department Physical Medicine and
Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
David W. Evans, MA, MD, FRCP, Queens' College, Cambridge, UK
Mohamed Y. Rady, MB BChir MA MD (Cantab), Department of Critical Care
Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
D. Alan Shewmon, MD Olive View-UCLA Medical Center, Sylmar, CA, USA
References
1. Daoust A, Racine E. Depictions of 'brain death' in the media:
medical and ethical implications. J Med Ethics.2013:Published Online
First: 12 April 2013 doi:2010.1136/medethics-2012-101260
2. The President's Council on Bioethics. Controversies in the
determination of death. A White Paper of the President's Council on
Bioethics. 2008; http://bioethics.georgetown.edu/pcbe/reports/death/.
Accessed 10 April 2013.
3. Shewmon A. Brain Death: Can It Be Resuscitated? Hastings Cent
Rep.2009; 39(2):18-23.
4. Joffe AR. Brain death is not death: a critique of the concept,
criterion, and tests of brain death. Rev. Neurosci.2009; 20(3-4):187-198.
5. Nair-Collins M. "Brain Death, Paternalism, and the Language of
"Death"." Kennedy Inst Ethics J.2013; 23(1):53-104.
6. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based
guideline update: Determining brain death in adults: Report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology.2010; 74(23):1911-1918.
7. Institute of Medicine (IOM) -National Academy of Sciences.
Clinical Practice Guidelines We Can Trust. 2011;
http://www.nap.edu/openbook.php?record_id=13058. Accessed 10 April, 2013.
8. Rady MY, McGregor JL, Verheijde JL. Mass media campaigns and organ
donation: managing conflicting messages and interests. Med Health Care
Philos.2012; 15(2 ):229-241.
9. Rady M, McGregor J, Verheijde J. Transparency and accountability
in mass media campaigns about organ donation: a response to Morgan and
Feeley. Med Health Care Philos.2013:Published online: 25 January 2013. DOI
2010.1007/s11019-11013-19466-11014.
10. Costas-Lombardia E, Fereres Castiel J. The Easy Success of the
Spanish Model for Organ Transplantation. Artif Organs.2011; 35(9):835-837.
11. Bentley TS, Hanson SG, Hauboldt RH. Milliman Research Report.
2011 U.S. organ and tissue transplant cost estimates and discussion. 2012;
http://publications.milliman.com/research/health-rr/pdfs/2011-us-organ-
tissue.pdf. Accessed April 1, 2013.
We would like to thank Professor Stewart Justman for his thoughtful
paper "Placebo: the lie that comes true", in which he highlights the
often neglected deception in research on placebos and points out the
potential harms related to half-truths or exaggerated claims about the
"power of the placebo" (1). We agree strongly with his conclusion that "it
is necessary to root the placebo effect in the attentive practice of
me...
We would like to thank Professor Stewart Justman for his thoughtful
paper "Placebo: the lie that comes true", in which he highlights the
often neglected deception in research on placebos and points out the
potential harms related to half-truths or exaggerated claims about the
"power of the placebo" (1). We agree strongly with his conclusion that "it
is necessary to root the placebo effect in the attentive practice of
medicine itself". We also agree with his other conclusion that the
"appropriate response to this dilemma is first of all to consider the
placebo effect as a therapeutic benefit arising from the conscientious
performance of the rituals of good medicine, and not as a resource to be
tapped by the use of trickery (with equivocations counting as trickery) or
dispensed in the form of pills."
As Justman also remarks, much of the confusion related to placebos
and placebo effects is related to the ambiguous nature and many
understandings of these concepts. We'd like to develop this point further
and repeat our earlier suggestion to replace the ambiguous "placebo
effect" with a new term "care effect" in the clinical context (2). In the
research context, the term "placebo effect" could be replaced by the
expression "the effect in the control group" when the outcome of the
research is discussed. The equivocal concept "impure placebo" confuses
more than it clarifies and should be abandoned totally. If a method of
treatment is ineffective in its own right, it should be called an
ineffective treatment for a particular patient or problem.
References:
1. Justman S. Placebo: the lie that comes true. J Med Ethics 2013;39:243-
248.
2. Louhiala P, Puustinen R. Rethinking the placebo effect. J Med Ethics;
Medical Humanities 2008;34:107-109.
Authors:
Pekka Louhiala, Hjelt Institute, University of Helsinki, Finland,
pekka.louhiala@helsinki.fi
Raimo Puustinen, Medical School, University of Tampere, Finland,
raimo.puustinen@uta.fi
For full disclosure, I should begin by saying that I read this paper because I am personally acquainted with one of the authors, Johann Roduit, with whom I had a brief exchange about the paper and who encouraged me to submit my few critical thoughts to this site. Also, I should say that I am not an expert in bioethics, but simply an interested layman.
As a layman, I read the paper with pleasure. The thoughts were clearl...
For full disclosure, I should begin by saying that I read this paper because I am personally acquainted with one of the authors, Johann Roduit, with whom I had a brief exchange about the paper and who encouraged me to submit my few critical thoughts to this site. Also, I should say that I am not an expert in bioethics, but simply an interested layman.
As a layman, I read the paper with pleasure. The thoughts were clearly articulated, and I learned something about the current debate within this particular field of ethics. The paper does a good job at laying out the respective positions of bioconservatives and bioliberals and pointing out "the crucial question of the ultimate goals of biotechnological interventions."
In our exchange about the paper, Mr. Roduit told me that his main criticism is directed against people who "refuse to speak of an ideal at all," although they "cannot avoid having an ideal influencing the way they wish to enhance." This point is well taken, but in my view, the paper goes too far in charging bioconservatives with an "untenable ambiguity between criticising and endorsing ideas of human perfection" (p. 1). I am also inclined to think that the paper goes too far in charging bioliberals with an "unconvincing" denial of the relevance of perfection, but here I will restrict my comments on the criticism of bioconservatives.
Of course, the authors of the paper are right that anyone who makes any kind of proposition in regard to human behavior has some kind of ideal in mind. Otherwise the person would not make a proposition at all. People who say that everyone should do as they please have the ideal of individual autonomy in mind. People who say that human perfectibility is not desirable thereby say that another human state is more desirable and hence, in a certain sense, more perfect.
But this observation, as true as it is, seems to me little more than a tautology. It says little more than, "People who make a normative statement, no matter of what kind, have a certain norm in mind." Naturally. But does that merit the charge that certain bioconservatives have an "untenable ambiguity" in regard to human perfectibility? I doubt it.
To make clearer why I doubt the merit of this charge, let me use a few examples from other fields. Take political philosophy, for instance. According to the thinking of the paper, one may charge Machiavelli's realpolitik with the same kind of "untenable ambiguity" as the authors charge bioconservatives, because Machiavelli makes the prescriptive (=idealistic) statement that a ruler should not be too idealistic but rather use whatever methods work to maintain order and keep society running in a reasonably safe state. One could then take the criticism of Machiavelli's ambiguity further and claim that his Prince is really just as idealistic as Plato's Philosopher-King, because he makes just as many normative statements about him as Plato does about his explicitly ideal ruler. Therefore, one might say, Machiavelli should bring his implicit idealism into the light of explicit discussion instead of pretending that he is abandoning the political idealism of the likes of Plato.
However, to my mind, such a charge is more sophistic than helpful and blurs the very important distinction between the idealism of Plato's Philosopher-King and the realpolitik of Machiavelli's Prince. Plato is clearly an idealist, and Machiavelli is clearly a realist, and making normative statements about being flexibly realistic does not turn him into an idealist.
To give another example, this time from the earliest literature we possess, which already deals with the big themes of the human condition and the ideal human life, let us take the Epic of Gilgamesh. Gilgamesh, an ancient king of Uruk (modern-day Iraq), loses his best friend and realizes that he, too, shall one day die. Hence, he goes on a quest to find immortality, but in vain. Not only does he learn that immortality is reserved for the one couple that survived the Great Flood in a boat, because it was a unique situation that led the gods to bestow immortality on them, but the rejuvenating Plant of Life is also stolen from Gilgamesh by a serpent. Gilgamesh therefore has to accept his mortality, and he proceeds to engage in great building projects in order to make a lasting name for himself in that way.
The Epic of Gilgamesh seems to make the point that, in order for a human to flourish, he or she needs to accept their mortality. In other words, the story can be said to set up a kind of ideal of what the good life is, but at the same time the story conveys the strong message that the good human life is far from perfect. "Ideal under the very imperfect circumstances" is not the same as perfection.
To give third and last example, the Greeks were instructed to "know thyself," that is, to know the limits of the human condition, and this self-knowledge can be said to have been an ideal. But the ideal consisted precisely in the acknowledgment that, under the circumstances, humans are not and can never be perfect.
In my view, it would be confusing to say that recognizing the existence of imperfection as a precondition for many good things is to erect another standard of perfection, as the paper seems to charge certain bioconservatives with doing. It is not another standard of perfection but simply the recognition that certain good things hinge on the existence of imperfection.
That's the two cents from a layman for now, written with much ignorance about the details of today's bioethical debate.
For clarity's sake, however, I would like to point out in reply that
I do not cite Ahsan to 'legitimize' any claim. Rather I present it as
legal authority for a claim about legal principle. The principle is clear,
though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies
to patients...
For clarity's sake, however, I would like to point out in reply that
I do not cite Ahsan to 'legitimize' any claim. Rather I present it as
legal authority for a claim about legal principle. The principle is clear,
though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies
to patients individually, and thus necessarily varies from patient to
patient. I do not for a moment consider that best interests supports the
measures discussed in the paper for all patients; rather I suggest that it
does so in some cases.
The respondents to my paper seem to suggest that a preponderance of
relgious opinion renders my interpretation of the law impossible.
Their argument rests on a fundamental failure to appreciate that the
law respects a plurality of distinct values. Many systems of beliefs are
respected.
It would not be true that it would be in everyone's best interests,
as that idea is understood in English law, to become organ donors. But it
is wrong to suggest that this means that it can be in no-one's best
interests.
In a recent article by Walter Sinnott-Armstrong and Franklin G.
Miller, the argument is made that ability should be the metric of value
among human life and thus the determining factor on what constitutes moral
harm when killing. Someone who has permanently lost all abilities no
longer has value and killing them would not only fail to add more harm and
it would also fail to take away any more value.
In a recent article by Walter Sinnott-Armstrong and Franklin G.
Miller, the argument is made that ability should be the metric of value
among human life and thus the determining factor on what constitutes moral
harm when killing. Someone who has permanently lost all abilities no
longer has value and killing them would not only fail to add more harm and
it would also fail to take away any more value.
In the authors' case, to say that "Betty is not worse of dead" is to
presume knowledge about death. It's taken for granted what the authors
believe about death is true: a descent into non-existence and nothingness.
However, we cannot say whether it is better to become nothing than to be
conscious and totally and irreversibly disabled mainly because we have
experienced neither, and we have no ability to comprehend what it would be
like to "be nothing" (a contradictory phrase, but one that captures the
farce in making the claim that someone is "not worse off dead" if one
presupposes nothing after death). I certainly don't believe that we
descend into nothingness when we die, and indeed the things that happen
after we die could be much worse than our present life, but I'm only using
the authors' own views to determine that they aren't justified to say that
Betty is not worse off dead; even if she were, it would be a matter of
personal preference toward either nothingness or total and irreversible
disability.
Furthermore, the authors divorce morality from truth when they say
"one advantage of this position is that it simplifies the structure of
morality." Either that which is most simple is always true, or else
morality and truth have no relationship and we pursue that which is most
useful to us, regardless of its veracity. Why should simplicity win on the
merit of simplicity alone? The authors identify the simplification of
morality as an advantage of this perspective, regardless of whether that
simplification is born out of truth: is it actually true that it is wrong
to kill a universally and irreversibly disabled person? The truth, it
seems, doesn't matter as much as the simplicity of the moral system.
The authors also assume that it is worse to cause a person to be deaf
and blind rather than only blind. However, this begs the question, for
this is only worse in their system of morality in which abilities are the
metric of value. In that system, it makes sense that it is worse to
deprive a person of two abilities rather than one. However, in other
systems, depriving a person of any abilities ("without adequate reason")
reaches maximum heinousness and to add increasing quantities of ability
deprivation to that doesn't make it any more wrong, but only more tragic.
The authors' example here, then, isn't helpful to them because it assumes
the system of value they're trying to establish.
The rebuttal to the objection regarding God's commandment is
superficial. First, it assumes that the strength of God's commandment is
in the reason that justifies his commandment and not the command itself.
This is not evidenced throughout Judeo-Christian theology, the theology
that I would be prepared to assert and defend; instead, God should be
obeyed because he is God. This is why Lot's wife was turned into a pillar
of salt: because she disobeyed God. It doesn't matter what God's reasons
were for commanding her not to look back on the destruction of Sodom and
Gomorrah. What matters is that he commanded it at all and his commands are
self-justifying because he is God. This leads us into a discussion
regarding the sovereignty of God and epistemology, which isn't the main
topic at hand, but suffice it to say that the authors dismiss this
objection without actually rebutting it.
The authors go on to further establish, in their rebuttal of the
anticipated objection by secular theorists, how they are begging the
question in their argument. The main question of their paper may be, "Why
is life valuable in this extreme case when it includes no ability?"
They're trying to show in their argument that killing people in this state
is not wrong because lack of ability constitutes total loss of value. To
dismiss this objection by assuming that the metric of value is ability is
to beg the question in the rebuttal.
They reduce moral theory to a matter of preference when they write,
"these arguments will have no force at all for those of us who prefer our
moral theories to be independent of religion." Therefore, it doesn't
matter what is actually true; what matters is what one prefers. They
further support this idea by stating that it is problematic to depend on
religious belief in philosophical theory as well as public policy. They
imply that what is good is an agreeable solution for all, even if that
means that the agreeable solution isn't what's actually true. Is this
right or even good? Unfortunately that small question alone is irrelevant
to those who do not care about what's right but instead only what serves
their preferences! Thus this discussion cannot even begin until we deal
with moral relativism, a discussion unto itself.
They go on to nearly refute their entire argument when addressing
concerns regarding whether using ability as the metric of value would lead
to the assignment of variable values to humans with non-zero quantities of
ability.
For their first response regarding possession of abilities greater
than plants, why would that be the case? Why plants in particular? If one
is going to hold the "minimal ability threshold" stance, does that mean a
human with, say, one ability is equivalent to a chimpanzee with one
ability? Indeed, under this view, why aren't chimpanzees and humans
equivalent, or any non-plant life? The authors fail to flesh out this
rebuttal to make it consistent with the rest of their argument.
Furthermore, they establish earlier in their argument that if it is wrong
to remove one ability, it is more wrong to remove two, and maximally wrong
(indeed, equivalent to murder) to totally and irreversibly disable
someone. Their argument cannot be paired with this objection because this
objection assumes that abilities do not have individual value but only the
trait of "ability possession" (in which a person may only possess one
ability) is what actually grants value.
Their second response (that it would be morally wrong to treat people
differently based on their different abilities) does a good job of
overturning the argument for which the paper was written. Are we not
treating the totally and irreversibly disabled person differently based on
their lack of ability? Yet the authors argue that one could rebut the
aforementioned objections by declaring that it's wrong to do just that.
The third response is antiquated: quality- and disability-adjusted
life years (QALYs and DALYs) are already used to compare people with
different disabilities and sets of abilities. This is not a perfect
system, but it's what's being used for any number of purposes now. If one
is going to respond in this way, one would have to make the point of doing
away with QALYs and DALYs.
The fourth response is essentially what the authors are doing in this
paper. They're insisting that ability should be the metric of value, yet
they haven't established why that should be the case and they've done a
poor job of dealing with the anticipated objections. Indeed, if ability is
the metric of value, then a myriad of questions are raised that the
authors don't address: for someone who is reversibly disabled, how many
abilities must they recover to gain value again and thus pull themselves
from the chopping block? What if they can follow simple commands? Write
their name? Speak? Maintain urinary and bowel continence? Do abilities
differ in value, as this would become a real concern in determining
whether to harvest someone's organs? If not, would it be accurate to say
all who are disabled at all are equally disabled?
The fifth and final response is essentially selling the agenda;
somehow get people to believe that what is wrong isn't that wrong, or what
is wrong is actually good. When variable value is assigned to humans, such
that some are worth less than others, that is the stuff out of which
tyrannies, discrimination, eugenics and persecution are made. It is not
hyperbole to indicate this because that is precisely the philosophy of
historical figures like Adolf Hitler: some people were worth more than
others during the Third Reich and some people were worth so little and so
detrimental to society that they were better off exterminated. This, of
course, is the extreme conclusion of the authors' argument, but the
authors' argument sets the precedent for it; it paves the way for other
arguments to march, one step at a time, toward that conclusion.
In stating that it is bad to shorten life and thus worse to shorten
it more in killing younger or healthier individuals, the authors assume
that quantity is what gives life value; in this particular point, not just
quantity of abilities, but quantity of years left to live. They neglect
the possibility that life, regardless of the quantity remaining, maintains
maximum value until death. An analogy would be currency: whether you have
$1000 or $1, a dollar is still worth a dollar (putting aside inflation and
other economic confounders). Thus, as you spend your money, your money
doesn't lose value. By the time you're down to your last dollar, it's not
worth $0.10 or some other amount; it's still worth a dollar. The
subjective value of that dollar to its owner may be greater (it becomes
more precious to its owner because the owner does not have the other
$999), but the objective worth of it is still one. If anything, as life
shortens, it becomes more precious (particularly for the atheist, who
believes that this is all we get!), so it may be more wrong kill people
with less time left to live.
In discussing violations of the dead donor rule, the authors miss the
mark in clearly establishing what death is. Brain death is merely a
surrogate marker for determining death proper. What we actually care about
is whether the organism itself, the person, is dead. We use brain death as
a marker for the organism's inability to maintain cohesion of its various
systems to the benefit of itself. According to Maureen Condic, a
neurobiologist at the Universty of Utah, when an organism can no longer
"act in a coordinated manner for the continued health and maintenance of
the body as a whole," it's considered dead (Condic, M. Life: Defining the
Beginning by the End. First Things. 2003). This appears to be the most
intuitive, holistic definition of death. The reason why we look for brain
death is because we care whether we're using machines to artificially
prolong the survival of an organism that can no longer perform this
fundamental function; it is not strictly to determine whether higher-order
brain function is lost. Thus Condic explains:
"It is often asserted that the relevant feature of brain death is not
the loss of integrated bodily function, but rather the loss of higher-
order brain activities, including consciousness. However, this view does
not reflect the current legal understanding of death. The inadequacy of
equating death with the loss of cognitive function can be seen by
considering the difference between brain death and "persistent vegetative
state" or irreversible coma. Individuals who have entered a persistent
vegetative state due to injury or disease have lost all higher brain
functions and are incapable of consciousness. Nonetheless, integrated
bodily function is maintained in these patients due to the continued
activity of lower-order brain centers. Although such patients are clearly
in a lamentable medical state, they are also clearly alive; converting
such patients into corpses requires some form of euthanasia."
Therefore if one is brain dead, one is properly dead because brain
death is a marker for the organism's permanent inability to coordinate the
maintenance of all its various sub-systems into a cohesive whole. The
authors' ignore the implication that brain death is being used as a
surrogate marker for the death of the organism in light of the fact that
we can use machines to keep the cellular processes of the organism going
without the organism ever being able to recover its coordinated manner by
which it sustains its life. To procure organs from these individuals is
not a violation of the dead donor rule; they're dead.
They raise a second example in which they believe the dead donor rule
is violated, yet they fail to point out that the decision has been made to
not resuscitate these individuals, just like anyone else with a "do not
attempt resuscitation" order in their chart. Obviously it's
philosophically inconsistent if a patient goes through vital organ
donation but has an advanced directive still in place to attempt
resuscitation. Irreversibility isn't included in the legal definition of
death because plenty of people who die could be resuscitated but are not
because of their advanced directive, yet we still declare them dead when
they enter into that state because we will not prevent them from naturally
progressing to the point at which their body loses the capacity to
maintain cohesion amongst its sub-systems.
Interestingly, Dr. Miller co-authored a paper in the New England
Journal of Medicine on the topic of the dead donor rule, and a point was
made that seems to stand contrary to the central argument of the article
in question (Truog and Miller. The Dead Donor Rule and Organ
Transplantation. 2008. NEJM):
"At the dawn of organ transplantation, the dead donor rule was
accepted as an ethical premise that did not require reflection or
justification, presumably because it appeared to be necessary as a
safeguard against the unethical removal of vital organs from vulnerable
patients. In retrospect, however, it appears that reliance on the dead
donor rule has greater potential to undermine trust in the transplantation
enterprise than to preserve it. At worst, this ongoing reliance suggests
that the medical profession has been gerrymandering the definition of
death to carefully conform with conditions that are most favorable for
transplantation. At best, the rule has provided misleading ethical cover
that cannot withstand careful scrutiny. A better approach to procuring
vital organs while protecting vulnerable patients against abuse would be
to emphasize the importance of obtaining valid informed consent for organ
donation from patients or surrogates before the withdrawal of life-
sustaining treatment in situations of devastating and irreversible
neurologic injury."
The question, it seems, is irrelevant as long as strict adherence to
informed consent and the advanced directive of the patient (if present) is
upheld. Those are our guiding principles in choosing to withdraw
aggressive care, whether it be from the patient with multi-organ failure
in the intensive care unit or the patient with metastatic cancer in the
outpatient setting who just wants to live his last two weeks free from the
burden of chemotherapy and other aggressive interventions. The valid
concern is that organs would begin to be harvested from people who have
reasonable chances of survival or are not even in imminent danger of
death. Yet we seem to navigate this labyrinth fairly well when patients or
their families request a cessation of aggressive care apart from concerns
of organ transplantation; the additional piece that must be added to it in
matters of transplantation is the avoidance of euthanasia and physician-
assisted suicide, the ethics of which will not be discussed here, but for
the sake of this discussion I take for granted as wrong. I suspect it
would be very difficult to determine a general rule that could apply to
all cases, but that each patient must be approached individually.
Interestingly, Dr. Truog and Dr. Miller identify that, at worst,
"this ongoing reliance [on the dead donor rule] suggests that the medical
profession has been gerrymandering the definition of death to carefully
conform with conditions that are most favorable for transplantation." It
seems that is exactly what is being done in this paper Dr. Sinnott-
Armstrong and Dr. Miller have submitted to the Journal of Medical Ethics
and the applications reach beyond the field of transplantation. The
authors are trying to figure a way to broaden the population that would be
available to donate their organs. With the precedent set, each following
step becomes easier to take and before long we really are harvesting
organs from people who are in no imminent danger of death. Indeed, the
reductio ad absurdum would be the harvesting of organs from individuals
who are disabled in some capacity and do not even want their organs
harvested. The authors attempt to stave off this objection by stating, "We
can hold the line for vital organ donation by continuing to restrict it to
those in a state of total (universal and irreversible) disability. It is
only these donors who would not be harmed or wronged by vital organ
donation, since all other donors have abilities to lose." Yet they are not
holding the current line (i.e., the dead donor rule). So the line is moved
this time and, perhaps even after the authors themselves are dead, still
others will desire to move the line and will make arguments in favor of
it. And another argument will be made to move the line further. This is
the power of precedent setting. Why should we trust those who move the
line to hold the line?
"What makes killing wrong" is a transparent attempt to do what Dr.
Miller denounces in his paper in the New England Journal of Medicine:
"gerrymander the definition of death," or in this case, gerrymander those
circumstances about which one might be declared suitable for
transplantation. The scope of this argument extends beyond organ
transplantation, however, and into the broader world of medicine. If
adopted, this view would color for the worse how we perceive the weak, the
sick, the aged and the unborn.
"Ahsan v University Hospitals Leicester NHS Trust" does not
legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to
legitimize elective mechanical ventilation and preservation of organs in
dying patients for transplantation [1]. Elective mechanical ventilation
alone does not preserve organs in donors for transplantation without
performing ad...
"Ahsan v University Hospitals Leicester NHS Trust" does not
legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to
legitimize elective mechanical ventilation and preservation of organs in
dying patients for transplantation [1]. Elective mechanical ventilation
alone does not preserve organs in donors for transplantation without
performing additional medical procedures. We have discussed elsewhere
several antemortem medical procedures for organ preservation that
included, but not limited to,: 1) endotracheal intubation, 2) invasive
positive pressure ventilation, 3) pharmacological and/or mechanical
support of the circulation, 4) invasive instrumentation of blood vessels
and body cavities, and 5) use of antemortem preservative drugs such as
anticoagulants and vasodilators [2,3]. Coggon cited Ahsan v University
Hospitals Leicester NHS Trust to argue in favor of the permissibility of
elective mechanical ventilation in end-of-life care of dying patients for
the specific purpose of organ preservation and donation [1]. We disagree
with Coggon's interpretation of the 2 standards applied in Ahsan case: (1)
patient's best interests; and (2) reasonableness of the proposed care
regime.
(1) The standard of patient's best interests
Section 4(6) of the UK Mental Capacity Act of 2005 states that in
determining what is in a person's best interests one "must consider, so
far as is reasonably ascertainable-- (a) the person's past and present
wishes and feelings (and, in particular, any relevant written statement
made by him when he had capacity), (b) the beliefs and values that would
be likely to influence his decision if he had capacity, and (c) the other
factors that he would be likely to consider if he were able to do so".
Furthermore, section 4(7) (b) of the Act affirms that one "must take into
account, if it is practicable and appropriate to consult them, the views
of-- anyone engaged in caring for the person or interested in his welfare"
[4].
In Ahsan v University Hospitals Leicester NHS Trust 2006 [5],
familial, cultural and religious considerations were significant factors
in determining the patient's best interest regarding what, where, when and
how to provide end-of-life care in the event of mental incapacity.
Although medical experts made the case "to disregard any familial, social,
cultural, religious or spiritual considerations in addressing" an
incapacitated person's best interests, Judge Hegarty QC came to a
different conclusion. Judge Hegarty QC stated in the final ruling: "[o]n
the contrary, I would have thought that most reasonable people would
expect, in the event of some catastrophe of that kind, that they would be
cared for, as far as practicable, in such a way as to ensure that they
were treated with due regard for their personal dignity and with proper
respect for their religious beliefs" [5]. In accordance with the UK Mental
Capacity Act of 2005, cultural and religious values and beliefs must be
considered and respected in end-of-life care. In the case of Ahsan, a
Sunni Muslim, the values, beliefs and rituals of the Islamic faith
determined the "best interests" in end-of-life care.
Coggon extrapolated from the Ahsan case, to argue that the person's
(donor) "best interest" in end-of-life care should include supplying
transplantable organs to a third party (recipient). However, if the
preparation and execution of procurement of transplantable organs directly
collide with the values, beliefs and rituals of a person's faith about end
-of-life care, then Coggon's argument is bound to fail. Indeed, most world
religions would nullify first-person consent to become an organ donor if
the process of donating transplantable organs is believed to constitute a
violation of enshrined faith-based values and beliefs about caring for
dying individuals [6-10].
(2)The standard of reasonableness of the proposed care regime
There are several practical deficiencies in Coggon's claim that
elective mechanical ventilation meets the standard of "reasonableness of
the proposed care regime"[5]. The proposed elective mechanical ventilation
is only one step of multiple sequential medical procedures that must be
performed successfully to preserve organs for transplantation.
Cardiovascular support is essential following elective mechanical
ventilation to perfuse and preserve transplantable organs. Acute
resuscitation and stabilization of both cardiac and circulatory functions
are generally required after invasive positive pressure ventilation [11].
If elective mechanical ventilation induces an acute cardiovascular
collapse in dying patients, that is refractory to cardiopulmonary
resuscitation, extracorporal membrane oxygenation (artificial heart-lung
machine) will have to be introduced so as to preserve organs for
transplantation [2].
Following elective mechanical ventilation, most donors who are dying
from neurological injuries fail to progress to the neurological criterion
of death to enable heart-beating organ donation [12]. In this situation,
elective withdrawal of mechanical ventilation is medically required to
induce arterial pulselessness (cardiac mechanical asystole) and meet the
circulatory criterion of death in controlled non-heart-beating organ
donation [13]. Almost 50% of potential donors, however, fail to progress
to arterial pulselessness within 60 minutes after withdrawing mechanical
ventilation [14,15]. Organs procured after 60 minutes generally sustain
warm ischemic injury and recipients are likely to develop primary
nonfunction or delayed function of the transplanted allografts [16]. This
raises additional practical questions about the end-of-life care of
potential donors who undergo elective ventilation. If they fail to die
within the required time to donate transplantable organs, what happen to
the still living but dying patients? Furthermore, considering that
potential donors should be transferred to the intensive care unit for
elective mechanical ventilation and antemortem organ preservation, should
this scarce resource be prioritized to potential donors rather than to
critically ill patients who are in need of life-support? Alternatively,
should potential donors be transferred to separate procurement units
especially designed for elective mechanical ventilation and antemortem
organ preservation?
In conclusion, we disagree with Coggon's interpretation of patient's
best interests and reasonableness of the proposed elective mechanical
ventilation in end-of-life care for the specific purpose of organ
preservation and donation. As other commentators have done earlier [17],
Coggon has mistakenly used the decision in Ahsan v University Hospitals
Leicester NHS Trust to support his position on the legal permissibility of
antemortem organ preservation in controlled heart-beating donation. Others
have mistakenly generalized that antemortem organ preservation upholds
human dignity and beneficence [18]. We assert that beneficence,
compassion, and human dignity in end-of-life care mean upholding and
respecting the cultural and religious values of dying patients [19]. We
think that the standards of person's best interests and the reasonableness
of proposed care invoked in Ahsan case can, instead, be a ground to
legitimately, even mandatorily revoke or overrule a prior first-person
consent if the process of organ donation is believed to constitute a
violation of the religious values and beliefs of the potential donor or
the surviving family.
Consultant, Department of Critical Care Medicine,
Mayo Clinic Hospital, Phoenix, Arizona, USA
Joseph L. Verheijde, PhD, MBA, PT
Associate Professor, Biomedical Ethics, College of Medicine, Mayo
Clinic
Department of Physical Medicine and Rehabilitation, Mayo Clinic,
Phoenix, Arizona, USA
References
1. Coggon J. Elective ventilation for organ donation: law, policy and
public ethics. J Med Ethics.2012:Published Online First: 7 December 2012
doi:2010.1136/medethics-2012-100992
2. Rady MY, Verheijde JL, Johnstone M-J. The general public is ready
for transparency about organ donation at the end of life. Em Med
J.2012;29(10):858-859.
3. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical
challenges of end-of-life organ procurement in emergency medicine.
Resuscitation.2010;81(9):1069-1078.
4. The National Archives on behalf of HM Government. Mental Capacity
Act 2005. http://www.legislation.gov.uk/ukpga/2005/9/contents.
5. The High Court of Justice Queen's Bench Division. Ahsan v
University Hospitals Leicester NHS Trust [2006] EWHC 2624 (QB). 2006.
6. The Lancet. Religion, organ transplantation, and the definition of
death. Lancet.2011;377(9762):271-271.
7. Rady MY, Verheijde JL. Brain-dead Patients Are Not Cadavers: The
Need to Revise the Definition of Death in Muslim Communities. HEC Forum.
2012:Published online: 28 September 2012, DOI: 2010.1007/s10730-10012-
19196-10737. http://dx.doi.org/10.1007/s10730-012-9196-7.
8. Jones DA. Loss of faith in brain death: Catholic controversy over
the determination of death by neurological criteria. Clinical
Ethics.2012;7(3):133-141.
9. Sanchez GM. Objections to Donation after Cardiac Death. A
Violation of Human Dignity. Natl Cathol Bioeth Q.2012;12(1):55- 65.
10. Shewmon DA. You only die once: why brain death is not the death
of a human being. A Reply to Nicholas Tonti-Filippini. Communio:
International Catholic Review.2012;39(Fall issue):422-494.
11. Watkinson P, McKechnie S, Wilkinson D, Salmon J, Young D.
Actively delaying death to increase organ donation. BMJ.2012;344:e1179
12. Kompanje EJO, de Groot YJ, Bakker J. Is Organ Donation From Brain
Dead Donors Reaching an Inescapable and Desirable Nadir?
Transplantation.2011;91(11):1177-1180
13. Bernat JL, Capron AM, Bleck TP, et al. The circulatory-
respiratory determination of death in organ donation. Crit Care
Med.2010;38(3):963-970.
14. de Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E,
Kompanje EJO. External validation of a prognostic model predicting time of
death after withdrawal of life support in neurocritical patients. Crit
Care Med.2012;40(1):233-238
15. Rabinstein AA, Yee AH, Mandrekar J, et al. Prediction of
potential for organ donation after cardiac death in patients in
neurocritical state: a prospective observational study. The Lancet
Neurology.2012;11(5):414-419.
16. Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, et al. Current
situation of donation after circulatory death in European countries.
Transpl Int.2011;24(7):676-686.
18. De Lora P, P?rez Blanco A. Dignifying death and the morality of
elective ventilation. J Med Ethics.2013:Published Online First: 8 January
2013 doi:2010.1136/medethics-2012-100995
19. Rady MY, Verheijde JL. Comfort Care, Withdrawal of Life-Support
Treatment, and Nonconsensual Euthanasia in the ICU. Crit Care
Med.2013:DOI: 10.1097/CCM.1090b1013e31827c31803ac.
I read Robert Card's recent paper entitled "Is there no alternative?
Conscientious objection by medical students" with great interest.1 That
Muslim students in America are able to conscientiously object (and this
was entertained) to the cross-gender consultation is somewhat startling. I
have just left the Middle East, where I worked as a medical educator for
five and half years (2006-2011), and, to the best of my knowledg...
I read Robert Card's recent paper entitled "Is there no alternative?
Conscientious objection by medical students" with great interest.1 That
Muslim students in America are able to conscientiously object (and this
was entertained) to the cross-gender consultation is somewhat startling. I
have just left the Middle East, where I worked as a medical educator for
five and half years (2006-2011), and, to the best of my knowledge, even in
the conservative, gender-segregated traditional Muslim culture of the
United Arab Emirates, not once did a male or female student refuse to
examine a patient of the opposite sex.
Several issues, many of which have been described by Padela and del
Pozo,2 should be taken into consideration in relation to Muslim students'
conscientious objection to the cross-gender consultation on religious
grounds. Although Islam prohibits touching or physical contact by the
opposite gender, unless appropriate (e.g. by a spouse), in some
circumstances, the "prohibited becomes permissible".3 Medicine is one such
circumstance. Islam does not preclude a doctor from examining the
opposite gender where a same gender physician is not available or in life
and death situations.2-6 Islam recommends first a same gender Muslim
physician, followed by a same gender non-Muslim and, failing their
availability, a Muslim of opposite gender, and lastly an opposite gender
non-Muslim doctor. 3,5 In cross-gender consultations, however, Muslim
women generally need to be accompanied by a same gender third party.3-5
The ancient literature on medical care attests to the possibility of and
necessity for cross-gender examinations. In the eighth century, Ibn
Quaddama wrote that it was permissible for a male doctor to inspect
whatever parts of the woman's body warranted during the medical
examination.4 Similarly, Ibn-Muflih stated that "A man doctor may inspect
the awra of a women's body as far as the medical examination warrants if
only a male doctor is available to treat her, even if he has to look at
her private parts. The same would be true if a man is ill and there is but
the woman doctor to treat him. She may inspect his body even his private
parts" (p. 3).4 Furthermore, this literature attests to the need for
Muslims to seek the most qualified practitioner for their medical
treatment. Some 600 years ago, Ibn Qayyim Al Jawziyya wrote in The
Prophetic Medicine that Muslims should seek the best authority in each
matter and field because such expertise will ensure that the task is done
with excellence.7 Implicit in this hadith (narrative originating from the
words or deeds of Prophet Muhammad) would be the need to consult an
opposite gender physician if he or she was the most qualified.
The insistence of modern Muslim patients for the same gender physician or
for Muslim medical students conscientiously objecting to the cross-gender
consultation is interesting considering the Islamic history of medicine
during Prophet Muhammad's life. During that time, the medical corps
comprised "lady healers" or asiyaat, who were responsible for treating
wounded soldiers, irrespective of the injuries. Cross-gender medical care
was established during the battles of Badr and Uhud, and so according to
the Prophet's tradition, the rule governing covering of areas of the body
was waived in the interest of medical treatment.3,4
During interviews with final year male and female clerks about the
cross-gender consultation in a society (United Arab Emirates) where women
are generally not free to travel without a member of their mahram (non-
marriageable male chaperone), some female students (more so than their
male colleagues) had initially been apprehensive about touching a male
body. Their mutawa (religious leader) reassured them that as medical
students, they had to treat both male and female patients and were
therefore allowed to touch males. From this study, it also emerged that
although students became more "comfortable" with cross-gender touching in
the clinical consultation, Emirati female patients in Obstetrics and
Gynecology and Emirati male patients in Urology often refused male and
female students, respectively. As little has been published in this
regard, a group of local female students surveyed Emirati women's
attitudes towards male and female medical students as well as canvassed
their physician preference. While their general preference was for a
female student or physician, other factors such as physician certification
and patient education impacted on what parts of the body the women would
or would not allow a male student or physician to examine.8,9
As I indicated at the start of my response, it was startling that
Muslim students in America could conscientiously object to the cross-
gender consultation. This is difficult to reconcile how Muslim students
living in a conservative, gender-segregated and traditional Middle Eastern
society were able to accept that in Islam medical care should supersede
religious teachings and how Muslim students living in a Western country do
not share the same understanding.
References
1. Card RF. Is there no alternative? Conscientious objection by medical
students. J Med Ethics 2012;38:602-4.
2. Padela A, del Pozo PR. Muslim patients and cross-gender interactions
in medicine: an Islamic bioethical perspective. J Med Ethics 2011;37:40-4.
3. Aldeen AZ. The Muslim ethical tradition and emergent medical care: An
uneasy fit. Acad Emerg Med 2007; 14(3): 277-8.
4. Hathout H. The male gynaecologist. Medical examination of the other
sex. 1986. http://www.islamset.org/bioethics/obstet/examin.html (accessed
21 November 2012).
5. Hedayat KM, Pirzadeh R. Issues in Islamic biomedical ethics: A primer
for the pediatrician. Pediatrics 2001;108: 965-71.
6. Hammoud MM, White CB, Fetters MD. Opening cultural doors: Providing
culturally sensitive healthcare to Arab American and American Muslim
patients. Am J Obstet & Gynecol 2005;193: 1307-11.
7. El-Qadar A. trans. Ibn Qay'em El-Jozeyah on The Prophet Medicine,
2007. http://www.islamhouse.com/p/51834 (accessed 21 November 2012).
8. McLean M, Al Ahbabi S, Al Ameri M, Al Mansoori M, Al Yahyaei F,
Bernsen R. 2010. Muslim women and medical students in the clinical
encounter: A United Arab Emirates study. Med Educ 44:306-15.
9. McLean M, Al Yahyaei F, Al Mansoori M, Al Ameri M, Al Ahbabi S,
Bernsen R. 2012. Muslim women's physician preference: Beyond Obstetrics
and Gynecology. Health Care Women Internat 2012;33:849-76.
Dear Editor:
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinio...
Dear Editor:
Benetar argues:
The evidence of injury to the child's sexual func...
We read with great interest Daoust and Racine's contribution to the ongoing debate about brain death and its ethical and medical implications [1]. The authors argue that little is known about how the public understands the concept of death determined by neurological criteria (DNC). They set out to trace common sources of public confusion about DNC and seek to "better define the relationship between expert and lay views...
We would like to thank Professor Stewart Justman for his thoughtful paper "Placebo: the lie that comes true", in which he highlights the often neglected deception in research on placebos and points out the potential harms related to half-truths or exaggerated claims about the "power of the placebo" (1). We agree strongly with his conclusion that "it is necessary to root the placebo effect in the attentive practice of me...
As a layman, I read the paper with pleasure. The thoughts were clearl...
I am grateful for the response to my paper.
For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies to patients...
In a recent article by Walter Sinnott-Armstrong and Franklin G. Miller, the argument is made that ability should be the metric of value among human life and thus the determining factor on what constitutes moral harm when killing. Someone who has permanently lost all abilities no longer has value and killing them would not only fail to add more harm and it would also fail to take away any more value.
In the author...
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to legitimize elective mechanical ventilation and preservation of organs in dying patients for transplantation [1]. Elective mechanical ventilation alone does not preserve organs in donors for transplantation without performing ad...
I read Robert Card's recent paper entitled "Is there no alternative? Conscientious objection by medical students" with great interest.1 That Muslim students in America are able to conscientiously object (and this was entertained) to the cross-gender consultation is somewhat startling. I have just left the Middle East, where I worked as a medical educator for five and half years (2006-2011), and, to the best of my knowledg...
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