Some people with very bad prognosis at birth and with a pack of bad
diagnoses grow up to become relatively happy people. Some don't. There are
many cases when fetuses that were presumed to have Down syndrome, apperaed
healthy babies at birth.
Courts try to avoid capital punishment and usually wait for years before
executing people with death sentence because of possible errors. Still,
sometimes (hovewer, rarely) truth com...
Some people with very bad prognosis at birth and with a pack of bad
diagnoses grow up to become relatively happy people. Some don't. There are
many cases when fetuses that were presumed to have Down syndrome, apperaed
healthy babies at birth.
Courts try to avoid capital punishment and usually wait for years before
executing people with death sentence because of possible errors. Still,
sometimes (hovewer, rarely) truth comes up after a person was executed.
So before even starting to think about the possibility of implementing the
"after-birth abortion" I would recommend authors to study at least several
thousands cases where infants were given bad prognoses, let's say, not
less than 20 years ago. If 99.99% will say that their lives was(is) not
worth living, that they are dreaming aboout being aborted or killed after
birth, then yes, the idea is worth thinking.
I even would let authors to include those who are already dead in this
99.99%. I assure you, many of these "sentenced to death" will appear
valuable and often happy people. Take Ruben Galliego, a quadriplegic,
father of two(?) who recently won a prestigious literature award for his
authobiography.
Or, take Hitler. He was healthy at birth, his mother did not do an
abortion, neither she wanted to have him up to the state. I believe, no
one in the human history caused so much grief and, yes, economcal losses
as this person, who definitely deserved to be annihilated at birth.
We will not solve the mankind problems by killing unwanted babies. Even
the sick ones.
However, severely ill babies really can ruin their families' lives. This
is a sad truth. Not everyone is capable of meeting such a challenge as
caring for a child that makes no progress. So even if the idea of
institutionalization didn't prove itself to be the best one, maybe it is
the solution that can, on the one side, gives babies with bad prognosis
(or unwanted ones) at least a chance to pull through, and, on the other
side, will let parents not to carry the burden they are not prepared to.
Or will give them time to reconsider. So I believe economical resources
should be used to build facilities where the goal would be not to
necesserily make an ill baby to survive, but rather give him a chance to
survive. Or, if his body fails, help him to die without suffering.
Sorry for errors, English is not my first language.
My second response is: this is one long attempt, disguised in pseudo-
learned language and academic words, to justify and rationalise the
killing of infants. The language, and the reputation of the journals in
which it is published, are meant to blind us to the sheer immorality of
what they propose. But with however much academic pomp they propose their
theory, even a ch...
My second response is: this is one long attempt, disguised in pseudo-
learned language and academic words, to justify and rationalise the
killing of infants. The language, and the reputation of the journals in
which it is published, are meant to blind us to the sheer immorality of
what they propose. But with however much academic pomp they propose their
theory, even a child (or perhaps especially a child) can see that they are
not wearing any clothes, and should be exposed as naked and ashamed.
Firstly, the authors propose that some human beings are more actual
persons than other human beings. The pigs in Animal Farm used the phrase
'some animals are more equal than others' to justify the abuses and
oppression of their rule over all other animals. [George Orwell, 1945.]
Likewise, Giubilini and Minerva use the concept of 'person' to make the
evil and morally repulsive act of infanticide sound right. Welcome
Newspeak 2.0.
The argument that one person or people group is less human or worthy
of respect than others, has been used to rationalise the worst evils in
human history. The Romans argued that Barbarians could be oppressed, taxed
and crucified, as opposed to Roman citizens. Abusers at Abu Ghraib prison
walked their victims on a leash like dogs, degrading them to the status of
animals or less. Blacks were argued to be less human than whites, so that
they could be sold as chattel, used and abused. Hitler justified his
"Endlosung" (final solution) to all of Germany's problems by defining Jews
and any non-Arians as being less human than Arians. Is that the kind of
society we want? Giubilini and Minerva merely substitute 'person' for
'human'. Otherwise the argument is similar. If we follow it, we will
become a society more callous and evil than that of Nazi Germany. Killing
our own newborns as if they were commodities. Treating babies as
disposable objects to keep or discard as we like.
Secondly, they play word games. There is the game of handpicking
their definitions to suit the purpose of supporting their proposal. For
instance "We take 'person' to mean ..." and "our definition of the concept
of harm ..." (italics mine). This is private opinion dressed up as
academic argument. Also, the whole proposition is based on a clever game
of circular definitions: a person is defined as one who can value harm or
benefit, and harm is defined as the loss of aims and plans which only a
person can value. Circular definitions prove as little as circular
reasoning - nothing.
Thirdly, the authors' argument centres on the false assumption that
the difference of a few days before or after birth makes so little
difference that it is zero. But little is not the same as zero, as anyone
with arsenic in their tea might appreciate. Africans are famous for
claiming that anyone can eat an elephant 'one slice at a time'. Giubilini
and Minerva must have asked themselves, 'How can we make infanticide look
philosophically sophisticated?' Answer: 'One day at a time.'
If parents can change their mind about keeping their baby one week
after his or her birth, why not a month or a year after birth? Or five
years, when other diagnoses may have come to light, such as Duchenne's
muscular dystrophy?
If one day makes no difference (even as momentous a day as that of a
baby's birth), then each one of us readers is at risk of being killed at
will, whatever our age. Indeed, the authors hint at this when they say,
'we do not put forward any claim about the moment at which after-birth
abortion would no longer be permissible'. If birth makes no difference,
then any limit is arbitrary, and someone will argue for 'just one day
more' until the victim has received their 100th birthday card.
Fourthly, the authors consistently refer to the foetus and newborn
eligible for abortion or killing by the pronoun 'she'. Though this most
likely represents a poor attempt at inclusive language, it does not
explicitly exclude covert support for selective abortion of female
foetuses or infanticide of baby girls. This is reinforced by their
statement that 'Indeed, however weak the interests of actual people can
be, they will always trump the alleged interest of potential people to
become actual ones, because this latter interest amounts to zero.'
(italics mine). In plain English this means that the flimsiest interest of
an older human has more value than the life of a newborn baby. That means
that if parents have any interest whatsoever to want a boy but not a girl,
they should be allowed kill their newborn baby girl and try again for a
boy.
My third response is one of surprise. Ironically Giubilini and
Minerva's reasoning serves the pro-life argument equally well. If killing
a newborn baby is called post-birth abortion, then equally abortion could
be called pre-birth killing. That is what the pro-life movement has argued
all along. The pro-choice movement has always meticulously avoided words
such as killing, insisting instead on euphemisms like 'termination' and
even 'abortion treatment' as if abortion cures a disease [Website of the
British Pregnancy Advisory Service, http://www.bpas.org/bpaswoman
(accessed 30th March 2012)].
Further, the authors claim that 'killing a newborn could be ethically
permissible in all the circumstances where abortion would be.' The exact
same reasoning can be used to argue that aborting a six week old embryo or
a 16-week old foetus could be ethically wrong in all the circumstances
where killing an infant or adult child is wrong. Surely the direction in
which the argument moves cannot make a substantial difference; whether it
moves forward in time from foetus to newborn, or backward in time from
child to newborn and foetus.
Giubilini and Minerva have given us much to consider. They have
created a perfect ethical storm without saying much new. I remember
reading their fellow Melbourne professor Peter Singer's work nearly thirty
years ago and encountering exactly the same arguments. [Kuhse H, Singer P.
Should the Baby live? The Problem of Handicapped Infants. Oxford: Oxford
University Press, 1985.] The title 'Why should the baby live?' points
clearly to Singer's 'Should the baby live?'. The authors' only innovation
is to widen the allowable reasons for infanticide from 'severe
abnormalities' (Singer); via diagnoses which come to light at some point
after birth; to 'the same reasons which justify abortion' (Giubilini and
Minerva). They even claim that any interest of any actual person (read:
adult, older child or even those animals they regard as persons!!),
however weak, is always of greater value than that of any newborn baby,
since the interest of the latter is zero. In plain English that means
infanticide on demand for the flimsiest of reasons. An adult dog has more
rights than a human newborn since the latter has none.
But what does their argument really show? That post-birth killing is
acceptable, or that pre-birth abortion is killing? That society is ageist,
protecting human babies after birth but allowing them to be killed before
birth? That baby P.'s abusers were not wrong to kill him but only wrong to
cause him pain and suffering in the process? That human capacity for
rationalising evil is endless? That ethicists can supply reasons to
justify any evil they wish to justify? That philosophy is like a knife
that can either kill or heal, depending on the decisions of the person who
manipulates it? That digging up old controversial ideas is the best way to
improve one's citation metrics and revive a flagging academic career?
Most of all, I believe, their argument shows that philosophical
ingenuity cannot make values for us human beings to live by, any more than
political spin can weave clothes for an emperor. The emperor will have to
find an honest tailor, and we human beings need to look elsewhere for a
reliable foundation for ethics.
In my senior year at Case Western Reserve University, I took a course
on satiric writing. I wrote a paper responding to the Roe v. Wade
decision, showing the logical result of proclaiming unborn babies were not
human. Sadly, Minerva & Giubilini have fulfilled one of my
predictions. Here is the paper from 34 years ago:
In my senior year at Case Western Reserve University, I took a course
on satiric writing. I wrote a paper responding to the Roe v. Wade
decision, showing the logical result of proclaiming unborn babies were not
human. Sadly, Minerva & Giubilini have fulfilled one of my
predictions. Here is the paper from 34 years ago:
The Final Solution to Overpopulation
Of course, abortion is the best form of birth control. Condoms break,
you can forget to take the pill, and IUDs can pierce a woman's uterus and
scar and injure her. Spermicidal jellies and foams are messy and not
likely to be used. Tubule ligation and vasectomies work only for those who
are willing to make such a commitment, as does abstinence. Pregnancies
caused by birth control mistakes are proverbial in our culture. The surest
solution to the world's greatest problem, that of overpopulation, is
abortion. It is safe when done early in pregnancy, and 100% certain to
eliminate an unwanted pregnancy. However, abortion doesn't go far enough
in reducing population growth, and in reducing population itself.
The world's population has increased nearly three billion since the
landmark Supreme Court decision, Roe v. Wade in 1973. World population
under the best estimates will stabilize at eleven billion after 2050. The
world's ecosystem is already severely stressed with the six billion people
on the earth. More needs to be done to reduce population. What is the next
step?
Roe v. Wade determined the first 23 weeks of pregnancy are eligible
for abortion since the fetus is not yet viable. More recent court rulings
have permitted abortions through the last trimester of pregnancy for the
health of the mother, mental and physical. Using the principle of
"viability" and the principle of what is best for the mental and physical
health of humanity, the next logical step is to permit "post natal
abortions" (PNAs) on non-viable "post natal fetuses" (PNFs).
Although the majority of PNFs are wanted, not a single PNF is viable.
It cannot survive without an adult caregiver. Further, they are a mental
and physical burden upon the caregiver and should not be permitted to live
without the full and willing desire of the caregiver. Why should PNFs be
permitted to burden our sorely taxed ecosystem by allowing unwanted ones
to grow to full maturity? Is it not kinder, gentler, and more humane to
safely terminate them should the caregiver find them a burden? Is not the
caregiver fully within their privacy rights to manage this life form
within their own home as they see fit?
There need be no moral qualms about this policy whatsoever. Our
society has already established the legal morality of abortion up through
the end of the third trimester. What difference should the simple process
of parturition make to morality of removing a non-viable life form from a
possibly miserable existence? Just as abortion removes the burden of an
unwanted fetus from society, so a PNA can terminate the mental and
physical burden of an undesired PNF. A simple injection of potassium
cyanide or a pill of the same can quickly and painlessly remove this
ecological disaster waiting to happen.
The benefits of PNA's cannot be exaggerated. They are safer than
abortions in the third trimester. They alleviate a financial burden on the
family and society in general, reserving resources for those individuals
chosen to enter the human family. With a worldwide policy of PNAs, all
individuals will be wanted. Without undesired PNFs, the negative influence
of humanity upon the earth will decrease, not increase. Air and water
pollution will begin to decrease. The welfare rolls will decrease,
reducing the tax burden.
Yet, even a vigorous, worldwide program of PNAs, administrated under
the auspices of the United Nation's World Health Organization (WHO) does
not go far enough. There are millions and billions of individuals
worldwide who are no longer viable. Although they were human at one time,
they are no longer self-supporting. Many can no longer communicate and are
not conscious. They are all draining society's resources and all require
care of some other human being. Using the same moral principle as Roe v.
Wade and other pro-abortion rulings, we may safely and ethically consider
such entities as "post human lives" (PHLs). In view of human induced
global warming and the possible worldwide catastrophe that is pending, is
it not nobler to remove these life forms from existence than to permit
them to continue to consume the world's limited resources? Such an act of
mercy would spare the functioning, productive humanity this unwanted
burden, and more importantly, would reduce the space pressures humanity
puts on endangered species worldwide. Concurrent with a program of PNAs
there must be a worldwide program of "post human abortions" (PHAs).
As good as PNAs would be, PHAs would be even better. PHLs consume far
more resources than PNFs. All the benefits enumerated for PNAs would be
multiply true for PHAs. Society would become free of all individuals who
are not productive. Taxes could be reduced, or the freed up funds could go
toward art, literature, and good public works. Cares and worries of old
age would be a thing of the past. Once a person becomes a burden to
anyone, they are simply considered a PHL and given a gentle PHA. The
social security trust fund will become adequate and even generous, with a
reduced future burden upon working humanity.
PNAs and PHLs have benefits even beyond these. They will give birth
to a new age of medical research. There will be an unlimited supply of
organs and stem cells for the benefit of human population. Very likely,
the human lifetime will be considerably extended. This will create
additional population pressure, so PNAs and PHAs need to be executed and
enforced ubiquitously.
How is a sweeping, worldwide program of PNAs and PHAs best to be
administrated and implemented? It should start with the UN. As part of UN
membership, every country should have laws that require every caregiver to
sign a certificate of humanity to their offspring or to any non-viable
entity in their care. At a minimum, these certificates should be renewed
annually, like drivers' licenses. Each country may add additional
requirements for their definition of viable humanity. This allows each
country to retain its own sovereignty and cultural distinctiveness. By
entrusting such a critical definition to each federal government, we can
be sure the same care and wisdom shown in governmental taxing and welfare
programs will be applied toward this critical program of PNAs and PHAs.
It is expected that some countries will put political requirements
into their definition of humanity, some will put religious requirements,
some physical requirements, such as a certain height, weight, body build,
or skin color. Aside from promoting cultural diversity, this mosaic of
laws will catch PHL's who travel from one country to another and further
reduce world population. The varied laws will also purify the human gene
pool, catching the ignorant and unwary, classifying them as PHLs and
terminating them, protecting mother Earth from the corrosive effects of
their former human existence.
Even such a beneficial program will surely have opposition. Religious
extremists and radical anarchists are likely to resist blessing mankind
with a healthier, less intrusive life upon this earth. A simple and
effective method of dealing with such evil-minded beings is to classify
them as PHLs and perform PHAs upon them. This action will quickly bring
about worldwide consensus for this uniquely effective approach to
population control.
With unwanted PNFs eliminated through PNAs, with burdensome PHLs
removed through PHAs, with humanity's genetic lines improved through the
forced evolutionary selection of diverse laws worldwide, a new age will
dawn. No longer will pollution wreck our planet's rivers, lakes, and
oceans. No longer will smog dominate cities. No longer will teeming
millions suffer and starve. No longer will species die out through human
encroachment upon their habitats. With the moral principles put forth in
Roe v. Wade, logically extended and applied, humanity will joyfully march
forward into a brave, new world.
Conflict of Interest:
I am a Christian, subject to Jesus Christ. There are no other competing interests.
Establishing Personhood
A recent publication of modern philosophical thought by two ethicists from
Melbourne, Australia, both with ties to Oxford University, Dr. Alberto
Guibilini and Dr. Francesca Minerva's "Afterbirth Abortion: Why Should the
Baby Live?" published February 23, 2012 in the Journal of Medical Ethics,
takes Descartes founding principle of modern philosophical thought: "I
think, therefore I am," to its log...
Establishing Personhood
A recent publication of modern philosophical thought by two ethicists from
Melbourne, Australia, both with ties to Oxford University, Dr. Alberto
Guibilini and Dr. Francesca Minerva's "Afterbirth Abortion: Why Should the
Baby Live?" published February 23, 2012 in the Journal of Medical Ethics,
takes Descartes founding principle of modern philosophical thought: "I
think, therefore I am," to its logical conclusion. The authors rationally
demonstrate their premise: since it is thinking that defines a human
being's existence, a human being that does not think is not a "person" and
in that lack, does not exist.
Therefore, they argue, if the philosophical term "personhood" is not
conferred to a fetus, why would it be conferred to an infant after it is
born?
Of course, based on their premise, they are right. Intellectually and
biologically an infant and a fetus are basically the same. So the authors
use the same philosophical argument that an infant is as worthless as a
fetus and the value of an infant's life should be determined by the same
parameters as that of the fetus' life: whether it is wanted or not.
Guibilini and Minerva's paper opens a Pandora's Box that segues Western
society to freely confer or remove "personhood" and ergo the legal
protections from any human being whose thinking may be compromised:
dementia patients, the mentally ill, stroke victims, PTSD, brain injuries,
autistic persons and those under 25 years of age whose pre-frontal cortex
is not yet mature.
Realizing that the argument further injects a "value" judgement that
becomes the very definition of human life, should cause all thoughtful
persons to remember that scientific theories underpinned laws leading to
horrors in human history: the Laws of Human Slavery and Chattel; Hitler's
Operation T-4; the Lebensborn Experiment; the Nuremberg Laws; based on
the American Jim Crow Laws; and those based on the Statutes of Kilkenny.
The obvious problem with Guibilini and Minerva's argument is that the
premise is flawed. To accept as a philosophical truth Descartes "I think,
therefore I am," defies logic. To fix the failed logic in the premise and
force it to work, philosophers assigned value to function (think) and
separated potential function from actual function. What wasn't done was to
focus on the agent that compels the verb "think" to action--"I". Man is
not merely function, but force as well. There is no effect without a
cause. "It is not thought that determines existence, but existence,
'esse,' that determines thought" -- St. Thomas Aquinas.
Thinking is merely one process in the state of being. The part does not
equal the whole. Rather, the whole is greater than the sum of its parts.
No one can have any function without first existing. If a philosophical
principle can be doubted prima facie intellectually, linguistically and
logically, then it is not a universal truth applicable to reality. If it
were, then replacing think with any other intransitive verb should not
make the sentence less true, but it does: I throw, therefore I am; I eat,
therefore I am; I lie, therefore I am--all are functions of a human's
nature, not the definition of it.
Modern philosophy failed to question the validity of its premise. Our duty
is to ask why ? If we don't, as history attests, once a society freely
agrees to the definition of a dehumanizing "value" for one segment of the
population for the "greater good," slowly but surely the definition of
those that qualify expands.
This article is so shameful. Newborn babies feel,breathe,bleed, and
learn. Once a baby is born, (I believe the moment it is conceived but that
is a different discussion), it is a person with rights. Who are you or
their parents to take away their opportunity to make a contribution to the
world? No one took away this author's opportunities in life by killing
them the moment after birth. No, no one had the right, no one even...
This article is so shameful. Newborn babies feel,breathe,bleed, and
learn. Once a baby is born, (I believe the moment it is conceived but that
is a different discussion), it is a person with rights. Who are you or
their parents to take away their opportunity to make a contribution to the
world? No one took away this author's opportunities in life by killing
them the moment after birth. No, no one had the right, no one even thought
about it. Once you were here that was it. Also, there are plenty of people
who would love to adopt a baby(disabled or not) and what right do you have
to suggest that opportunity should be destroyed? Babies are such innocent
creatures that have the potential to become anything if given some
encouragement let alone a chance to survive. Trying to "play God" is a
dangerous road and I don't recommend it for anyone.
In the Journal of Medical Ethics, Joffe et al. recently published an article titled: What do patients value in their hospital care? An empirical perspective on autonomy
centred bioethic [1] This empirical study evaluates whether patients’ willingness to recommend their hospital to others is more strongly associated with their belief that they were treated with...
In the Journal of Medical Ethics, Joffe et al. recently published an article titled: What do patients value in their hospital care? An empirical perspective on autonomy
centred bioethic [1] This empirical study evaluates whether patients’ willingness to recommend their hospital to others is more strongly associated with their belief that they were treated with respect and dignity than with their belief that they had adequate say in their treatment.[see note 1]
Joffe et al. go on to suggest that confirmation of these empirical hypotheses would constitute a prescription for elevating the principle of respect for persons to the level that the principle of respect for autonomy currently enjoys in our model of the ideal patient-physician relationship ([1] p.104). In other words, they suggest that by some means empirical findings could influence our ranking of the normative principles. Earlier in the article, they make an even stronger claim about the influence of empirical data on our acceptance of normative principles. They suggest that if it were demonstrated empirically that some patients prefer to delegate medical decisions to health care professionals a serious challenge would be levied against the normative assumptions underlying the principle of respect for autonomy, at least under the mandatory autonomy view, which holds patients not only have a right but also an obligation to act autonomously ([1] p.103). In light of many recent empirical studies challenging the centrality of patient autonomy and shared decision-making in bioethical theory, I think it is instructive to evaluate the means by which empirical findings, like those offered in Joffe et al., strengthen or weaken our arguments for ethical principles. In particular, I will be interested in how Joffe et al. propose their data lead them to the normative conclusions they reach.
In the last paragraph of their essay, Joffe et al. write, “we do not recommend that patients’ perspectives should unilaterally determine ethical frameworks. We do, however, believe that data such as those presented here can contribute to the search for reflective equilibrium in bioethics”([1] p.107). The term “reflective equilibrium,” as the authors note, was introduced by John Rawls. At least in its first instance, it refers to a way of constructing a moral theory by balancing one’s considered moral judgments against one’s moral principles, until one’s judgments and principles form a consistent set—that is, a moral theory (Rawls [2], p.288). Joffe et al.’s idea seems to be that by surveying patients’ perspectives they will be able to capture one side of this equilibrium, considered moral judgments or moral principles (they do not specify which), and in so doing contribute to the desired end: a consistent ethical framework to govern medical encounters, built (at least in part) from the principles and moral judgments of the patient community. Whatever the merits of this goal, however, Joffe et al. fail to capture either the considered moral judgments or the moral principles of those they survey and so fail to contribute to the moral theory they seek to construct.
Rawls defines considered moral judgments as those judgments in which our moral capacities, which he considers analogous to our linguistic capacities, are “most likely to be displayed without distortion”--e.g. those offered without hesitation, given without strong emotions like fear, and made in the absence of conflicting interests (Rawls [3] p.47). The distinction between considered judgments and judgments generally is important. When constructing a moral theory for a particular community—for instance, the patient community—we want to use only those judgments that reflect the respondents’ real moral sensibilities, and not those stemming from superficial prejudices or their mood on the day they happen to respond. This raises two important questions, however, for researchers, like Joffe et al., using the reflective equilibrium: (1) precisely how considered do considered judgments have to be if they are to count, and, more practically, (2) how can a researcher know whether he or she is collecting them (i.e. what survey method, if any, is appropriate for the task)? While it is difficult to give a positive answer to these questions (and I will not attempt to do so here), some survey methods, such as the mailed questionnaires Joffe et al. use, seem particularly inadequate. Rawls suggests certain external conditions favor the formation of considered judgments: “the person making the [considered moral] judgment is presumed…to have the ability, the opportunity and the desire to reach a correct decision (or at least, not the desire not to)”(Rawls [3], p.48). Very likely, however, many of Joffe et al.’s respondents lacked the necessary ability, opportunity, or desire to reflect on their moral judgments when responding to the questionnaire they received in the mail. Furthermore, even if a number of patients did offer legitimate considered judgments, there is no way to distinguish these from those made by respondents’ who lacked the requisite ability or desire. While the size of Joffe et al.’s study is of value for its ability to more accurately reflect a population’s response to its survey questions, because of the practical limitations that come with its size, the study falls short of capturing patients’ considered moral judgments.
Any empirical approach, like Joffe et al.’s, using reflective equilibrium faces a second challenge: why do we want peoples’ considered moral judgments to influence our ethical theories in the first place? In his influential critique of reflective equilibrium, DW Haslett writes, “given the wide differences between people’s considered moral judgments, and given that these differences are, as we know, largely just a reflection of differences in upbringing, culture, religion, and so on, it would appear that, far from having a reason for giving people’s considered moral judgments initial credibility, we have instead a reason for initial skepticism”.[4]
If moral judgments are liable to reflect superficial prejudices, one could argue, considered moral judgments are liable to reflect deep-seated ones. Surely this prejudice is something ethicists would like to overcome, not codify. While I do no think this challenge is insurmountable, [see note 2] it does demand that researchers justify the inclusion of considered judgments in ethical theory before using the method of reflective equilibrium. Joffe et al. have failed to do this.
Joffe et al.’s study is susceptible to a second line of critique. Even if the study’s use of mailed surveys is appropriate, the study fails to capture either patients’ considered judgments or principles, because, put simply, it doesn’t ask for considered judgments or principles. Instead, it asks patients whether providers respected their person or respected their autonomy, and then tests patients’ responses to these questions against whether they report being satisfied with their care. If a provider’s acting with respect for persons is a better predictor of patient satisfaction than her acting with respect for autonomy, Joffe et al. conclude that the principle of respect for persons should be assigned as much importance ethically speaking as the principle of respect for autonomy. As should be clear, this conclusion does not follow from Rawls’s conception of how one constructs a moral theory. In a Rawlsian view .[see note 3] , a moral theory requires knowing which principles patients hold, not whether those principles are associated with patient satisfaction. Joffe et al. seem to be operating with an underlying utilitarian assumption to the effect that what we ought to do ethically speaking is whatever will lead to the greatest patient satisfaction. Though there may be reasons for accepting this utilitarian assumption (which Joffe et al. do not provide), certainly there are others for rejecting it. For instance, though patient satisfaction may give a hospital a very good reason to change a policy, we probably do not want to say this reason is a good ethical reason. It is just good business sense. This is an especially important point given the principles that Joffe et al. evaluate. Respect for autonomy and respect for persons are traditionally viewed deontologically--that is it terms of duties or rights, which are valued for their own sake rather than the consequences (e.g. patient satisfaction) that they produce. In any case, these utility considerations take us far from patients’ actual moral views, the very things Joffe et al., by invoking Rawls’s reflective equilibrium, propose to capture.
Lastly, there is a question of their instrument’s validity. As I have been arguing, Joffe et al. claim to assess whether patients are treated according to the principles of respect for autonomy and respect for persons. Yet, their single item assessing respect for autonomy - the question, "do you feel you had your say?" - does not do the principle justice. The principle of autonomy not only requires that the health care provider ask the patient for his opinion, but also that she act on the patient’s opinion. Their instruments are similarly inadequate for the principle of respect for persons, which, they suggest, includes "autonomy, fidelity, veracity, avoiding killing, and justice" as well as "respect for the body, respect for family, respect for community, respect for culture, respect for the moral value (dignity of the individual), and respect for the personal narrative"(104). How are we to know whether patients had all or any of these in mind when they answered the question, “did you feel like you were treated with respect and dignity while you were in the hospital?” Joffe et al. acknowledge that these ethical concepts are a bit unwieldy for a survey of manageable length. However, these practical considerations should be used not only to excuse the study but also to question its ability to clarify the ethical concepts it claims to assess. They should prod us to ask, regardless of the survey’s scale and the limitations its size produces, does this survey really address what we mean by the principles of respect for autonomy and respect for persons?
With any empirical study in bioethics, there is a gap between the empirical hypothesizes the study confirms and the normative conclusions its authors would like to draw from it. In their article Joffe et al. hoped to bridge this gap by invoking Rawls’s notion of the reflective equilibrium. As I have explored, however, Joffe et al.’s study does not contribute to either side of the reflective equilibrium they imply, and, thus, they fail to demonstrate how their findings challenge the centrality of autonomy and shared decision-making in bioethics.
Joffe et al.’s failures are instructive, however, in so far as they suggest how we might better bridge research and theory. The use of the reflective equilibrium in empirical research has promise, provided researchers are clear about:
(1) how to define considered moral judgments and/or principles,
(2) how their methodology capture these judgments and/or principles reliably,
(3) how the inclusion of considered moral judgments strengthens rather than weakens bioethical theory, and
(4) how their instruments are valid for the judgments or principles they mean to assess.
In addition, empirical research can contribute to bioethics by questioning the assumptions implicit or explicit in our normative views. Joffe et al. try to do just this when they argue that patients’ desire to delegate decision-making challenges the mandatory autonomy view, in the introduction of their paper ([1] p.103). However, if empirical findings are to defeat a particular normative principle, the assumption those findings challenge must be logically necessary for our holding that principle. For instance, without showing patients’ desiring autonomy is necessary for our holding the mandatory autonomy view, the studies that Joffe et al. cite, even if valid, can be interpreted variously as devaluing the mandatory autonomy view or as recommending that we better educate patients on the value of autonomy. This normative question cannot be settled empirically.
Empirical researchers have the potential to contribute substantially to bioethics, but their work needs the kind of philosophical and empirical rigor that comes from truly interdisciplinary collaboration and must be informed by a careful reflection on the proper relationship between descriptive and normative ethics (Sulmasy and Sugarman).[4] Joffe et al. take us part of the way down that path. An exciting research itinerary lies ahead.
References
(1) Joffe S, Manocchia M, Weeks J C, Cleary P D. What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. J Med Ethics 2003; 29:103-108.
(2) Rawls J. The independence of moral theory. In: Freeman S, editor. Collected papers / John Rawls. Cambridge, MA: Harvard University Press, 1999. p.286-302.
(3) Rawls J. A theory of justice. Cambridge, MA: Harvard University Press, 1971.
(4) Haslett DW. What is wrong with reflective equilibria? The Philosophical Quarterly 1987; 36(148):305-311.
(5) Sulmasy DP, Sugarman J. “The many methods of medical ethics (or, thirteen ways of looking at a blackbird).” In: Sugarman J, Sulmasy DP, editors. Methods in Medical Ethics. Washington, D.C.: Georgetown University Press, 2001.
(6) Delden JJM, Thiel GJMW. Reflective equilibrium as a normative-empirical model in bioethics. In: Burg W, Willligenburg T, editors. Reflective equilibrium: essays in honour of Robert Heeger. Dodrecht: Kluwer Academic Publishers, 1998. p. 251-259.
(7) Rawls J. Political liberalism. New York: Columbia University Press, 1993.
Notes
Note 1:
Joffe et al. also evaluate whether patients’ reporting they had confidence and trust in their health care providers significantly predicted whether they would recommend their hospital to others. For simplicity’s sake, I only address Joffe et al.’s treatment of the respect for persons and the respect for autonomy principles in this response.
Note 2:
See, for instance, Delden and Theil,[6] in which the authors convincingly argue that a reflective equilibrium-like methodology may be valuable for capturing the norms of health care providers and that knowledge of these norms may guide individual providers.
Note 3:
I say “a Rawlsian view” rather than “Rawls’s view” because in his Theory of Justice Rawls advocates balancing a single person’s considered moral judgments (e.g. Rawls’s or his reader’s) with a single person’s moral principles (Rawls [3]p.50). Although he later gestures towards reflective equilibrium a an exercise that involves the considered moral judgments of others (Rawls [7], p.8), it is probably safest to say “Rawslian.”
the concept of brain death (BD) refers to two different but strictly
related conditions: the death of the brain ("the irreversible cessation of
all functions of the entire brain, including the brain stem"[1]) and the
patient's death certified by neurological criteria.
In his letter, C. Levyman strongly supports both aspects of the
concept. Actually, even if nobody challenges the fact the BD i...
the concept of brain death (BD) refers to two different but strictly
related conditions: the death of the brain ("the irreversible cessation of
all functions of the entire brain, including the brain stem"[1]) and the
patient's death certified by neurological criteria.
In his letter, C. Levyman strongly supports both aspects of the
concept. Actually, even if nobody challenges the fact the BD is a point of
no return, many authors have questioned that BD identifies the loss of all
intracranial functions [2-10] and also the equivalence between BD and the
patients biological death has been called into question [6,8,10-17]. The
debate is very fascinating and intriguing. We believe that labeling either
position as regressive/progressive does not help in the discussion, which
should be open and respectful.
On the other hand, this problem is totally unrelated to our paper,
which dealt with the problem of defining the vital status of non-heart-
beating organ donors (NHBD). We argued that, given current protocols
(which are clearly different from the protocols for brain-dead patients),
at the time of organ retrieval it is impossible to define the death of
NHBD on either neurological [18] or cardio/respiratory criteria.
References
(1) The Uniform Determination of Death Act (UDDA), as expressed by the
President's Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioural Research (1981) Defining death: a report on the
medical, legal, and ethical issues in the determination of death.
Washington, D.C.: U.S. Government Printing Office.
(2) Evans DW, Hill DJ (1989) The brainstem of organ donors are not dead.
Catholic Medical Quarterly. 40: 113-121.
(3) Truog RD, Fackler JC (1992) Rethinking brain death. Crit Care Med
20:1705-1713.
(4) Veatch RM (1993) The impending collapse of the whole-brain death
definition of death. Hasting Center Report 23(4):18-24.
(5) Halevy A, Brody B (1993) Brain death: reconciling definitions, criteria
and tests. Ann Intern Med 119: 519-525.
(6) Singer P (1994) How death was redefined. In: Singer P Rethinking life
and death. The collapse of our traditional ethics. St. Martin's Press, New
York, pp 20-37.
(7) Truog RD (1997) Is it time to abandon brain death? Hasting Center
Report 21:29-37
(8) Kerridge IH, Saul P, Lowe M, McPhee J, Williams D (2002) Death, dying
and donation: organ transplantation and the diagnosis of death. J Med
Ethics 28: 89-94.
(9) Facco E, Munari M, Gallo F, Volpin SM, Behr AU, Baratto F, Giron GP
(2002) Role of short latency evoked potentials in the diagnosis of brain
death. Clinical Neurophysiology 113: 1855-1866.
(10) Truog RD, Robinson MR (2003) Role of brain death and the dead-donor
rule in the ethics of organ transplantation. Crit Care Med, 31(9):2391-
2396.
(11) Danish Council of Ethics (1988). Death Criteria: a report. The Danish
Council of Ethics, Denmark.
(12) Arnold RM, Youngner SJ (1993) The dead donor rule: should we stretch
it, bend it or abandon it? Kennedy Inst Ethics J 3: 263-278
(13) Shewmon DA (1997) Recovery from "brain death": A neurologist's
Apologia. Linacre Quarterly 64:30-96.
(14) Shewmon DA (1998) Chronic “brain death”: meta-analysis and conceptual
consequences. Neurology 51:1538-45.
(15) Shewmon DA (1998) "Brain-stem death", "brain death" and death: a
critical re-evaluation of the purported evidence. Issues Law Med 14: 125-
45.
(16) Shewmon DA (1999) Spinal shock and 'brain death': somatic
pathophysiological equivalence and implications for the integrative-unity
rationale. Spinal Cord 37:313-24.
(17) Shewmon DA (2001) The brain and somatic integration: insights into the
standard biological rationale for equating "brain death" with death. J Med
Philos. 26(5): 457-78.
(18) The Ethics Committee, American College of Critical Care Medicine,
Society of Critical Care Medicine (2001) Recommendations for non-heart-
beating organ donation. A position paper. Crit Care Med 29(9): 1826-1831.
I am deeply worried about the guest editorial by Dickens.[1] Please see my comments below
Trying to dispel some of the counter arguments to sex selection, your argument of prospective parents’ autonomy is void. If anyone has a right to determine his or her sex, it would be the person concerned, in this case the unborn child. Surely, the parents will not have surrogate decision making pow...
I am deeply worried about the guest editorial by Dickens.[1] Please see my comments below
Trying to dispel some of the counter arguments to sex selection, your argument of prospective parents’ autonomy is void. If anyone has a right to determine his or her sex, it would be the person concerned, in this case the unborn child. Surely, the parents will not have surrogate decision making power in the absence of a dire need to make a choice, i.e. due to avoid hereditary sex related disease? Would the child be able to sue the parents for making a bad choice?
The threat of neglect or abuse a girl might face, should her ‘deselection’ not be permitted, amounts to hostage taking of the unborn life. Does the same not apply also to the burden a family or society may put on a woman, by forcing her into multiple pregnancies, until she delivers the desperately wanted son? What is more, the fact that a law might be ignored or disregarded, has rarely been an accepted argument for its repeal.
In fact, should promale sex selection become widespread in a already sexist society, this would most likely be a prerogative for the affluent and resourceful, reinforcing the existing inequality. Say predominantly male children would be born to privileged parents; they will provide them with more opportunity, leaving the other sex to grow up in even more disadvantaged circumstances.
But the slippery slope becomes most obvious if we imagine racially discordant couples wanting to determine their offspring’s race and color, be it based on (justified?) fears about societal abuse, neglect and disadvantage, or their wish to ‘balance their families’, or even only as a matter of taste...
Reference
(1)
Can sex selection be ethically tolerated. Dickens BM. J Med Ethics 2002; 28: 335-6.
Five arguments put forward for a "zero tolerance policy" have been
summarised by Cullen, who, we believe, has also hinted at their
weaknesses.[1]
There is the "empirical" claim that sexual contact in the P-P-R is "almost always harmful to the patient". But the evidence in support
of this argument consists mainly of case reports and small case series of
patients receiving psychotherapy. No represen...
Five arguments put forward for a "zero tolerance policy" have been
summarised by Cullen, who, we believe, has also hinted at their
weaknesses.[1]
There is the "empirical" claim that sexual contact in the P-P-R is "almost always harmful to the patient". But the evidence in support
of this argument consists mainly of case reports and small case series of
patients receiving psychotherapy. No representative studies are known.
There is no evidence to suggest that harm following a failed relationship
with a health professional is any different to that following the break up
of a relationship with a non health professional.
Personally, we do not
doubt that intimate relationships between doctor and patient have the
potential to be harmful to patients´ and can have negative effects on
patients´ future ability to establish a trusting relationship with a
doctor.
The second argument considered by Cullen is based on "principles": To
look at the relevant underlying ethical principles and examine whether the
proposed course of action is consistent with each them. Zelas has proposed
a set of preconditions to be met if sexual contact is to be acceptable:
Trust, power balance and consent have been identified. Cullen states that
even if one accepts trust, power balance, and consent as necessary
conditions they do not justify a zero tolerance position. We disagree with
this conditions. Where trust is, balance of power is dispensable.
The third, "virtues-based", argument suggests that the virtues
ethicist considers the virtues necessary in a good doctor and attempts to
demonstrate that a virtuous doctor can not enter into a sexual
relationship with a patient. Cullen criticises that this argumentation
twists the concept of virtues until virtues become duties be followed
regardless of circumstances. We would add that when advice how to act is
based merely on virtues, the principle of action may not be connected with
individual reality and may lack contact with the cultural environment.
The fourth argument in favour of a zero tolerance is an "a priori"
one. It is argued that the P-P-R is defined as displaying certain
properties, e.g. the P-P-R must have "property X" (emotional distance and
detachment). Sexual contact cannot have “property X”. Is it not
unrealistic and does it not disregard professional principles, in
particular those applied in specialties requiring a P-P-R of a close and
personal nature, to demand affective neutrality and detachment between
doctor and patient?
Cullen calls the fifth argument "counterfactual". If sexual contact
between doctors and patients were allowed then there would be unacceptable
consequences. A typical unacceptable consequence would the breakdown of
the trust essential to a P-P-R. The argument asserts that the consequences
of a policy that allowed sexual contact between doctors and patients would
be harmful. Isn't a policy of prohibition more likely to undermine the
patient's trust in his/her doctor? Can right thinking and right feeling
ever be enforced? If right doing has to be enforced, would it not give
rise to fears that laws might be broken?
The history of prohibition is a long one, and rarely has to report
about successes, where attitudes or behaviours were supposed to be
enforceable. According to Leggett the injunction against sexual
intimacies still functions to preserve the good name of the healing
professions. Others have written urging that while such responses may be
appropriate, they should be the outgrowth of serious considerations and
open-minded contemplation of the ethical, moral, and therapeutic issues
involved. We would like to stimulate debate on how doctors and therapists
should handle sexual feelings towards patients and whether there is
adequate cause for the injunction prohibiting any sexual relationships
with patients and for its enforcement by ethical and disciplinary bodies.
We look forward to a social climate where the doctor, when experiencing a
feeling of personal affinity with a patient, is encouraged to reflect on
it so as to identify restricting factors and possible consequences.
Patients may not understand the ethics or the potential harm involved in a
doctor-patient social or sexual relationship, but the doctor should. We
have summarised elsewhere important factors to be taken into account when
considering initiation of a romantic relationship with a patient.
Reference
(1) Cullen RM. Arguments for zero tolerance of sexual contact between doctors and patients. J Med Ethics 1999; 25: 482-486.
P Patel’s article in “Research Ethics: A natural stem cell therapy?
How novel findings and biotechnology clarify the ethics of stem cell
research,” in the April issue of the Journal did not clarify as much as it
could have.
Rather than exploring the “naturalness” of stem cell therapy, a
better understanding would come with examining “destructive” and “non-
destructive” stem cell therapy. Firs...
P Patel’s article in “Research Ethics: A natural stem cell therapy?
How novel findings and biotechnology clarify the ethics of stem cell
research,” in the April issue of the Journal did not clarify as much as it
could have.
Rather than exploring the “naturalness” of stem cell therapy, a
better understanding would come with examining “destructive” and “non-
destructive” stem cell therapy. First of all, however, we must clarify the
definition of the term “embryo.”
The blastocyst, with its inner cell mass, is by definition, an embryo
, without regard to how that organism began. In animals (Dolly the sheep,
Hwang Wu Suk’s “Snuppy,” and the cats, horses, mice, etc.) that have been
cloned by somatic cell nuclear transfer, there is no immediate
fertilization of the oocyte. In nature, the the generation of cell
division is initiated by the penetration of the zona pellucida by the
sperm, in the lab, it may be the electrical stimulation of a “renucleated
oocyte” or even of the oocyte, itself, in some species. Nevertheless, the
donor nucleus did, remotely, result from the fertilization of an oocyte by
a sperm. Science fiction has dealt with the parentage of the clone and the
consensus of these thinkers seems to be that the “parents” of a clone are
both the donor and his/her parents. (Try Lois McMasters Bujold’s
Vorkosigian series.)
As to the determination of the ethics of stem cell research, those of
us who object to the destruction of the embryo by technology and
intentional intervention are concerned with the destruction of a living
human organism, who is developing – as nearly as we can tell – in the same
way that other human organisms do at that stage or age. On the other hand,
there would be no ethical problem if there is no organization and/or no
life.
I’m afraid that the biggest problem is one of time – the time since
the author submitted his article (and possibly, the time since I wrote
these lines.) There is a report of a human embryo that was created from
the replacement of the haploid nucleus of an oocyte by the diploid nucleus
of an embryonic stem cell. In Korea, Hwang Wu Suk able to produce one
very damaged line of stem cells, although there is dispute as to whether
the line came from a human clone or as a result of apparent
parthenogenesis.
Beverly B. Nuckols, MD
Life Ethics.org
New Braunfels, Texas
Some people with very bad prognosis at birth and with a pack of bad diagnoses grow up to become relatively happy people. Some don't. There are many cases when fetuses that were presumed to have Down syndrome, apperaed healthy babies at birth. Courts try to avoid capital punishment and usually wait for years before executing people with death sentence because of possible errors. Still, sometimes (hovewer, rarely) truth com...
My first response is: this is sickening.
My second response is: this is one long attempt, disguised in pseudo- learned language and academic words, to justify and rationalise the killing of infants. The language, and the reputation of the journals in which it is published, are meant to blind us to the sheer immorality of what they propose. But with however much academic pomp they propose their theory, even a ch...
In my senior year at Case Western Reserve University, I took a course on satiric writing. I wrote a paper responding to the Roe v. Wade decision, showing the logical result of proclaiming unborn babies were not human. Sadly, Minerva & Giubilini have fulfilled one of my predictions. Here is the paper from 34 years ago:
The Final Solution to Overpopulation
Of course, abortion is the best form of bi...
Establishing Personhood A recent publication of modern philosophical thought by two ethicists from Melbourne, Australia, both with ties to Oxford University, Dr. Alberto Guibilini and Dr. Francesca Minerva's "Afterbirth Abortion: Why Should the Baby Live?" published February 23, 2012 in the Journal of Medical Ethics, takes Descartes founding principle of modern philosophical thought: "I think, therefore I am," to its log...
This article is so shameful. Newborn babies feel,breathe,bleed, and learn. Once a baby is born, (I believe the moment it is conceived but that is a different discussion), it is a person with rights. Who are you or their parents to take away their opportunity to make a contribution to the world? No one took away this author's opportunities in life by killing them the moment after birth. No, no one had the right, no one even...
Dear Editor
In the Journal of Medical Ethics, Joffe et al. recently published an article titled:
What do patients value in their hospital care? An empirical perspective on autonomy centred bioethic [1]
This empirical study evaluates whether patients’ willingness to recommend their hospital to others is more strongly associated with their belief that they were treated with...
Dear Editor
the concept of brain death (BD) refers to two different but strictly related conditions: the death of the brain ("the irreversible cessation of all functions of the entire brain, including the brain stem"[1]) and the patient's death certified by neurological criteria.
In his letter, C. Levyman strongly supports both aspects of the concept. Actually, even if nobody challenges the fact the BD i...
Dear Editor
I am deeply worried about the guest editorial by Dickens.[1] Please see my comments below
Dear Editor
Five arguments put forward for a "zero tolerance policy" have been summarised by Cullen, who, we believe, has also hinted at their weaknesses.[1]
There is the "empirical" claim that sexual contact in the P-P-R is "almost always harmful to the patient". But the evidence in support of this argument consists mainly of case reports and small case series of patients receiving psychotherapy. No represen...
Dear Editor,
P Patel’s article in “Research Ethics: A natural stem cell therapy? How novel findings and biotechnology clarify the ethics of stem cell research,” in the April issue of the Journal did not clarify as much as it could have.
Rather than exploring the “naturalness” of stem cell therapy, a better understanding would come with examining “destructive” and “non- destructive” stem cell therapy. Firs...
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