For simplicity, I will assume (as I actually believe) that all human
embryos are
persons, since Bovens is trying to argue that granting this assumption,
the
use of rhythm or Natural Family Planning (NFP) is if anything more morally
problematic than the use of hormonal contraception, at least in respect of
embryonic death. Let me grant Bovens' empirical assumptions, though they
do not seem based...
For simplicity, I will assume (as I actually believe) that all human
embryos are
persons, since Bovens is trying to argue that granting this assumption,
the
use of rhythm or Natural Family Planning (NFP) is if anything more morally
problematic than the use of hormonal contraception, at least in respect of
embryonic death. Let me grant Bovens' empirical assumptions, though they
do not seem based on sufficient empirical data.
Now, there is nothing morally problematic about conceiving someone
who
will die. Otherwise, every case of human conception would be morally
problematic simply because human beings are mortal. When a conscientious
couple deliberately conceives a child, they presumably believe that it is
better
to conceive a child who will live and die than not to conceive a child at
all.
Clearly nobody has been wronged.
At the same time, it would be deeply morally problematic to conceive
a child
and to perform an additional act, before or after the conception, that
causes
the conceived human being's death. Consider a couple who to conceive a
child and deliberately inject the embryo or ovum with a time-delay toxin
that
would cause the child to die at some specified future point. It does not
matter whether the specified future point is in fourteen days, fourteen
years,
forty years or eighty years. The couple is directly responsible for the
death of
the human being, and as long as the death occurred at a time at which the
law accounted the child a person, the couple would presumably be legally
responsible at least for manslaughter. Someone is also clearly wronged
here:
Were the couple not to have injected the toxin, their child at least might
have
lived longer.
Likewise in a case where use of hormonal contraception has made the
uterus
inhospitable to implantation, the use of the hormonal contraception is an
act
additional to conception by which the woman has brought it about that the
child would be unable to survive more than about two weeks. Thus, the
woman is directly responsible for the inhospitable conditions that would
render implantation impossible or less likely.
Moreover, it seems at least possible that someone is wronged by this
act. It
seems possible that the child who was conceived at time A might have been
conceived at time A even had the contraception not been used, but would
then have been better able to implant.
Now in a case where uncontracepted sexual intercourse at a given time
leads
to a failure of implantation, a single act--intercourse--causes a human
being
to exist and to exist under conditions that make it impossible for the
human
being to survive more than about two weeks. But there is only one action
here, and a fairly direct result of this action is conception. It is
simply that
the conceived child is, we assume, certain to die within about two weeks.
The
couple is not directly responsible for the death, since the couple did not
create the conditions inhospitable to implantation.
Furthermore, nobody is wronged by this act. For the child conceived
at this
point in time, call the time A, would not have come into existence had the
couple abstained from the intercourse. Of course, if the couple engaged
in
intercourse at a different time, call it B, then perhaps the child
conceived then
would have lived longer. But that would have been a different child. By
having intercourse at time A rather than at B, the couple is not wronging
the
child they are conceiving, since that child is not worse off for being
conceived
and living for two weeks than for not being conceived at all. Nor are
they
wronging the child they would have conceived at time B, since one cannot
wrong someone who never exists. Moreover, there is no action the couple
could have done to give the child who actually comes to exist a chance to
live
a longer life. No one has been wronged.
A crucial assumption in my argument is that it is not worse to live
for two
weeks and die than not to live at all. A lot of pro-life people think
that a
human life, no matter its quality or length, is better than no life at
all, and
Bovens' argument was addressed to pro-life readers. But I can argue for
my
assumption even without regard for this controversial (though I think
correct)
pro-life position. For there are several things that are bad about the
typical
death of an adult human being. A typical list might be: (a) The human
being
is deprived of a future like ours, (b) various communities, friends and
family
are deprived of this human being's life, (c) the human being's plans and
desires are interrupted, (d) the human being suffers pain in dying (spiritual,
emotional and/or physical) and (e) friends, family and others suffer.
Now, when the human being who dies is an embryo, the bads are like
(a) and
(b), as well as like (e), but not like (c) and (d), since the embryo does
not seem
to have plans, desires or pains. The bads in (a) and (b) are indeed
serious.
However, they are not bads relevant to the question whether it would be
better to live for only two weeks or not to have lived at all. For (a)
and (b) are
deprivations of goods. And the goods in question, namely a future like
ours
and connection with various social networks, are lacking on both the
scenario
where the child lives for only two weeks after fertilization and on the
scenario
where no conception occurs. Thus the only relevant badness in the NFP
scenario is that in (e). But that is suffering that at most happens to
the
couple, and an informed and competent individual is the best judge whether
an instance of her suffering is worthwhile or not. Moreover, in practice,
the
couple does not know about the death of the embryo, and so the death does
not cause specific pain, though knowing that deaths might occur could
cause
a moderate amount of psychological pain over time.
Thus, there is nothing wrong with conceiving someone who will live
for only
two weeks after fertilization, as long as one had no way of conceiving her
in
such a way that she would have lived longer.
The pro-life objection to hormonal contraception is not to embryonic
death
per se, but to the causing of conditions inhospitable to embryos, embryos
that quite possibly (very difficult questions about identity are relevant
here)
could have lived longer were it not for these conditions.
I am very grateful to Professor Bovens for a number of enlightening
discussions.
I do not think that Dr Biegler’s thesis demands any legally "counterintuitive claims". On the contrary, what he suggests seems in many ways to be intuitively right. His law is wrong, not his intuition. The law is sometimes counterintuitive (and downright unethical) in some situations in order to preserve principles which generally give just results....
I do not think that Dr Biegler’s thesis demands any legally "counterintuitive claims". On the contrary, what he suggests seems in many ways to be intuitively right. His law is wrong, not his intuition. The law is sometimes counterintuitive (and downright unethical) in some situations in order to preserve principles which generally give just results.
To take his points in turn:
(a) He says that “in most circumstances where a DNR order is written the doctor has already assumed a duty of care in relation to the patient”, and cites Kennedy and Grubb in support of the proposition that in relation
to emergency care, simply being on duty in an emergency department implies
an undertaking to provide emergency care.
All this is uncontroversial. But it is irrelevant to the argument,
because simply to assert that a duty of care exists is meaningless unless
one specifies exactly what there is a duty to do. What is in issue here is
whether a doctor can be required to assume a duty to do something very
specific which he may think is clinically contraindicated. The mere
existence of some duty of care does not imply anything at all about the
demands of that duty in particular clinical circumstances.
(b) His contention that the “best interests” criterion is applicable
in the case of competent patients is simply wrong in law. The common law
is robust in its defence of the human right to do life-endangeringly
eccentric things which would cause any half-competent doctor to scream.
Lord Goff, in Bland, put it like this:
"…it is established that the principle of self-determination requires
that respect must be given to the wishes of the patient, so that, if an
adult patient of sound mind refuses, however unreasonably, to consent to
treatment or care by which his life would or might be prolonged, the
doctors responsible for his care must give effect to his wishes, even
though they do not consider it to be in his best interests to do so..”[2]
This was classically demonstrated by the recent case of Miss B. [3]
She was paralysed from the neck down, and required mechanical ventilation.
She decided that her life was not worth living, and told her treating
clinicians to turn off the ventilator. They refused, no doubt thinking
that it was in her best interests to stay alive. It was not considered
remotely arguable that the clinicians were legally right. Since Miss B was
competent, she had an absolute right to decline medical treatment, even if
that meant her death. In a battle between the autonomy of a conscious
patient and the perceived “best interests” of the patient, the law says
that autonomy always wins. Or, put another way, the interest in honouring
autonomy always trumps any other interest which might be identified.
(c) He rightly indicates that a “prior refusal of resuscitation might
constitute [an advanced directive]”. But to talk about a “compelling duty”
to adhere to an advanced directive again conflates the law of negligence
with the law of consent. An advanced directive can only be an indication
of what the patient thinks will constitute his best interests if the
specified circumstances arise. That indication may be legally conclusive
against the treatment which the doctor thinks is in the patient’s best
interests. Treatment in such circumstances would be an assault [4]. It is
a wholly different proposition to say that to fail to comply with an
advanced directive that there should be treatment in such circumstances
would be actionable. The law of consent is happy for doctors to be told
that they must not do things: the law of negligence is not happy for them
to be told that they must.
I do not say that the law stands up to much logical scrutiny: it does not. It is, in this area at least, shabbily pragmatic. But it is clear enough, and its philosophically dubious fixes seem to do a reasonable job.
References
(1) Biegler P, Patient consent to DNR orders: some legal observations
[electronic response: 23 January 2004] jmedethics.com
(2) Airedale NHS Trust v Bland [1993] AC 789 at 864
(3) B v An NHS Trust [2002] 1 FLR 1090
(4) A good illustration, although not a case of a formal advanced directive, is Malette v Shulman (1990) 67 DLR (4th) 321.
Readers generally would have thought the original article to be about
early
embryo loss and NFP. The Response of 12th June seem to have moved on
somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures
giving
overall observed and estimated embryo losses; and not so much in
observational studies of healthy...
Readers generally would have thought the original article to be about
early
embryo loss and NFP. The Response of 12th June seem to have moved on
somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures
giving
overall observed and estimated embryo losses; and not so much in
observational studies of healthy natural human conception, but in IVF
studies,
human studies giving sub-groups with medical problems, animal AI studies,
and human and animal studies where ovulation or fertilisation were
manipulated to varying extents, and from which there is 'extrapolation'
and
'guess'.
In healthy human populations conceiving naturally, the decreased survival
rates related to delayed implantation rather than "ageing" gametes.
Atypical
cycles – a very vague term – deserve investigation rather than quotation
as
the norm, and cycle variations provide no problem to modern NFP.
The opening section shoehorns modern NFP in with a calculation-based
approach that no-one has advocated for 40 years, and later on Bovens
equates or identifies NFP with contraception in any form.
Whatever the disagreements about percentages and extrapolations, the
ethics
of natural conception cannot be decided on their basis.
In his later paragraphs on ethics, Bovens seems effectively to equate
early or
late foetal loss with induced abortion. This is compounded by his
suggesting
that foetal loss be regarded as a side effect of intercourse, if this is
in any way
"targeted". "Fanciful thought experimentation" follows, in which
particular
conditions are imposed on any double-effect consideration.
Conjecture is of use if it leads to clarification; but the only end result
here is a
construct whose practical meaning is to try to strip natural human
conceiving, if in any way informed, of any innocence or presumption of
good.
We write in response to the original article “Differences in medical
students’ attitudes to academic misconduct and reported behaviour across
the years-a questionnaire study” by Rennie and Rudland published in this
journal April 2003 edition.[1] Current and former Dundee Medical School
students are concerned at the media misinterpretation of the study and the
consequences that this branding of “disho...
We write in response to the original article “Differences in medical
students’ attitudes to academic misconduct and reported behaviour across
the years-a questionnaire study” by Rennie and Rudland published in this
journal April 2003 edition.[1] Current and former Dundee Medical School
students are concerned at the media misinterpretation of the study and the
consequences that this branding of “dishonesty” will have on Dundee
Medical School’s reputation and also as individuals embarking on their
medical careers.
This study was originally published in the BMJ in 2001,[2] the data
being collected more than two years prior to that. In the student response
to this original study, it was noted that the study had taken place at the
time of the introduction of the new curriculum and “students were being
asked to produce excessive documentation. Some students did not reference
source information properly-partly due to time pressures and partly due to
genuine ignorance of proper codes of reference practice”.[3] Further to
that, the “Scenarios” as described in the published paper, were phrased
more ambiguously than the actual scenarios that were used in the
questionnaires.
Dundee Medical School took the initial study very seriously. However,
they embraced the information from the study in a positive way. Guidelines
concerning what was considered fraud and plagiarism in terms of submission
of work were established. A code of practice was also developed and this
now has to be signed by all medical students on entry to Dundee.
Although much further statistical analysis has been done on this
study since that original publication, it still contains all the original
raw data. Republishing of this study and the media misinterpretation of it
has lead to a whole new generation of Dundee students feeling that they
have been marked out as “dishonest” when the Dundee Medical School
curriculum has now for several years fully implemented Guidelines to guard
against any misconduct.
References
1. Rennie SC, Rudland JR. Differences in medical students’ attitudes
to academic misconduct and reported behaviour across the years-a
questionnaire study. J Med Ethics 2003;29:97-102
2. Rennie SC, Crosby JR. Are "tomorrow's doctors" honest?
Questionnaire study exploring medical students' attitudes and reported
behaviour on academic misconduct. BMJ 2001;322:274-275
Comments to the paper of L Bovens “The rhythm method and embryonic
death“,
J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if
conception occurred on the fringes of the fertile period looking into data
concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P.
et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl,...
Comments to the paper of L Bovens “The rhythm method and embryonic
death“,
J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if
conception occurred on the fringes of the fertile period looking into data
concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P.
et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl, G. et
al. 1985). Also no association was found between aged spermatozoa and
early pregnancy loss (Wilcox, A. J., Weinberg, C. R. et al. 1998). In the
late 1980s, the issue of aging gametes and pregnancy outcomes was
thoroughly investigated, although the author does not seem to be aware of
this literature (Simpson, J. L., Gray, R. H. et al. 1988;Simpson, J. L.,
Gray, R. H. et al. 1997).
Bovens fails to make the necessary moral distinction between natural loss
of an embryo and loss caused by deliberate human intervention. Natural
Family Planning does not cause loss of the embryo, and is not intended to
do so. On the other hand, the oral contraceptive pill, the morning-after
pill, Norplant, and the IUD all may cause abortions because one of their
mechanisms of action is to impede implantation of the embryo in the
uterine endometrium.
Alcom (in the reference listed cited as Alcorn!!), who was cited in the
paper (Alcom, R 2005;Alcom, R and Larimore, WL 2006), stated that
regardless of the likelihood of implantation failure under such
circumstances, any such failure is spontaneous, not induced, and thus, for
Alcorn, is a miscarriage, which he does not consider ethically
problematic.
It is only at the very end of his paper that Bovens admits to the
possibility that his probabilistic arguments about the likelihood of
implantation failure can potentially be addressed by making the
distinction between artificially inducing an environment "in utero"
inhospitable to implantation vs. its natural occurrence as part of the
ovulatory cycle. But he fails to admit that Alcom makes this distinction
all along.
Boven’s first assumption that 50% of natural human conceptions are
lost is an often-repeated figure based on problematic research in 1956
using histological analysis of hysterectomies where intercourse was
encouraged prior to surgery. The higher figure of 78% often quoted rests
on a 1975 analysis of a hypothesis based on a series of weak assumptions.
In summary, we think that concerning the Natural Ethics of Harris
(see references in the article) the article fails to acknowledge the
distinction between natural loss and loss caused by deliberate human
intervention; common sense and every criminal law system recognises the
importance of knowledge and intent in human responsibility. In particular,
the fact that accidental deaths happen does not justify causing similar
deaths. Bovens adopts Harris’ perspective, that the knowledge that some
embryos will not naturally survive, amounts to convicting any couple then
continuing to conceive naturally of “destruction” of embryos.
Philosophically however it is even more problematic to think that people
cannot have a say by controlling their reproductive life. Technically we
can spend our whole life in bed trying to have babies, since every moment
that passes is an opportunity 'lost'. Indeed this in itself is a reductio
ad absurdum of Boven's argument.
Finally, I am concerned as such an article in a well known ethical
journal obviously influences various publications (Catholic News Service,
6/2006 and catholic news, 7 Jun 2006) to statements as such “…using
natural family planning to have only one or a maximum of two children is
nothing other than a kind of series of brief parentheses within an entire
conjugal life willingly made sterile". Bovens did not write it directly,
but his article paves the way for rejecting NFP as a method of family
planning for religious people as well. Is that what we want?
Reference List
1. Alcom,R. (2005) Does the birth control pill cause abortions?
Gresham, OR: Eternal Perspective Ministries, 50-73.
2. Alcom,R. and Larimore,W. (2006) Does the birth controll pill
cause abortions? The growing debate about the abortifacient effect of the
birth controll pill and the principle of the double effect. Ethics in
Medicine, in review.
3. Frank,P., Freundl,G., and Gray,R.H. (1985) [Natural family
planning. Introduction and epidemiologic studies] Gynakologe., 18, 224-
230.
4. Freundl,G., Gnoth,C., and Frank-Herrmann P. (2001) Freundl,G.
(ed), Kinderwunsch - Neue Wege zum Wunschkind. Gräfe und Unzer, München, 1
-289.
5. Raith,E., Frank,P., and Freundl,G. (1999) Raith-Paula,E., Frank-
Herrmann P., and Freundl,G. (eds), Natürliche Familineplanung heute mit
ausführlicher Darstellung der Zykluscomputer. Springer, Berlin, 1-273.
6. Simpson,J.L., Gray,R.H., Perez,A. et al (1997) Pregnancy outcome
in natural family planning users: cohort and case-control studies
evaluating safety. Adv.Contracept., 13, 201-214.
7. Simpson,J.L., Gray,R.H., Queenan,J.T. et al (1988) Pregnancy
outcome associated with natural family planning (NFP): scientific basis
and experimental design for an international cohort study.
Adv.Contracept., 4, 247-264.
8. Wilcox,A.J., Weinberg,C.R., and Baird,D.D. (1998) Post-ovulatory
ageing of the human oocyte and embryo failure. Hum.Reprod., 13, 394-397.
I am surprised by glaring omissions in your article, Ethical problems
arising in evidence-based complementary and alternative medicine by Ernst,
Cohen and Stone. Their paper undoubtedly presents an outdated picture of
the development of complementary and alternative Medicine (CAM) in the UK
at this time
The authors state “that providers of CAM are often not medically
trained” and that “their...
I am surprised by glaring omissions in your article, Ethical problems
arising in evidence-based complementary and alternative medicine by Ernst,
Cohen and Stone. Their paper undoubtedly presents an outdated picture of
the development of complementary and alternative Medicine (CAM) in the UK
at this time
The authors state “that providers of CAM are often not medically
trained” and that “their understanding of anatomy, physiology, pathology
and other disciplines of Western Science may be limited…” It goes on to
say, “ Unlike the situation of widespread licensure in the US for
chiropractors, acupuncturists, massage therapists and to some extent
naturopathic physicians, most CAM professions in the UK are not
statutorily regulated (the only two exceptions in the UK are chiropractors
and osteopaths.)”
The authors fail to report that statutory regulation of the UK herbal
and acupuncture sectors is now imminent. There is no mention that in 2,000
the House of Lords Select Committee on Science and Technology published a
report on CAM [1] and that this report specifically called for the
statutory regulation of the acupuncture and herbal medicine sectors. Nor
do the authors refer to evidence given to the Select Committee (Sections
5.51 and 5.52) by the Under Secretary for State for Public Health, Yvette
Cooper, who told the Committee that on safety grounds, the Government had
specifically identified acupuncture and herbal medicine as therapies that
it would like to see achieve statutory self-regulation. She also pointed
out (Section 5.44) that the 1999 Health Act now provided a fast-track
route for the statutory regulation of a health profession previously only
achievable by cumbersome primary legislation.
The article also omits to mention that in 2001, the Government
responded to the Select Committee Report recommending that herbal medicine
and acupuncture should as soon as possible seek statutory regulation under
the Health Act 1999 [2] and that the following year the Department of
Health set up two independent committees, the Herbal Medicine Regulatory
Working Group (HMRWG) and the Acupuncture Regulatory Working Group (ARWG)
to give detailed consideration of how statutory regulation of acupuncture
and herbal medicine could best be achieved. Both Committees met regularly
throughout 2002/3 and published their recommendations in September
2003.[3,4] Having considered these two reports, the Government is set to
publish, any day now, a public consultation document seeking views on
aspects of the statutory regulation of herbal and acupuncture
practitioners in the UK. Following a thirteen-week consultation period,
the Government will once again take stock before finally consulting on
draft legislation that will eventually lead to legislation laid before
Parliament. Although there is no firm timetable, we anticipate the
statutory regulation of UK herbalists and acupuncturists to pass into law
in 2006. I submit that all this presents a very different picture to the
one painted by Ernst, Cohen and Stone.
As for training, it is accepted by the herbal profession that
herbalists of all traditions require a good standard of western medicine
including pharmacology. The Core Curriculum published in the HMRWG report
is a detailed account of this training, which is overseen by the
Accreditation Board of European Herbal Practitioners Association.
Traditional acupuncturists too must be trained in conventional western
medicine so that they can recognise the limits of their competence and
know when to refer. Several British Universities currently offer degree
training in these disciplines and such training has now been available for
the past decade. The UK leads the world in the development of CAM and its
level of acceptance surely does not so much represent a “challenge to
healthcare professionals of all disciplines” as Ernst et al assert, but
rather a golden opportunity to integrate the best of orthodox and CAM for
the benefit of millions of patients who clearly wish to access both
modalities.
References
(1) House of Lords’ Select Committee on Science and Technology,
Session 1999-2000. 6th Report. Complementary and Alternative Medicine. The
Stationary Office, 2000.
(2) Department of Health. Government Response to the House of Lords Select
Committee on Science and Technology’s Report on Complementary and
Alternative Medicine. The Stationary Office, March 2001.
(3) Recommendations on the Regulation of Herbal Practitioners in the UK A
Report from the Herbal Medicines Regulatory Working Group, published on
behalf of the HMRWG by the Prince of Wales’s Foundation for Integrated
Health, 2003.
(4) The Statutory Regulation of the Acupuncture Profession, the Report of
the Acupuncture Regulatory Working Group, published on behalf of the ARWG
by the Prince of Wales’s Foundation for Integrated Health, 2003.
I very much like Levy’s first argument in his letter of response[1]:
‘[I]t is false to think that in all cases in which X is worse off as a result of Y's actions, X has had her rights violated by Y.’
Levy makes a good point that members of society are not discriminating against the deaf, when they use the spoken word and audible alarms, and so forth, as part of their everyday lives. Nobody...
I very much like Levy’s first argument in his letter of response[1]:
‘[I]t is false to think that in all cases in which X is worse off as a result of Y's actions, X has had her rights violated by Y.’
Levy makes a good point that members of society are not discriminating against the deaf, when they use the spoken word and audible alarms, and so forth, as part of their everyday lives. Nobody in the hearing community is personally responsible for the everyday difficulties faced by the deaf.
Levy seems to accept my claim that our society could have developed some other way. Societies develop through the actions of their citizens. We might imagine that X, who is deaf, is worse off than Y because Z, their distant ancestor, helped to spread the use of a spoken language which X cannot use. The failure of Levy’s argument lies in his second claim, which is essentially that Z was justified in establishing this logocentric norm because of the particular usefulness of hearing and the spoken word. Levy’s argument is meant to establish the innocence of both Y and Z, but I think that Z’s innocence is much harder to show.
It seems to me that it is just false that the primacy of the spoken word ‘reflect[s] the advantages of using all the modes of communication available to us’. We certainly do not use all of the available modes of communication. We do not use smell for signaling, we do not blow air on each other’s faces by way of speech, and we rarely touch to communicate. We do not communicate by dance or by blinking. Each of these modes has its own unique advantages and each could presumably be used as a complex, syntactic language. Though no current society uses these modes of communication, they all happened to develop so that those who cannot smell, blow or taste are not disadvantaged. Certainly, there are some minor advantages to hearing which are irreplaceable by other senses, but this is also true of smell, on which we do not depend at all. If we voluntarily live without sign language, which is uniquely useful in many situations, it is hard to see why we should view the discriminatory use of speech as a justified, non-arbitrary choice.
Sometimes the mere absence of a sense can have its own advantages, depending on the environment we live in. There are minor advantages to everyone being deaf or blocking their ears - for example, the ability to use deafeningly loud machinery in all places, at all times. Cars would run more efficiently without mufflers. Construction could proceed at night. One could own a Chihuahua. Deaf people could claim that the choice to deafen oneself and run an un-muffled motorbike would simply ‘reflect the advantages’ of being deaf. From this perspective, the natural benefits of hearing offer no justification at all for the elevated position of the spoken word in our society.
Levy’s claim that ‘our social world is necessarily designed so that certain abilities are rewarded more than others and certain limitations are more constraining’ is probably one of life’s harsh truths. Yet, as seems to admit, it is a contingent, historical fact that the limited, constrained people are the deaf people. Furthermore, as I have discussed, it is not a historical fact which has its basis in any clearly justified choice – unless it is justified by the fact that the deaf are a minority group. Perhaps Levy means to imply that, when building social rules, we may privilege the interests of the majority over the interests of the minority, since this arrangement will result in a lower level of suffering. Then, if deaf people were in the majority, the hearing should be doomed to a life of tinnitus caused by the noisy machinery run by the deaf. Their ‘aural hypersensitivity’ would seem like a necessary limitation, since their suffering would be caused by their social environment. Perhaps this suffering would be ‘simply inevitable’ and not discriminatory at all – but before we agree with that, let us consider the following argument:
What if it was ‘inevitable’ due to some similarly arbitrary facts of history, that black children were worse off than white children? Suppose we lived in a country where current attitudes were not particularly discriminatory, but where past discrimination, by people who are now dead, had left blacks with a tiny share of the wealth. Suppose we also agree that X, who is wealthy, does not wrong Y, who is poor, when X refuses to give Y his money. This is in line with the common-sense, capitalist morality that constitutes much of our society at present.
In such a society, the wealthy white majority would not be wronging the poor racial minority, when they simply hold on to their own money. The impoverished black minority would be less well off due to historical misfortune, and not wronged or discriminated against by any living people.
On Levy’s arguments, and these two premises, we should ‘think much less of’ black parents who do not surrender their children to wealthy infertile whites. We should tell them that, due to the actions of our now-dead forebears, they should not raise children who will be poor like them. I find this conclusion unacceptable, and I think it elucidates the problem with Levy’s argument.
The passage of history may absolve current individuals of discriminations from which they benefit. But it does not mean that the society is a just and non-discriminatory one. We have a discriminatory society comprised of non-discriminating individuals, clinging justly to their inherited lot. That is the problem for the deaf. Their children will be worse off as a result of some unjustified historical choices, and not their own reproductive choices. We should not require them to make reproductive choices which validate some historical injustice, no matter how prudent those choices are.
When we tell the deaf that their deaf children will be worse off, we are using the injustice of our society as a coercive tool, as an ultimatum. When we do this, we become responsible for the discriminatory nature of our society, and we wrong the deaf, just as we wrong a person when we hold them at gunpoint. Thus, the situation is in some ways unlike Levy’s description of the crazed gunman in the park – perhaps a more enlightening description would be this:
“Today there was a crazed gunman in the park who shot at everyone he saw. Nonetheless, some parents came to the park and their child was shot. The gunman thought much less of the parents whose child he had killed”.
Combining children and gene therapy has the potential to precipitate
quite an
ethically volatile mix. Consent may be impossible to obtain from a child.
Yet,
if we require valid consent from all research subjects, then will there
not be
large groups of people, children included, in need of the benefits of
research
who will never get them? Thus we arrive at the conclusion that through
any
number...
Combining children and gene therapy has the potential to precipitate
quite an
ethically volatile mix. Consent may be impossible to obtain from a child.
Yet,
if we require valid consent from all research subjects, then will there
not be
large groups of people, children included, in need of the benefits of
research
who will never get them? Thus we arrive at the conclusion that through
any
number of philosophical arguments parents are able to consent for their
children. However, consent is only a small part of the picture.
Clinical equipoise must be satisfied for a trial to be ethical, and I
am not so
sure that it would be satisfied in a trial involving cystic fibrosis, gene
therapy,
and children. The authors mention that several other children who
underwent retroviral gene therapy for a different ailment developed
leukaemia. These children had life-threatening illnesses, but the
development of leukaemia seems to be quite relevant. It seems that the
onus
to prove, if possible, the children did not develop leukaemia as a result
of
retroviral gene therapy lies with the potential investigator of any
retroviral
gene therapy trial involving children.
The authors’ survey is interesting, because they themselves claim
there may
be significant risks associated with a gene therapy trial but make no
mention
of any risks in the survey. How can such a survey accurately reflect a
person’s attitudes towards gene therapy? Surely, if the risks were
clearly
explained on a consent form people would react quite differently.
While it is probably correct to claim that the research questions at
hand
cannot be answered in any other way that realization alone must not give
us a
scintilla of motivation for commencing retroviral gene therapy trials on
children with cystic fibrosis. Only after more evidence, be it indirect,
has
been gathered to demonstrate the safety of such a procedure should
clinical
trials begin. However, in the absence of the availability of such
evidence the
trials may be ethical.
Regarding the Symposium on consent and confidentiality.[1]
We read with interest the recent papers on informed consent
published in a recent edition of the JME.[1] Whatever their differences,
and however much they questioned some aspects of the duty to respect
autonomy through attempting to obtain informed consent for therapeutic
interventions, there was a general agreement that competent adult...
Regarding the Symposium on consent and confidentiality.[1]
We read with interest the recent papers on informed consent
published in a recent edition of the JME.[1] Whatever their differences,
and however much they questioned some aspects of the duty to respect
autonomy through attempting to obtain informed consent for therapeutic
interventions, there was a general agreement that competent adult patients
are entitled to a core of basic information about their clinical options.
There was also a consensus that training in the process of obtaining
consent was important. In our experience, there are two different
dimensions of such training that are of particular interest. On the one
hand, students require good theoretical understanding of the ethical and
legal background to the professional emphasis now placed on informed
consent. On the other hand, they need practical training in relevant
communication skills and how to apply them to obtain consent for specific
clinical procedures To do so, doctors must obviously also have a good
understanding of these procedures. In a recently conducted study among
junior doctors in England (Schildmann J, Cushing A, Doyal L, Vollmann J.
The ethics and law of informed consent: knowledge, views and practice of
Pre Registration House Officers - manuscript submitted for publication),
we encountered serious problems as regards such understanding. No matter
how good their philosophical and legal knowledge may be, PRHOs will not be
able to deliver the minimal standards of informed consent outlined by
O’Neil unless, suffice it to say, they know what – practically speaking -
they are talking about![2]
Thus, in contrast to the results of the study of G Bravo et al.
published in the same issue of this journal, almost all PRHOs taking part
in our survey had a good legal understanding of the differences between
competent and incompetent patients.[3] This may be interpreted as a
positive result of the curriculum change at their specific medical school
which includes sustained sessions about informed consent. These embrace
ethics, law and communication skills. Despite this understanding, however,
the junior doctors taking part in our study still experienced problems
about their role in the consent process. These pertained to time pressure
and a lack of support by senior doctors, as well as pressure on them at
times to obtain consent in circumstances where they had been taught that
they should not . This gap between the standards of informed consent
currently taught to medical students and the clinical realities that they
face, and into which they are thrusts, is an ongoing problem.[4]
If informed consent is to fulfil the purpose of respecting the
autonomy and dignity of patients, sufficient resources are required to
train young doctors to do the job properly, especially as regards their
understanding of procedures for which they are providing information and
their competence as communicators. One thing is clear. If they cannot
complete the task in accordance with the guidance issued by both the GMC
and the Department of Health, they should not be doing it at all.[5,6]
Trusts and Colleges should ensure that all supervisory staff are aware of
their responsibilities in this regard.
References
1. Symposium on consent and confidentiality. J Med Ethics 2003; 29:2-
40.
2. O'Neill O. Some limits of informed consent. J Med Ethics 2003; 29:4
-7.
3. Bravo G, Paquet M, Dubois MF. Knowledge of the legislation
governing proxy consent to treatment and research. J Med Ethics 2003;
29:44-50.
4. Doyal L. Closing the gap between professional teaching and
practice. British Medical Journal 2001; 322:685-686.
5. Department of Health. Reference Guide to Consent for Examination or
Treatment. http://www.doh.gov.uk/consent/refguide.htm (accessed March 27,
2003).
6. General Medical Council. Seeking patients' consent: the ethical
considerations. London: General Medical Council, 1998.
Luc Bovens’s assumption that intercourse on the fringes of the
fertile phase of the menstrual cycle by users of rhythm will result in
increased embryo loss is not based on convincing evidence (J Med Ethics,
2006;32:355-356). In fact, some scientific evidence points to the
opposite conclusion. Researchers at the US National Institutes of Health
Science reported they found no evidence for this associa...
Luc Bovens’s assumption that intercourse on the fringes of the
fertile phase of the menstrual cycle by users of rhythm will result in
increased embryo loss is not based on convincing evidence (J Med Ethics,
2006;32:355-356). In fact, some scientific evidence points to the
opposite conclusion. Researchers at the US National Institutes of Health
Science reported they found no evidence for this association based on
single acts of intercourse during the fertile window.(1) In a subsequent
study they did find a significant increase in pregnancy loss from acts of
intercourse on the estimated day of ovulation, but the study had severe
limitations due to imprecise timing of intercourse and in estimating what
acts of intercourse actually caused the pregnancy.(2) But neither of
these studies involved couples using rhythm or what is commonly known as
natural family planning (NFP).
Researchers from Johns Hopkins and Georgetown University conducted a
prospective study that included 373 unplanned and 367 planned pregnancies
which occurred from women who were taught natural family planning (NFP) at
5 centers worldwide. The researchers found no significant differences in
adverse pregnancy outcomes including spontaneous abortion rates between
the two groups of women.(3) Although these same researchers found some
evidence of poor pregnancy outcomes from unintended pregnancy compared to
NFP couples who intended pregnancy, the poor pregnancy outcomes were only
from couples who had a history of early pregnancy loss.(4) The largest
study to test the hypothesis that users of NFP with unintended pregnancies
have different pregnancy outcomes than couples that practice spontaneous
intercourse resulted in no difference in pregnancy outcomes.(5)
Bovens’s assertion about ageing gametes with use of rhythm and
resulting spontaneous embryo wastage is not new. In fact moral
theologians postulated this possibility in the 1970s.(6) Back then, their
assertions were based on poorly designed research studies and
circumstantial evidence. One of the studies was a thesis that involved a
retrospective assessment of parents of mentally handicapped children from
one Dutch village who were asked, up to 10 years later, to recall when the
conception intercourse occurred. These couples practiced a calendar-based
system of NFP, not the more modern methods that rely on biological markers
of fertility. The same researcher also provided circumstantial evidence
of an increase of Downs Syndrome by young Catholic mothers using NFP.(7)
Guerrero and Rojas tested the ageing gamete theory and seemed to show an
increase in the spontaneous abortion rate and possibly malformations based
on the recordings of the basal body temperature thermal shift and timing
of artificial insemination.(8) However, we now know that the thermal
shift is a very imprecise method of estimating the fertile phase, and
conclusions based on this biological marker are fraught with error. Poor
scientific studies result in poor outcomes and false conclusions.
Physiological mechanisms in the human being facilitate fresh gametes
for the process of fertilization. During the fertile phase of the cycle,
estrogen stimulated cervical mucus serves the purpose of filtering out
defective sperm. Only the most robust succeed in reaching the ovum.
Furthermore, the ovum is viable only about 12 – 24 hours. Approximately 50
-75% of spontaneous abortions are a result of chromosomal abnormalities of
the embryo, and most of these occur by chance.(9) How much of this
chromosomal damage is due to ageing gametes from intercourses on the
fringes of the fertile phase has not been documented. Other factors
contributing to early embryonic loss include uterine abnormalities,
immunologic disorders, bleeding disorders, endocrine disorders,
infections, and environmental factors such as smoking. The more
troublesome ageing factor is oocytes from older women, especially when
they have intercourse with older men. Women in modern developed countries
tend to delay (largely by use of hormonal contraception) having children
until later in life, often at an age when their fertility is in decline
and their oocytes are diminished and genetically old.(9,10)
In fact, it could be postulated that couples using hormonal
contraception will contribute to higher spontaneous abortion rates and
poorer pregnancy outcomes than couples using other forms of family
planning. Many couples who are on hormonal contraception will eventually
discontinue the contraceptive pill to achieve a pregnancy. (Please note
that couples do not stop using NFP when they want to achieve a pregnancy –
in fact, NFP helps couples to target the fertile phase). Couples who
discontinue hormonal contraception often experience irregular menstrual
cycles, delayed ovulation, longer follicular phases, and shortened luteal
phases.(11) Longer follicular phases and shortened luteal phases have
been cited as factors that could contribute to oocyte ageing and early
spontaneous embryo loss.(12) Millions of women discontinue hormonal
contraception each year to achieve a pregnancy. Should we ask them to
avoid achieving a pregnancy until their cycles normalize?
The highest probabilities of pregnancy from an act of intercourse
during the fertile window are the two days before the day of
ovulation.(13) We do know that there are factors that decrease this
probability such as poor quality cervical mucus, the age of the woman and
the man (not the age of the gametes), and smoking.(14,15) If you accept
absolute numbers of natural preimplantation losses of 50%, then it is
likely that these will occur much more (in absolute terms) with
intercourse during the days of highest fertility. That is, if 50% of all
zygotes fail to implant, since there are many more zygotes formed at days
of peak fertility, there will be many more failed implantations during the
high fertile time. This is true even if the percentage of failed
implantations on the extreme margins of the fertile period were to be
slightly higher (say 1% or 5% more) - a possibility that we can't entirely
exclude.
From an ethical standpoint, even if you hold to the assertion that
fertilization on the margins of the fertile time results in embryos loss,
that doesn’t mean NFP use is causing embryo deaths in any morally relevant
sense. Thisis the case for at least two reasons, first, intercourse at
these times is not unique to NFP users. Where is the evidence that NFP
users have intercourse on the edges of the fertile phase significantly
more than the general population? Research has indicated couples have
intercourse more frequentl on the weekend when there is more time and less
stress.(16) Weekend intercourse will result in intercourse anytime during
the fertile phase, including the fringes. Second, having intercourse at
these times does not equal doing anything (either “action” or "omission")
to the woman or the embryo to cause the embryo’s death – as is the case
when a woman uses an abortifacient drug or device. The parallel Bovens
tries to draw between the two cases just doesn’t work. The point is
basically the same as one would make in distinguishing between [non-
abortifacient methods of] contraception and NFP. They both avoid
fertilization, but contraception does so by doing something to the act of
intercourse – either an "action" or [in the case of withdrawal] an
"omission" – that takes away as much as possible of the fertility it would
otherwise have. NFP does nothing of the sort.
NFP helps couples to monitor, understand, and live with their
fertility. Contraception works to block, suppress, or destroy fertility --
actions that are contra fertility and, at times contra life. Fertility
for many couples is a precious and awesome gift. Human life is precious
and at the most vulnerable during the passage from the fallopian tubes to
the womb. The assumption that intercourse on the edges of the fertile
phase leads to the utilization of aged gametes and increased embryonic
destruction is plausible, but there is scant evidence of this among human
beings. The assumption that practicing NFP results in the use of aged
gametes and increased embryonic death has no good evidence and in fact
some good evidence to the contrary. The use of NFP is not an action or
omission against embryonic human life anymore than normal human living and
loving. Taking Bovens’s notion to the extreme would mean that couples
should not have intercourse at all – since, it might result in a
spontaneous abortion. Perhaps the real absurdity is the thinking that
what is natural is bad and what is destructive of fertility is good.
Separating sexuality from fertility is a dualistic system counter to
the natural intent of the sexual act. It only works in a fantasy world
with a false sense of sexual freedom by use of condoms, hormonal
contraception, emergency contraception, abortion as a backup, IVF when a
perfect child is wanted, and sterilization when fertility is no longer
desired. This dualism creates a false representation of human being, human
relations, human boding, and the transmission of human life.
References
1. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse
in relation to ovulation, effects on the probability of conception,
survival of the pregnancy, and sex of the baby. N Engl J Med,
1995;333:1517-1521.
2. Wilcox AJ, Weinberg CR, Baird DD. Post-ovulatory aging of the
human oocyte and loss of pregnancy. Hum Reprod, 1998;13:394-397.
3. Bitto A, Gray RH, Simpson JL, Queenan JT, Kambic RT, Perez A,
Mena P, Barbato M, Li C, Jennings V. Adverse outcomes of planned and
unplanned pregnancies among users of natural family planning: a
prospective study. Am J Public Health, 1997 Mar;87(3):338-43.
4. Gray RH, Simpson JL, Kambic RT, Queenan JT, Mena P, Perez A,
Barbato M. Timing of conception and the risk of spontaneous abortion
among pregnancies occurring during the use of natural family planning. Am
J Obstet Gynecol, 1995 May;172(5):1567-72.
5. Barbato M, Bitto A, Gray RH, Simpson JL, Queenan JT, Kambic RT,
Perez A, Mena P, Pardo F, Stevenson W, Tagliabue G, Jennings V, Li C.
Effects of timing of conception on birth weight and preterm delivery of
natural family planning users. Adv Contracept, 1997;13:215-28.
6. Haring B. New dimension of responsible parenthood. Theological
Studies, 1976:37:120-132.
7. Jongbloet PH. The ageing gamete in relation to birth control
failures and Down syndrome. Eur J Pediatr, 1985 Nov;144(4):343-7.
8. Guerrero R, Rojas OI. Spontaneous abortion and aging of human
ova and spermatozoa. N Engl J Med, 1975;293:573-575.
9. Speroff L, Fritz MA. Recurrent early pregnancy loss. Chapter in
Clinical Gynecology Endocrinology and Infertility. Phildelphia:
Lippincott Williams & Wilkins, 2005:1069-1101.
10. ESHRE Capri Workshop Group. Fertilty and ageing. Human Reprod
Update, 2005;11:261-267
11. Gnoth C, Frank-Hermann P, Schmoll A et al. Cycle characteristics
after discontinuation of oral contraceptives. Gynecological
Endocrinology, 2002;16:307-317.
12. Tarin JJ, Pérez-Albala S, Cano A. Consequences on offspring of
abnormal function in ageing gametes. Hum Reprod Updates, 2000;6:532-549.
13. Wilcox AJ, Dunson D, Baird DD. The timing of the "fertile
window" in the menstrual cycle: day specific estimates from a prospective
study. BMJ, 2000 Nov 18;321(7271):1259-62.
14. Dunson DB, Colombo B, Baird DD. Changes with age in the level
and duration of fertility in the menstrual cycle. Hum Reprod, 2002
May;17(5):1399-403.
15. Scarpa B, Dunson DB, Colombo B. Cervical mucus secretions on the
day of intercourse: an accurate marker of highly fertile days. Eur J
Obstet Gynecol Reprod Biol, 2006 Mar 1;125(1):72-8.
16. Wilcox AJ, Barid DD, Dunson DB, McConnaughey DR, Desner JS,
Weinberg DR. On the frequency of intercourse around ovulation: evidence
for biological influences. Hum Reprod, 2004;19:1539-1543.
Acknowledgements: I wish to thank Joseph Sanford, MD and Professor
Kevin Miller for ideas included in my response.
Dear Editor,
For simplicity, I will assume (as I actually believe) that all human embryos are persons, since Bovens is trying to argue that granting this assumption, the use of rhythm or Natural Family Planning (NFP) is if anything more morally problematic than the use of hormonal contraception, at least in respect of embryonic death. Let me grant Bovens' empirical assumptions, though they do not seem based...
Dear Editor
I am grateful to Dr Biegler for his response.[1]
I do not think that Dr Biegler’s thesis demands any legally "counterintuitive claims". On the contrary, what he suggests seems in many ways to be intuitively right. His law is wrong, not his intuition. The law is sometimes counterintuitive (and downright unethical) in some situations in order to preserve principles which generally give just results....
Dear Editor,
A response to Bovens' reply to his critics.
Readers generally would have thought the original article to be about early embryo loss and NFP. The Response of 12th June seem to have moved on somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures giving overall observed and estimated embryo losses; and not so much in observational studies of healthy...
Dear Editor
We write in response to the original article “Differences in medical students’ attitudes to academic misconduct and reported behaviour across the years-a questionnaire study” by Rennie and Rudland published in this journal April 2003 edition.[1] Current and former Dundee Medical School students are concerned at the media misinterpretation of the study and the consequences that this branding of “disho...
Comments to the paper of L Bovens “The rhythm method and embryonic death“, J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if conception occurred on the fringes of the fertile period looking into data concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P. et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl,...
Dear Editor
I am surprised by glaring omissions in your article, Ethical problems arising in evidence-based complementary and alternative medicine by Ernst, Cohen and Stone. Their paper undoubtedly presents an outdated picture of the development of complementary and alternative Medicine (CAM) in the UK at this time
The authors state “that providers of CAM are often not medically trained” and that “their...
Dear Editor
I very much like Levy’s first argument in his letter of response[1]:
‘[I]t is false to think that in all cases in which X is worse off as a result of Y's actions, X has had her rights violated by Y.’
Levy makes a good point that members of society are not discriminating against the deaf, when they use the spoken word and audible alarms, and so forth, as part of their everyday lives. Nobody...
Dear Editor,
Combining children and gene therapy has the potential to precipitate quite an ethically volatile mix. Consent may be impossible to obtain from a child. Yet, if we require valid consent from all research subjects, then will there not be large groups of people, children included, in need of the benefits of research who will never get them? Thus we arrive at the conclusion that through any number...
Dear Editor
Regarding the Symposium on consent and confidentiality.[1]
We read with interest the recent papers on informed consent published in a recent edition of the JME.[1] Whatever their differences, and however much they questioned some aspects of the duty to respect autonomy through attempting to obtain informed consent for therapeutic interventions, there was a general agreement that competent adult...
Dear Editor,
Luc Bovens’s assumption that intercourse on the fringes of the fertile phase of the menstrual cycle by users of rhythm will result in increased embryo loss is not based on convincing evidence (J Med Ethics, 2006;32:355-356). In fact, some scientific evidence points to the opposite conclusion. Researchers at the US National Institutes of Health Science reported they found no evidence for this associa...
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