Journal of Medical Ethics

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Whither religion in medicine?

Fri, 2019-10-25 14:52

Few topics in medical ethics stimulate as much heated debate as the question of the proper place of religious beliefs in medical practice. Typically, this debate is orientated towards questions about the religious beliefs held by medical practitioners, and in particular the appropriate limits that ought to be placed on these beliefs shaping care in ways that might impact negatively on patients’ interests. In this issue, however, it is the religious beliefs of patients themselves, and how these beliefs ought to be responded to by clinicians, that is the focus of analysis.

In their Feature Article, Greenblum and Hubbard (pages 705–10) articulate a strong position in response to this issue. Their fundamental claim is that clinicians should not deliberate about religious commitments with religious patients when these patients are drawing on these commitments in the medical decision-making process. They present two main arguments in support of this...

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Ulysses Contracts in psychiatric care: helping patients to protect themselves from spiralling

Fri, 2019-10-25 14:52

This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment (time 2), they may still be less competent than they were when they signed the Ulysses Contract (time 1). As such, even if competent at time 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis (the claim that allowing harm is as bad as doing harm), this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary.

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When does an advantage become unfair? Empirical and normative concerns in Semenyas case

Fri, 2019-10-25 14:52

There is a fundamental tension in many sports: human sex is not binary, but there are only two categories in which people can compete: male and female. Over the past 10 years, the International Association of Athletics Federations (IAAF) regulations have been at the centre of two notable legal disputes. The Court of Arbitration for Sport (CAS) reached two contradictory rulings: in the first case (Dutee Chand vs Athletics Federation India and IAAF), the IAAF regulations for the eligibility of athletes to compete in the female category were suspended (24 July 2015) on grounds of "discrimination against the female category"; in the latter (Caster Semenya and Athletics South Africa vs IAAF), the regulations were reaffirmed (1 May 2019) on grounds that although discriminatory, they are necessary to maintain a "level playing field" and to "protect" the female category. Although Semenya’s case has paved the way for questioning existing gender norms in sport, a new stable norm has yet to emerge from her case. The pharmacological solution put forward by IAAF to the tension between fairness and inclusivity of bodies non-conforming to two sexes is not, however, the only possible solution/resolution to the case, as I aim to show in this paper. Here I present some reflections on this topic and suggest how CAS should approach the case if it hopes to resolve it.

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Responding to religious patients: why physicians have no business doing theology

Fri, 2019-10-25 14:52

A survey of the recent literature suggests that physicians should engage religious patients on religious grounds when the patient cites religious considerations for a medical decision. We offer two arguments that physicians ought to avoid engaging patients in this manner. The first is the Public Reason Argument. We explain why physicians are relevantly akin to public officials. This suggests that it is not the physician’s proper role to engage in religious deliberation. This is because the public character of a physician’s role binds him/her to public reason, which precludes the use of religious considerations. The second argument is the Fiduciary Argument. We show that the patient-physician relationship is a fiduciary relationship, which suggests that the patient has the clinical expectation that physicians limit themselves to medical considerations. Since engaging in religious deliberations lies outside this set of considerations, such engagement undermines trust and therefore damages the patient-physician relationship.

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Remaining ambiguities surrounding theological negotiation and spiritual care: reply to Greenblum and Hubbard

Fri, 2019-10-25 14:52

Readers have much to consider when evaluating Greenblum and Hubbard’s conclusion that ‘physicians have no business doing theology’.1 The two central arguments the authors offer are fairly convincing within the confines they set for themselves, the provisos they stipulate and their notions of ‘privacy’ and ‘public reason’. However, I would ask readers to consider two questions, the answers to which I believe the authors leave opaque. First, what is theological negotiation? Second, what makes chaplains the singular group of healthcare professionals responsible for theological negotiation? In this Commentary, I explore these questions not with the goal of rejecting the authors’ conclusion, but rather with the goal of highlighting relevant considerations when evaluating the authors’ central tenets.

First, I would like readers to consider Greenblum and Hubbard’s descriptions of theological negotiation. They categorise theological negotiation into metaphysical, normative and alternative responses, and hold that this kind of negotiation...

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Professionalism eliminates religion as a proper tool for doctors rendering advice to patients

Fri, 2019-10-25 14:52

Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials.

Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The medical profession’s rules of conduct...

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Public reasons private roles: legitimising disengagement from religious patients and managing physician trauma

Fri, 2019-10-25 14:52

Greenblum and Hubbard argue that physicians are duty-bound by the constraints of Rawlsian ‘public reason’ to avoid engaging their patients’ religious considerations in medical decision-making.1 This position offers a number of appealing benefits to physicians. It will appear plausible because Rawls’s philosophical tradition of Political Liberalism enjoys the status of ideological orthodoxy in institutions tasked with forming the moral imaginations of physicians and other elites.2 3 It casts the physician in the role of a ‘reasonable person’ occupying the space of public reason whose medical and ethical judgments are opposed by ‘sectarian’ religious patients who refuse to be reasonable. This narrative authorises the exclusion of patient religious considerations from medical decision making when they do not ‘translate’ into reasons recognised by ‘reasonable’ medical professionals and manages the trauma of overwhelmed physicians by legitimising disengagement from difficult interactions with religious patients.

The authors’ arguments...

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Responding (appropriately) to religious patients: a response to Greenblum and Hubbards 'Public Reason argument

Fri, 2019-10-25 14:52

Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or their proxies) make medical decisions.i They provide two arguments for this position: The Public Reason Argument and the Fiduciary Argument. In this essay, I show that the Public Reason Argument fails. Greenblum and Hubbard may provide good reason to think that physicians should not invoke their own religious commitments as reasons for a particular medical decision. But they fail to show that it is wrong for physicians to cite the patient’s own religious commitments as reasons for a particular decision. As such, if Greenblum and Hubbard’s thesis is to survive, the Fiduciary Argument (or some unmentioned argument) will have to do the bulk of the work.

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Doing theology in medical decision-making

Fri, 2019-10-25 14:52
Introduction: theology in the examining room

Religious considerations in medical decision-making have enjoyed newfound attention in recent years, challenging the assumption that the domains of biological and spiritual flourishing can be cleanly separated in clinical practice. A surprising majority of patients desire their physicians to engage their religious and spiritual concerns, yet most never receive such attention, particularly in cases near the end of life where such attention seems most warranted.1–3 As physicians Aparna Sajja and Christina Puchalski recently wrote in the AMA Journal of Ethics theme issue on ‘Religion and Spirituality in Healthcare Practice’, modern medical training is ‘falling short of preparing physicians to help patients with the metaphysical needs of their illness’.4

It would seem then that both patients and physicians might challenge the conclusions proffered by philosophers Jake Greenblum and Ryan Hubbard in ‘Responding to Religious Patients:...

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The importance of prudence within inclusive bioethics

Fri, 2019-10-25 14:52

I should declare at the outset that I much enjoyed this thoughtful paper and personally agree with its overall stance. For the last 20 or more years I have been a member of various British and European bioethics committees—typically appointed to them because I am a theologian—and, within them, I have tried assiduously to adhere to public reason arguments.

However, I do so, not out of a sense of moral obligation, but because I regard public reasoning to be more appropriate and inclusive on these committees than specifically religious reasoning. This is my main point of difference with this otherwise admirable paper.

Although towards the end of their paper the two authors do admit to rare exceptions, it does seem that there is a deontological basis to their Public Reason Argument. They state explicitly that ‘physicians have a moral duty to avoid engaging substantive religious considerations when helping patients...

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Physicians duty to refrain from religious discourse: a response to critics

Fri, 2019-10-25 14:52

We recently argued that—contrary to what we call the dominant view—physicians ought to avoid engaging patients on religious grounds.1 The six responses to our article present an array of concerns and have provided us with the opportunity to consider further aspects of our view. While we cannot reply to all the relevant issues, our aim here is to reply to the most significant concerns.

Against our Public Reason Argument, Nick Colgrove maintains that physicians are not relevantly akin to public officials and should therefore not be constrained by public reasons. Colgrove does not take issue with the idea that it may be reasonable for public officials to justify their policymaking according to public reasons because their policies affect a diverse population. But since ‘the [medical] decision being made is not binding for other patients,’ physicians need not be constrained by public reasons.2 Colgrove’s criticism hinges...

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Subjects of ectogenesis: are 'gestatelings fetuses, newborns or neither?

Fri, 2019-10-25 14:52

Subjects of ectogenesis—human beings that are developing in artificial wombs (AWs)—share the same moral status as newborns. To demonstrate this, I defend two claims. First, subjects of partial ectogenesis—those that develop in utero for a time before being transferred to AWs—are newborns (in the full sense of the word). Second, subjects of complete ectogenesis—those who develop in AWs entirely—share the same moral status as newborns. To defend the first claim, I rely on Elizabeth Chloe Romanis’s distinctions between fetuses, newborns and subjects of ectogenesis. For Romanis, the subject of partial ectogenesis ‘is neither a fetus nor a baby’ but is, instead, a ‘new product of human reproduction’. In this essay, I begin by, expanding upon Romanis’s argument that subjects of partial ectogenesis are not fetuses while arguing that those subjects are newborns. Next, I show that the distinction that Romanis draws between subjects of partial ectogenesis and newborns needs to be revised. The former is a kind of the latter. This leads us to an argument that shows why different moral statuses cannot be justifiably assigned to subjects of partial ectogenesis and subjects of complete ectogenesis, respectively. As subjects of partial ectogenesis share the same moral status as newborns, it follows that subjects of complete ectogenesis share the same moral status as newborns as well. Iconclude by considering implications that this essay may have for the research and development of AW technology and conceptual links between a subject’s moral status and birth.

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Artificial womb technology and the significance of birth: why gestatelings are not newborns (or fetuses)

Fri, 2019-10-25 14:52

In a recent publication, I argued that there is a conceptual difference between artificial womb (AW) technology, capable of facilitating gestation ex utero, and neonatal intensive care, providing incubation to neonates born prematurely. One of the reasons I provided for this distinction was that the subjects of each process are different entities. The subject of the process of gestation ex utero is a unique human entity: a ‘gestateling’, rather than a fetus or a newborn preterm neonate. Nick Colgrove wrote a response to my paper, claiming that my distinction between the subject of an AW and a newborn (in intensive care) was false. He claims that I have not accounted for the proper definition of ‘birth’ and that gestatelings are not a distinct product of human reproduction. Further, Colgrove posits that even if I can successfully distinguish gestatelings from preterms, such a distinction is morally irrelevant because the entities would have the same moral status. In this paper, I address the three challenges raised and defend the claim that gestatelings are unique entities. Moreover, I argue that moral status should not be considered ipso facto determinative in the debate about AWs.

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Ethical dangers of facial phenotyping through photography in psychiatric genomics studies

Fri, 2019-10-25 14:52

Psychiatric genomics research protocols are increasingly incorporating tools of deep phenotyping to observe and examine phenotypic abnormalities among individuals with neurodevelopmental disorders. In particular, photography and the use of two-dimensional and three-dimensional facial analysis is thought to shed further light on the phenotypic expression of the genes underlying neurodevelopmental disorders, as well as provide potential diagnostic tools for clinicians. In this paper, I argue that the research use of photography to aid facial phenotyping raises deeply fraught issues from an ethical point of view. First, the process of objectification through photographic imagery and facial analysis could potentially worsen the stigmatisation of persons with neurodevelopmental disorders. Second, the use of photography for facial phenotyping has worrying parallels with the historical misuse of photography to advance positive and negative eugenics around race, ethnicity and intellectual disability. The paper recommends ethical caution in the use of photography and facial phenotyping in psychiatric genomics studies exploring neurodevelopmental disorders, outlining certain necessary safeguards, such as a critical awareness of the history of anthropometric photography use among scientists, as well as the exploration of photographic methodologies that could potentially empower individuals with disabilities.

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What constitutes a reasonable compensation for non-commercial oocyte donors: an analogy with living organ donation and medical research participation

Fri, 2019-10-25 14:52

There is a growing consensus that the offer of a reasonable compensation for oocyte donation for reproductive treatment is acceptable if it does not compromise voluntary and altruistically motivated donation. However, how to translate this ‘reasonable compensation’ in practice remains unclear as compensation rates offered to oocyte donors between different European Union countries vary significantly. Clinics involved in oocyte donation, as well as those in other medical contexts, might be encouraged in calculating a more consistent and transparent compensation for donors if the elements that constitute a reasonable compensation are explicated. In doing so, lessons can be learnt from living organ donation and medical research participation. Practices in which the elements of a reasonable compensation for the individuals involved have already been more defined in the literature. By means of analogical reasoning, we will outline the different components of a reasonable compensation and subsequently apply these to the context of oocyte donation. We will argue that oocyte donors should first of all be reasonably reimbursed direct expenses related to the donation, without standard remuneration of lost wages. Second, donating oocytes requests a serious time investment, therefore donors are entitled to suitable compensation for their time spent and efforts made. Finally, we will explain that a reasonable compensation consisting of these two components allows for altruism to remain the key value of oocyte donation for reproductive treatment. However, if we acknowledge that donors’ motives are more complex and often include reasons from self-interest, the reasonable compensation may be complemented with modest (non)monetary benefits.

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Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Fri, 2019-10-25 14:52

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent—all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily.

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Too much medicine: not enough trust? A response

Fri, 2019-10-25 14:52

In their paper ’Too much medicine: not enough trust?' Zoë Fritz and Richard Holton explore the connection between trust and overtreatment and overinvestigation. Whilst their paper is insightful, here I argue that much more could be made of a doctor’s (mis)trust and how this exacerbates overtreatment and overinvestigation. By taking Fritz and Holton’s view of trust as having ‘our best interests at heart’ as my starting point, I argue that doctor’s do not always trust that patients or the system has their interests at heart and so use overtreatment and overinvestigation to protect themselves. I also point to the tensions created by a lack of trust on the doctor’s part as a focal point for much needed sustained ethical analysis.

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Too much medicine and the poor climate of trust (authors response)

Fri, 2019-10-25 14:52

Joshua Parker has made many interesting points1, and we welcome the opportunity to develop the ideas of ‘Too Much Medicine, Not Enough Trust’.2 We will address: (i) the asymmetry between the trust that patients extend to doctors, and the trust that doctors extend to patients; (ii) our reasons for doubting that litigation or complaints reflect a betrayal of the patient–doctor relationship and (iii) the importance of institutional trust, both for the doctor and the patient.

First, though, a clarification. We do not say that, in general, to trust someone requires thinking that they have ‘our best interests at heart’. We think that claim and others like it are false.3 What we say is that in the specific case of a patient trusting a doctor, the patient will expect that the doctor has their best interests at heart; and that living up to that expectation is...

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Ethics of organ procurement from the unrepresented patient population

Fri, 2019-10-25 14:52

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act (RUAGA) of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion.

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Responsibility for health

Tue, 2019-10-15 15:15

The question of whether any of us can truly be held responsible for what we do is an issue that occupied the ancient Greeks and continues to entertain our leading thinkers. Whether we can be held responsible for our health, or lack thereof, has additional layers of complexity because of the way in which what we do over time impacts our health. Those of us who have ever self-deceptively wondered about the apparent shrinking of our belt or at the fact that the stairs seem to have multiplied are familiar with the idea that our health can change gradually over time as a result of successive choices that we have made. While there are one-off behaviours that can have an impact on health, for example, a single exposure to a very high level of radiation, in general, ill health develops over time, within an environment and complex set of...

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