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Author Archive: Bioethics Today

About Bioethics Today

Last month, I was honored to be named one of the BBC 100 Women of 2019, which is a list they compile each year of inspiring and influential women. The list includes women from around the world of all ages (from teenagers to nonagenarians) and various professions. People from around the world will be familiar with the names of some of the women, such as Alexandria of Ocasio-Cortez, Megan Rapinoe, and Greta Thunberg, while other women will be new to the world stage.

This year’s theme was the female future and some of the 100 Women were invited to London or Delhi to answer the question, “What would the future look like if it were driven by women?” In my talk, I claimed that a future driven by women would engender more male contraceptive options. Currently, women are responsible for the vast majority of contraception and have over a dozen contraceptive options, whereas men have only 2 options – condoms and vasectomy – and under 10% of women worldwide rely on male methods. The introduction of “the pill,” which was the first long-acting, reversible contraceptive and the first hormonal contraceptive, was a significant milestone in women’s rights since it allowed women to effectively control their reproduction without their partners’ knowledge or involvement. It is important for women to have a variety of contraceptive methods available so they can control their fertility yet being the main ones responsible for contraception also comes with a variety of disadvantages, including physical, emotional, social, financial, and time-related burdens. Additionally, the lack of male contraceptive options inhibits men’s reproductive autonomy.

The goal of my talk was to enumerate the factors that have led to our current contraceptive arrangement so that we can figure out how to move towards a future with more male contraceptive options. I discussed three factors that have led to the disparity in contraceptive options for women and men. First, we tend to overlook men's reproduction. When people think of reproduction they typically think of pregnant people and that generally means women. The conflation of women and reproduction reinforces the alignment of contraceptive responsibility with femininity. Second, there is not sufficient funding to bring male contraceptives to market. Pharmaceutical companies aren't interested in male contraceptives because they assume that men aren't interested in contraception and that women won't trust men.  Third, side effects common in new male contraceptives, which are similar to the side effects in female hormonal methods (e.g. weight gain, diminished libido, etc.), are considered emasculating and therefore unacceptable.

In order to have a future with new male contraceptives, we need to change gender norms. I discussed three areas where we are moving towards more gender equality, but need to continue to head down this path in order for new male contraceptives to become reality. First, we need to continue to make more progress on unpaid household labor: although women still do more household work like taking care of children, doing laundry, and cooking dinner, men today are doing much more than they did even a few decades ago. Taking the male pill is a natural extension of men's increased household and childcare involvement. Second, we have to change gendered perceptions about contraception. Contraception is typically thought of as “women's work,” but we need to reframe it as something that men can and should participate in too. Third, we also need to do a better job teaching about sex in general and specifically regarding LGBTQ rights and consent. Shared contraceptive responsibility fits in with a more comprehensive approach to sex education that values inclusivity and benefits all types of couples, not just those in the heteronormative paradigm. Shared contraceptive responsibility reinforces consent by conceptualizing sex is a joint endeavor that both parties need to contribute to and be responsible for.

I am hopeful for future with more male contraceptive options because I think it will decrease unmet contraceptive need worldwide, unburden women from bearing most of the responsibility for contraception, increase men's reproductive autonomy by giving them more options and, overall, it will advance gender equality.

For more on this topic, see my recent article in BBC Health News, “Are We Ready for Men to Take the Pill?”

 

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Sometimes patients who lack decision-making capacity refuse treatment that would be in their best interests. Imagine, for example, a patient suffering from acute schizophrenia who adamantly and persistently refuses to take antipsychotic medication that would relieve his symptoms. And suppose, further, that this patient poses no danger to himself or others, but that his mental illness prevents him from understanding his diagnosis as well as his likely prognosis with and without the treatment. Should a provider treat such a patient over his objections?

 

My reflections begin with the observation that in most cases of this kind, physicians tend to respect the patient’s incapacitated refusal, either by honoring it, or, at the very least, by treating it with great seriousness. Why? The simple answer is a legal one: in New York and many other states, it is against the law to treat patients over their objections except in cases in which the treatment will prevent them from endangering themselves or others. My interest here, though, is ethical rather than legal: what ethical justification can we offer for this practice?

Answering this question is challenging in part because honoring incapacitated refusals is not obviously justifiable by appeal to any of Beauchamp and Childress’s famous four principles of biomedical ethics: The decision to honor an incapacitated refusal has nothing to do with the fair distribution of benefits and burdens, and so it is not a matter of justice. Nor can it be justified by appeal to beneficence or non-maleficence, as allowing the patient to forgo treatment would make him worse off. The principle of autonomy does not provide support for honoring the refusal, either, at least on a classical understanding of “autonomy.” This is because autonomy is traditionally understood to involve more than the mere ability to do what one happens to want at a given moment. Rather, autonomy is a matter of rational self-governance: it requires a baseline level of understanding of one’s situation, one’s options, and the possible consequences of selecting one of those options. The right of autonomy is a right to make otherwise permissible decisions without the influence of distorting factors, such as intoxicating drugs, false and misleading information, and coercive threats. Severe mental illness is one of these distorting factors insofar as it prevents a patient from making informed decisions that express his values. In the case I began with, the patient did not understand either his diagnosis or his prognosis, he did not have a good grasp of his options, and he was in no position to weigh different courses of treatment and assess their compatibility with his goals and ideals. Indeed, we may even suppose that treating such a patient over his objections would be the only way to restore his capacity for autonomous self-governance.

To be clear, I am not making the case that we ought to override all incapacitated refusals. I do not believe that we should. My point here is that strict adherence to the four-principle model would make it seem as though we obviously should. After all, beneficence would strongly recommend overriding an incapacitated patient’s wishes, and none of the other principles would recommend honoring them. But this apparent clarity is a mirage: the choice of whether to honor incapacitated refusals is plainly a difficult one, and this difficulty is reflected in the seriousness with which our practice and law approach them. Indeed, in their handbook, Addressing Patient-Centered Issues in Health Care, the American Society for Bioethics and Humanities explains that the strenuous objections of incapacitated patients “should be given ethical weight, and sometimes considerable, or even definitive weight.”

This weightiness is evidence of an unexposed value. Like autonomy, this value seems to demand a kind of interpersonal respect. Unlike autonomy, the capacity we are supposed to value and respect is not a capacity for self-governance in light of a basic understanding of relevant information and one’s goals. Whether one articulates this hidden value as a novel “form” of autonomy that has nothing to do with informed self-governance, or as something altogether new, is not important. No matter what we call it, we must explain exactly what this value is and why we ought to take it seriously. That is the heart of the challenge.

This is a task that I am beginning to undertake as part of my research here at AMBI. By the time I write my next blog post, I hope to be able to share at least some progress toward an answer. 

 

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In recent years HIV prevention science has been revolutionized by the realization that some of the drugs originally approved to treat HIV infection are also very effective at preventing HIV infection in people considered at high risk, such as those with HIV-positive partners. Known as “pre-exposure prophylaxis” or “PreP”, the HIV medication Truvada (tenofivir plus an older antiviral called emtricitabine) is now taken on a daily basis by millions of people worldwide in order to prevent HIV infection. While optimists see PreP as an important step on the road to “ending AIDS”, critics note that the drug’s $20,000-a-year price tag impedes adequate access both within the U.S. and globally

On October 3, the politics of PreP became even more fraught when the FDA granted approval to a second HIV drug to be used preventatively – but only by men. “Descovy” is made by Gilead Sciences—the same pharmaceutical company that makes Truvada—and in fact differs from Truvada only slightly in its chemical structure. For reasons that Gilead has failed to make clear, the clinical trial of Descovy was conducted almost exclusively in men (transgender women made up about 1% of the 5400 person cohort). For this reason, the FDA refused to approve its use in “those who have receptive vaginal sex.”

The case of Descovy is ripe with some of the same ethical issues that have plagued HIV drug development since the epidemic began.

First, AIDS activists have been fighting pharmaceutical price-gouging since 1987, when members of the newly founded group ACT UP occupied the New York Stock Exchange to protest the high cost of AZT. Since then access to HIV medications has improved both domestically and globally due to generic competition and dedicated funding programs, but Truvada’s $20,000 price tag shows that companies are still willing and able to charge whatever the market will bear. Moreover, by all appearances Descovy’s FDA approval was timed to coincide with the 2020 expiry of the Truvada patent, thus allowing Gilead to charge what they will for a new PrEP formulation just as they lose market exclusivity on the old one.  This is despite the fact that Descovy is neither a superior drug nor a new one. (The clinical trial showed that it was simply “non-inferior” to Truvada, and although it was only recently submitted for FDA approval, records show that it was invented no later than 2000.)

Secondly, women have fought for recognition from the AIDS scientific community (and the scientific research community more broadly) since the early days of the epidemic.  Until 1993 the CDC’s list of “AIDS-defining illnesses” failed to include the gynecological conditions most often suffered by women with advanced HIV disease. In protest, the activist art collective Gran Fury made a poster quipping “Women Don’t Get AIDS, They Just Die From It” and posted it in bus shelters across New York City.  HIV/AIDS is not the only scientific arena that has failed to include women in research. It was only in 2014 that the National Institutes of Health established a policy requiring its scientists to use both female and male animals and cells in their research. Many NIH-funded scientists, it turns out, prefer to use only male animals because they feel that the estrous cycles of females would muddy their results.

The ethical principle at stake here is justice. Both the high price of PrEP and the exclusion of women from PrEP (and other) trials are unjust, though in different ways. The pricing of PrEP represents a breach of social justice in that it contributes to an unequal society in which people’s physical well-being is determined by their ability to pay for life-saving medications. In other words, health is stratified by wealth. Unfortunately, this problem is hardly limited to HIV medications (got insulin? Millions don’t). In addition, the exclusion of women from the Descovy trial is an example of unjust research design, as it effectively prevents women from benefitting equally (or at all) from this research. Worldwide, the majority of adults living with HIV are women, and women also account for 48% of new HIV infections. Yet, a 2016 literature review found that women remain significantly underrepresented in HIV/AIDS trials, making up an average of only 19% of participants in trials of antiretroviral drugs. HIV medications—including tenofivir, the main ingredient in Truvada and Descovy—can metabolize differently in women versus men, and antivirals can also act differently in vaginal versus rectal mucosa, the two major avenues of sexual infection. In other words, there are clear epidemiological and biological reasons why HIV drug trials need to include women as well as men.

In the case of Descovy, it is unclear why a clinical trial of over 5000 people conducted across 93 locations in the U.S., Canada, and Western Europe didn’t face scrutiny earlier for its exclusion of cisgender women.  Did Gilead feel that including women would “muddy” their results? Or are women simply a less lucrative drug market, given that most women at high risk for acquiring HIV live in low income countries where antiretroviral drugs are discounted or donated if they are available at all? The Gran Fury artists first made their sardonic protest poster in the early 1990s. Nearly 30 years later, why does Gilead still think “women don’t get AIDS”?

 

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** This article was originally featured on the Genetic Literacy Project on October 1, 2019. This article, along with more information and additional links can be found at: https://geneticliteracyproject.org/2019/10/01/foxs-almost-family-vs-the-handmaidens-tale-sequel-the-testaments-different-takes-on-the-dangers-of-sperm-bank-donations/ .  **


I'm dreading the debut of the Fox TV series Almost Family on October 2. In it, Julia Bechley discovers that her dying dad, a famous fertility doctor, had made dozens of personal DNA donations that are now millennials, at least two of whom have unknowingly hooked up.

Many of us in the donor-conceived (DC) community have already seen the series as the Australian show Sisters on Netflix. I hope the new incarnation changes the ending, which was the worst since the supposedly-dead Bobby Ewing appeared in the shower in the 1986 finale of the TV series Dallas and revealed that the entire season, in which he’d died, had been a dream. 

The 2013 film Delivery Man preceded both versions of Dr. Bechley’s misadventures. In it, Vince Vaughan is the befuddled father of 533 twenty-somethings, thanks to long-ago sperm donations. A lot of them.

The danger of unintentional inbreeding

We hardly need fictional accounts of surprise insta-families. The situation is very real, thanks to a convergence of factors: poor regulation of assisted reproductive technologies over decades, the past prioritization of sperm donor privacy over offsprings’ right-to-know, and the rise of consumer DNA testing that probably no donors, and not even their doctors, ever imagined.

And so the media continues to spit out the stories, still with a tone of awe:

  • “A growing family,” from the Associated Press, recently covered 31-year-old Morgan Richardson’s discovery of 15 half-siblings.
  • The New York Times Magazine cover from June 30, 2019, displayed all 32 half-siblings of Eli Baden-Lasar, to accompany his photo essay “Brothers, Sisters, Strangers.”
  • A class action lawsuit in Indianpolis is targeting a doctor who too widely spread his seed.

Well-meaning friends who know I’ve discovered six half-siblings over the past year send me these articles. I wish they wouldn’t. Not because they upset me anymore, but because the overactive sperm donor stories that make it to the media are a tiny tip of a non-melting, actually explosively growing, iceberg.

Judging from the half dozen private Facebook groups I’m in, and perusing the Donor Sibling Registry, it’s clear that we number in the tens of thousands, and perhaps an order of magnitude more.

The problem isn’t with sperm donation itself, which is after all a way to circumvent infertility, but with using sperm from a single man for too many recipients, because the anonymity introduces the possibility of dating one’s half sibling. And that could spawn inadvertent consanguinity (“shared blood”). Unintentional inbreeding.

When two people share a disease-causing recessive mutation inherited from a shared ancestor, like a great-grandparent, each of their potential kids has a 25% risk of inheriting the associated disease. It’s Mendel’s first law in action.

The anonymity of sperm donations robs the descendants of recipients of the choice not to have children with their blood relatives. A way to methodically avoid consanguinity is described in The Testaments, the sequel to Margaret Atwood’s classic 1998 novel The Handmaid’s Tale

Gilead’s solution: good record-keeping

Gilead is centered in what was once Boston, with tentacles reaching up and down the east coast. People are assigned to rigidly defined classes by roles and occupations, and a few men rule to a horrific degree. With rampant infertility due to pollution, fertile young women serve as Handmaids to maintain the population.

Handmaids are forced into a red-draped, white-bonneted sameness and assigned to Commanders whose Wives (official castes are capped) haven’t conceived, and then are ritually raped during their fertile periods. The Wives watch and assist the sanctioned serial sexual assaults, then steal, own and raise the resulting children.

Sometimes Handmaids sneak off to become pregnant by someone else, such as a lowly male employee of the household, because if she doesn’t conceive within a year or so, she’s blamed, reassigned, and if that fails too, killed and hung on the Wall like others who disobey the law.

Because in Gilead the mommy isn’t the mommy and the daddy sometimes isn’t the daddy, someone has to track the genetics to avoid consanguinity.

The task of recording and maintaining the true genealogies, inscribed in volumes of the Bloodline Genealogical Archives in a locked room in a heavily guarded mausoleum-like building, falls to the Aunts, a select group of women who are allowed to read and think.

Explains Aunt Lydia:

It’s essential to record who is related to whom, both officially and in fact: due to the Handmaid system, a couple’s child may not be biologically related to the elite mother or even to the official father, for a desperate Handmaid is likely to seek impregnation however she may. It is our business to inform ourselves, since incest must be prevented: there are enough Unbabies already.

Unbabies are the unfortunate consequence of those recessive genes matching up, as well as other birth defects arising from the wrecked environment.

A particular concern is that the Commanders, generally older men, go through many Wives and beget many children. They find crude ways to bring early demise to the Wives, such as poisoning, frequently replacing them with younger models (Atwood claims never to write a scene that doesn’t actually happen).

A fresh, new Wife could, biologically speaking, be a Commander’s daughter. Or even a granddaughter.

“With so many older men marrying such young girls, Gilead could not risk the dangerous and sinful father-daughter inbreeding that might result if no one was keeping track,” Lydia writes in her journal, which forms one of three narrative threads of The Testaments, read from a distant future.

Inspiration from a religious community

Atwood’s Bloodline Genealogical Archives of Gilead may have borrowed from the “confidential premarital testing system” Dor Yeshorim (Hebrew for “upright generation”). The program screens potential partners for mutations in the same recessive genes responsible for diseases that are more prevalent in the Jewish population.

Holocaust survivor and rabbi Josef Ekstein began Dor Yeshorim in Brooklyn in 1983, following the birth of his third child to have inherited the devastating Tay-Sachs disease from the two carrier parents. Today, the organization has an international reach. The process identifies people by numbers, and carriers aren’t told what they carry, just with whom they shouldn’t procreate.

By 2010, more than 300,000 young people worldwide had taken carrier tests for an ever-expanding list of diseases through Dor Yeshorim, and more than 20,000 individuals are screened each year. Similar programs operate throughout the world. Call it eugenics or artificial selection, but Dor Yeshorim has practically vanquished certain devastating diseases.

A brief history of sperm donation

The Handmaids of Gilead knew when sex was being forced upon them. Everyone knew. But in a sickening example of truth being stranger than fiction, women who were artificially inseminated decades ago in the US to help them conceive sometimes didn’t know what was happening to them. Dani Shapiro details the practice in her book Inheritance: A Memoir of Genealogy, Paternity, and Love.

Which one is the dystopia?

In 1909, physician Addison Davis Hard published a letter in The Medical World detailing the insemination of a woman with “carefully selected seed.” He and six other medical students witnessed the event at Sansom Street hospital of Jefferson Medical College in Philadelphia in 1884 and were pledged to keep secret the “artificial impregnation.” The husband made no sperm.

Dr. Hard wrote:

The woman was chloroformed, and with a hard rubber syringe some fresh semen from the best-looking member of the class was deposited in the uterus, and the cervix slightly plugged with gauze. Neither the man nor the woman knew the nature of what had been done at the time, but subsequently the Professor repented of his action, and explained the whole matter to the husband.

The oblivious woman gave birth to a healthy boy, who grew up to become a businessman whom the good Dr. Hard reported having met.

The 1909 paper ends with the peculiar admonition that “the mother is the complete builder of the child,” and lists how her parts are echoed in the child. But this was just nine years after the rediscovery of Mendel’s work, a scientific achievement not nearly as celebrated as that of his contemporary, Charles Darwin. And it’s unlikely that the medical school professor performing the insemination in 1884 had read Mendel’s paper on peas, published in 1865.

I can even understand why physicians in 1953, when I was conceived, might not have considered the fact that each parent contributes half of the genetic material. Watson and Crick’s paper was published in April of that year and I apparently became an “artificially inseminated product” two months before that. I had no idea that I was and don’t even know if my mother knew.

But what was the excuse for ignorance of genetics in 1979?

That year, a seminal article in The New England Journal of Medicine reported a survey of 379 doctors who’d performed artificial insemination by donor in 1977, yielding 3,576 births. Some men indicated that they’d made multiple donations, the winner a man whose sperm impregnated 50 women. And the recipients tended to live in the same communities.

That study inspired the opening of the first sperm bank. Didn’t any medical professional think about what might happen if unknowing half-siblings married? A talk show host did.

I remember an episode of the Phil Donohue show from the 1980s featuring a few couples, from Chicago, who’d somehow found out they were half-siblings, long before spit-in-the-tube consumer DNA testing. They’d all partook of product from the Repository for Germinal Choice, a sperm bank in Escondido, California, that for a time collected, froze, and shipped deposits from Nobel Prizewinners.

Limiting sperm donations today

Although a quick perusal of sperm bank websites reveals that they nowadays try to limit availability of one man’s gametes to 25 to 30 women, the emphasis isn’t enough and the number is still unsettlingly high, because it doesn’t mirror normal human reproduction. Who normally has two dozen half siblings?

At the California Cryobank, the Policy of Offspring Limits states:

The maximum goal is 25-30 family units worldwide per donor. Each donor is limited by the length of time he remains active in the program. CCB also limits the total number of vials distributed and monitors pregnancy and birth reports to help maintain this goal.

The Cryos International Sperm & Egg Bank also limits distribution to 25, but will deliver sperm to a customer’s home! To share, all one needs is a turkey baste

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Adult patients are presumed to have decisional capacity and have a right to refuse medical treatment, not only from an ethical perspective but also a legal one.  Patients with capacity have the right of bodily integrity and personal autonomy, and the right to not be touched without consent.  The situation becomes more problematic when adult patients, whom have been determined to lack decisional capacity, actively object to recommended medical treatment or intervention believed to be in their best interest. For this patient population treatment over objection becomes a challenging ethical and legal issue that should not be taken lightly by healthcare providers.   These patients, who may have the ability to not only verbally express strong preferences against treatment, may also physically resist any bodily intrusions.  In most cases the required effort to force treatment, using sedation or restraints, becomes ethically problematic.  At the same time, in cases where it seems apparent that the patient will benefit from the recommended medical treatment, allowing patients without capacity to not receive this treatment is ethically troublesome. 

There is no universal answer to situations in which patients without capacity refuse treatment.  The question is:  Should we employ a case specific approach that carefully considers the following factors:  the patient’s reason for refusal (preferences), harms/risks/consequences without the recommended treatment, the likelihood of the proposed treatment doing good, associated risks of the proposed treatment, and the likely emotional effect of forced treatment on the patient?

One of the most ethically complex decisions in medicine is in deciding when to override the autonomy and/or preferences of a patient deemed to lack decisional capacity and treat over the patient’s objection.  This challenge exists even in the presence of a healthcare agent or surrogate decision-maker.  The ethical justification for overriding a patient’s refusal of medical treatment relies on the assessment of decisional capacity and even if determined to lack capacity, patients may have capacity for some decisions but not for more complex decisions.  Capacity is fluid and can fluctuate over time, particularly with conditions in which cognitive impairment is present.  There are clinical situations in which beneficence outweighs autonomy and in which the use of a soft paternalistic intervention is ethically justifiable whenever it may effectively lead to a greater well-being.   A soft paternalistic intervention serves to protect patients from decisions that may significantly and needlessly alter their life.  In a situation in which the autonomy and/or preferences of a patient are considered to be most important, the use of a paternalistic intervention would not be justified, regardless of the patient’s well-being.

Allowing a patient to suffer preventable harm that can almost certainly be averted with medical intervention seems to be contrary to the ethical principle of beneficence.  The challenge is in identifying and balancing the risk vs. benefit.       

 

 

 

 

 

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“Based on an Actual Lie”—thus begins The Farewell, a film that follows 30-year-old Billi from her New York City home to Changchun, China, where she and her family visit her dying grandmother Nai-Nai.  Billi’s family arrives in Changchun under the guise of a wedding celebration for Nai-Nai’s grandson, but they have really come together to all be with Nai-Nai before she dies of stage IV lunch cancer. The ‘actual lie’ on which the story is based concerns the withholding of grim health information from the family’s matriarch; but this very substantial lie coexists with myriad other well-intentioned lies that various family members tell one another throughout the movie.

The Farewell is a good reminder that disease often affects an entire network, and that medical ethics is, much to the chagrin of many analytic philosophers, embedded in a highly complex web of cultural and sociological forces.  Billi’s father admits to Billi that their strategy of lying to Nai-Nai about her condition wouldn’t fly in the United States; yet the viewer discovers, along with Billi, that norms in China dictate against medical honesty when that honesty brings with it bad news.  

This cultural clash is most stark when we witness the bilingual Billi speak to Nai-Nai’s doctor in English right in front of Nai-Nai, who speaks only Mandarin.  Billi interrogates the physician about whether lying to Nai-Nai is the right thing to do, and he affirms that Nai-Nai has advanced lung cancer and reassures Billi that “it’s a good lie.”  Here, the truth is right in front of Nai-Nai, but just out of reach.

The central tension of the film concerns the interplay between informational disclosure, harm, and autonomy.  Nai-Nai’s family is deeply concerned about the harm that disclosure of her disease status would cause, and this concern appears to be the main driver of their decision to withhold information.  But I have to wonder whether there are other factors in play—e.g. avoidance or denial—that are also contributing to their decision.  And in focusing so much on harm, the family ignores Nai-Nai’s autonomy—and with it, her vibrant, hilarious personality—as worthy of consideration and respect.  When, if ever, does information cause the type of harm that the bioethical principle of nonmaleficence dictates against?  And when, if ever, does this type of harm justify a disregard for autonomy?  These are hard questions to answer.

In the film’s coda, we learn that Nai-Nai is still alive six years later.  As a viewer, I was not sure how to take this information: is it evidence that Nai-Nai’s family did the right thing by lying to her, therefore giving Nai-Nai the opportunity to live six more years in blissful ignorance?  Or does her unexpected longevity make the lie all the more nefarious, since it robbed Nai-Nai of the chance to view each one of those nearly 2200 days as an especially precious gift?  

The most likely answer is that it depends—it depends on what Nai-Nai herself would have wanted.  And with the exception of Billi, Nai-Nai’s family members do not give this question any thought when deciding on what they think is best for Nai-Nai.  We do learn that Nai-Nai lied to her late husband when he was terminally ill, which Nai-Nai’s children seem to think justifies their doing the same to Nai-Nai.  But we also witness the sting of humiliation when Nai-Nai learns that her husband lied to her for years about his smoking habit.  We see throughout the film, from several different angles, how we often don’t really know the people whom we believe we know best of all.

As for me?  Well, I’d want to be told the truth.  But I’d also want the opportunity to leave that truth by the wayside, should I deem it too much of a nuisance, and walk away no worse for the wear.  If only that were a real possibility—for Nai-Nai, for Nai-Nai’s family, and for the rest of us.


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A Catholic physician who invokes conscientious objection to refuse offering a legal service in a secular institution is legally protected from retaliation by their employer.  However, a secular physician who attempts to invoke conscience legislation to provide a legal service in a Catholic institution is not legally protected.  In the bioethics literature on conscientious objection, this is sometimes referred to as the asymmetry problem.  

This is precisely the situation that has played out recently in Colorado where a veteran physician, Dr. Barbara Morris, was fired after suing her employer for the right to assist her patient, Cornelius Mahoney, in ending his life.  The employer is Centura Health, a system jointly run by Catholic and Seventh-Day Adventist churches that believes physician aid in dying to be an intrinsically evil act even though it is now legal in Colorado.  Dr. Morris sued the hospital on the grounds that its faith-based policy violates the law that now permits physicians to provide physician aid in dying.  

Positive claims of conscience involve an insistence on performing some act, whereas negative claims of conscience involve a refusal to perform an act.  Bioethicist Mark Wicclair has pointed out that, in health care, positive claims of conscience often align with liberal values (e.g., providing abortion, emergency contraception, physician aid in dying), whereas negative claims of conscience often align with conservative values (e.g., refusals to perform abortions, provide emergency contraception, or physician aid in dying).  Given that positive claims of conscience tend to be asserted by those with liberal values, and negative claims asserted by those with conservative values, does the asymmetry problem represent a legal bias towards conservative over liberal values?  

At first pass, this may seem like a straightforward case of unjustified bias, but there are important reasons to consider positive claims of conscience different from negative claims.  The first reason involves the value integrity of the institution employing the physician.  Secular hospitals committed to providing ethically controversial yet legal services to patients (e.g., abortion) are often able to accommodate conscientious refusals while upholding their commitment to providing a service.  With good communication and some advanced planning, it is generally possible to locate another willing provider to step in and provide the service.  However, it is not as easy for an institution to maintain value integrity if physicians are able to provide services the hospital conscientiously objects to.  For a hospital that objects to physician aid in dying, if only one physician asserts a positive conscience claim to provide that service then the hospital is no longer able to uphold their values.  A second reason to think positive claims of conscience are different from negative claims is that the hospital is forced to provide the resources by which the physician enacts physician aid in dying.  Nothing stops a physician who believes in providing physician aid in dying from organizing with other like-minded individuals and opening a clinic that provides this service, but situations similar to what unfolded in Colorado ask institutions to provide physicians with the resources needed to perform an act with which the institution morally objects.  Not only would the Catholic hospital be unable to uphold their value, it must pay for the service it objects to.  These concerns show the asymmetry problem in conscientious objection may not be a case of simple bias but may be driven by substantive reasons why conscientious refusals are different from conscientious provisions.  

However, there may be other reasons to consider constraining conscientious refusals, such as instances where refusal creates a significant barrier of access for the patient.  In the Colorado case, the patient did not want to be referred to another institution because of the additional diagnostics, travel, and costs that would be encountered in the face of debilitating symptoms.  Should burdens of access to legal medical services be considered when deciding how to respond to conscientious refusals, and, if so, how great of a burden is needed to justify what sort of limitations can be placed on a conscientious refusal?  

Beyond these considerations, there is a range of additional issues looming over how to handle conscientious refusals in health care.  Are those exercising a conscientious refusal obligated to inform or even refer patients for medical procedures they do not agree with?  Should conscientious refusals be permitted in emergencies?  Although conscientious refusals often focus on abortion or physician assisted suicide, what about other procedures, such as the provision of IVF or organ procurement?  Should conscientious refusals only be permitted for procedures, or can a physician conscientiously refuse to treat a type of patient?  For example, there have been cases of Muslim medical students refusing to see patients of the opposite sex, a physician who refused to treat democrats, and a group of physicians who objected to treating sexual dysfunction in convicted sex offenders.  Should conscientious refusals need to satisfy a standard of reasonability, such as consistency with empirical facts or the goals of medicine?  These questions show that these cases of conscientious objection are rarely straightforward, making the topic a place for lively discussion in bioethics now and likely for some time in the future.  


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Quality of life transplantations (e.g. hand, face, etc.), in contrast to life-saving transplantations (e.g. heart, lungs, etc.), have become increasingly popular and have gained more acceptance in the medical and lay communities. In the last two decades transplants for sexual and reproductive organs—specifically allogenic transplantations of the uterus, ovary, and penis—have emerged as yet another type of quality of life transplants. The purpose of uterus transplantations is to allow cisgender women with absolute uterine factor infertility to experience pregnancy. Although the first uterus transplantation took place in 2000, it was not until 2014 that there was a successful live birth baby gestated in a transplanted uterus. As of this year, 60 transplants have been reported worldwide with 13 children born as the result. In contrast to women seeking uterus transplantations, those who undergo ovary transplantations have a functioning uterus but lack functioning ovaries. Rather than using IVF to conceive, women can receive an ovary transplant (usually just a slice of ovary rather than an entire ovary) so that they begin ovulating and can conceive via heterosexual intercourse or intrauterine insemination. Shockingly, the first performed ovary transplantation occurred in 1895 and that there was even a reported birth in 1906, though it is unclear if this birth was a direct result of the ovary transplant. Ovary transplants were neglected for about a century until the early 2000s and since then there have been at least a dozen ovary transplants and births. For cisgender men, the emerging transplantation surgery for sexual and reproductive organs is penis transplantation, which has been used for men who have sustained genitourinary injuries (e.g. a botched circumcision, penile cancer, and war injuries). As of this year there have only been four successful penis transplants worldwide with the first unsuccessful attempt in 2006 and the first successful one in 2015.

These three transplantations involving sexual and reproductive organs raise numerous ethical issues. However, rather than delving into these ethical issues, I want to highlight an omission. I have extensively searched the medical literature, the news media, and social media and not seen anything about clitoris transplantation. 

One might propose that the reason there isn’t anything out there about cultural transplants is because surgery involving the external female genitalia and vagina are rare or don’t exist. Yet this is not the case. Certain genital surgeries, though not common, are considered the standard of care such as the creation of a neovagina for ciswomen and intersex women with vaginal aplasia (i.e. an undeveloped vagina). The goal of this surgery is to allow for “normal” sexual activity which is typically seen as heterosexual intercourse. Additionally, cosmetic female genital surgery is increasingly common and in fact is the fastest-growing type of cosmetic surgery. The main cosmetic genital surgeries are either geared at enhancing the aesthetics of the external genitalia (e.g. labiaplasty to reduce the size of the labia minora) or aimed at “tightening” the vagina presumably for the sake of a male partner (e.g. vaginal “rejuvenation” surgery). 

One might propose that the reason clitoris transplantations are not being discussed is because there is no need for them. Yet, this is also wrong and the need for clitoris transplantations far exceeds the need for other types of sexual and reproductive transplantations. There are over 200 million women and girls who have experienced female genital cutting and 3 million girls undergo it each year. Even if many, and even most, of the women who have undergone female genital cutting are not interested in restorative surgery like clitoris transplantation, this number still far exceeds the one in 500 women who have absolute uterine factor infertility (and consequently may be interested in uterus transportation) and the number of men who have injuries that would warrant a penis transplantation (for instance, one study put the number of traditional ritualistic circumcisions that result in penile amputation in the hundreds annually).

So why then is no one discussing clitoris transplantation? Unfortunately I believe the answer is simply that culturally we discount women’s sexuality. In other words, the idea of clitoris transplantation has not been explored because we as a society do not value women’s sexual pleasure. We do, in contrast, strongly value women’s fertility (hence the attention to uterus and ovary transplantation) and women’s sexual appeal for the male gaze (hence the genital surgeries focused on improving the aesthetics and experience for men). Furthermore, men’s virility and the existence of “normal” male genitalia is extremely important on the social level, which is why penis transplants have received so much attention. There is growing attention to female sexuality (dys)function as well as continuing global advocacy against female genital cutting. Perhaps clitoris transplantation will become something more than a figment of my imagination if we as a society place more value on women’s sexuality and sexual pleasure. 

This blog is based on a talk I gave, “The Ethics of Clitoris Transplantations: A Constructive Response to Female Genital Cutting” at the European Conference on Philosophy of Medicine and Health Care in August 2019). For references, please contact me.


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We all may remember that Donald Trump’s personal physician, Dr. Harold Borenstein, released a glowing hyperbolic endorsement of then candidate Donald Trump’s health. He stated that "If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency." He further stated that "His physical strength and stamina are extraordinary," The apparent problem with this letter, as Dr. Borenstein now states, is that he did not actually compose the letter. In an article published recently on the CNN website Dr. Borenstein indicates that he did not write that letter, that it was, in fact, dictated by Donald Trump. Let me make it clear that I am not writing about Donald Trump’s ethics and honesty. This has been the subject of thousands of commentaries which can be found almost anywhere. My intention is to address Dr. Borenstein’s ethics and honesty. Because Dr. Borenstein is a physician and was acting in his capacity as a physician in writing and releasing that letter it is fully appropriate to evaluate the moral underpinning of that action by the standards of medical ethics. These principles constitute the basis of moral conduct by all physicians and medical care providers.

While statements of core medical ethical principle vary it is commonly accepted that the principles include respect for persons, beneficence, non-maleficence, and justice. The first, respect for persons, focuses on the manner in which the medical practitioner acts towards the patient. However, this statement was a communication to the general public and needs to be respectful towards them. Dr. Borenstein’s statement is only respectful if it is true and verifiable otherwise it is misleading. There is no way Dr. Borenstein can know that Trump is “unequivocally, will be the healthiest individual ever elected to the presidency." Thus, he is being dishonest and possibly provides misinformation with which citizens will determine who to vote for as President.

Beneficence essentially means doing good.  It is unclear to me that a hyperbolic statement such as this could be viewed as beneficent. How can it be beneficent to mislead? Analogously non-maleficence means do no harm. If this statement is untrue and leads to people making choices about their vote based upon untrue information it does in fact do harm. Finally, it cannot possibly be just to assist in misleading people in making important decisions. It is unjust to the voters and unjust to the other candidate.

Thus, I feel quite confident that it is apparent that in providing a physician’s imprimatur to a hyperbolic statement that was in fact written Donald Trump himself and allowing that statement to influence individual’s decisions on an important matter was a failure to act as an ethical physician. These are the standards that Dr. Borenstein is accountable to uphold. He did not.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.



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The First Amendment of the United States Constitution states that Congress shall make no law respecting an establishment of religion or prohibiting the free exercise thereof (O’Brien 2005). In recent news, the U.S. Department of Health and Human Services created a new division called the Conscience and Religious Freedom Division. This change grants healthcare workers the option to be involved or not be involved in care for patients that contradicts with their personal religious or moral beliefs (Pear 2018). The policy change creates a legal and ethical dilemma with at least two sides. 

Arguably, prior to this newly outlined protection, healthcare workers were not able to freely exercise their religious beliefs and therefore challenges their First Amendment right. President Trump states that “religious people would no longer be bullied by the federal government because of their religious beliefs” (Pear 2018).  

On the other hand, it may be debated that this new provision challenges the First Amendment from another angle because it’s respecting an establishment of religion, which as a result, may discriminate against anyone that does not share a religious belief with the medical professionals they interact with. At the top of the list may be women and the LGBTQ community, which is a recognizable violation of the Fourteenth Amendment and Equal Protection clause (Menikoff 2001, 25). 

In the days following this news a major question was: what does this mean for women’s rights? Roe v. Wade established that based on the right to privacy it is a woman’s legal right to have an abortion (Menikoff 2001, 53). Similarly, obstetricians/ gynecologists may choose to no longer prescribe contraceptives and if they do, the pharmacist may not have to fill the prescription if it contradicts their beliefs. There is the right to privacy and barriers already in place for women to have access to an abortion or contraceptives such as Plan-B. One roadblock mentioned was resources being unavailable to women within a reasonable radius. Additionally, under the Religious Freedoms Restoration Act, an employer does not need to provide coverage for contraceptives. Since companies are tried as a “person” as seen in Burwell v Hobby Lobby this may allow employers to run wild and could even lead to insurance companies picking and choosing what procedures they cover (Liptak 2014). Or, in an extreme example what if there are not any “in-network” physicians that are aligned with the patient’s beliefs?

A physician has duties that arise from the patient-physician relationship, particularly surrounding patient abandonment.  The relationship may be terminated by either the patient or the physician at any time. However, if the physician ends the relationship then tort law would require the physician to not terminate the relationship at an unreasonable time. An example of this under the new policy could be if a doctor is treating a gay male or female suddenly decides that since they now have government backing, they no longer must treat this patient. It may be argued that physicians are already refusing to treat certain patients. Prior to now it was a best practice for physicians to refer a patient to another medical professional in order to continue care and if not there may be legal ramifications for patient abandonment. If the physician chooses to terminate the relationship based on conflicting religious or moral beliefs it is unlikely they will feel required to provide a referral. 

Patients also have the right to be treated in an emergency situation and this right is protected by the Emergency Medical Treatment and Labor Act (EMATLA) which shields against discrimination of any kind (Menikoff 2001, 368). Meaning, even if there is not a prior patient-relationship the patient must be treated based on the physician’s contractual agreements. Violating this contract may result in patient abandonment or malpractice. What will happen if a pregnant woman is having complications that require an abortion and the on-call physician or the emergency room physician doesn’t share the same religious beliefs? Will the new policy impact EMATLA?

The creation of the Conscience and Religious Freedom Division is in the infant stages. It is not evident how a policy of this nature will be rolled out if medical professionals begin to utilize their freedom to exercise religious rights. It’s doubtful that this will be carried out in a non-discriminatory manner; and unfortunately, under the new provision it may be irrelevant since medical professionals will be protected. In conclusion, this exemplifies how the bioethics field continues to navigate gray areas. These areas become more undefined as laws and policies that contradict one another are introduced.   

Works Cited
Liptak, Adam. “Supreme Court Rejects Contraceptives Mandate for Some Corporations.” The New York Times, 30 June 2014, www.nytimes.com/2014/07/01/us/hobby-lobby-case-supreme-court-contraception.html.

Works Cited
Menikoff, Jerry. Law and Bioethics. Georgetown University Press, 2001.
O'Brien, David M. Constitutional Law and Politics. 6th ed., vol. 2, W.W. Norton & Company, 2005.
Pear, Robert, and Jeremy W. Peters. “Trump Gives Health Workers New Religious Liberty Protections.” The New York Times, 18 Jan. 2018, www.nytimes.com/2018/01/18/us/health-care-office-abortion-contraception.html.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and a Graduate Certificate in Clinical Ethics. For more information on AMBI's online graduate programs, please visit our website.

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