Tag: autonomy

Blog Posts (50)

March 24, 2016

A Few Thoughts On Abortion and Valuing Human Life

Who could be against life? Ancient natural law theory in the Catholic tradition tells us that human beings desire to live, and that life is good, therefore humans have an obligation to live and not kill other human beings. This ancient wisdom has been instilled into western ways of moral thinking. So, who could not be prolife in terms of how we place value on all individual human life?

Who could be against human freedom? Individual human beings should be free to live peacefully in accordance with their own values and life goals. This is a basic tenet of democracy that has shaped moral and political thinking in the West for the past four centuries. So, who could not be against the exercise of free choice, especially about something so basic as having control over our bodies?

The two value perspectives contained in the prior two paragraphs, all things equal, are eminently reasonable and most ethically unproblematic. These two value positions represent two fundamental principles of ethics—the intrinsic value of all individual human lives and the right of free individuals to govern their own lives and bodies—that guide us in living an ethical life and making ethical decisions. It is when these fundamental principles come into direct conflict that a serious, a near irresolvable, ethical conflict arises. There is no greater direct conflict of these two ethical principles than right of women to have an abortion. It is commonly assumed that one is either on one side of this moral abyss or the other and the twain shall never meet. It seems to me one of the central tasks of ethical reflection on this issue is to find as much meaningful middle ground as possible. In this brief blog I’ll offer a few ideas in this regard, which advocates on either extreme will likely find unsatisfactory.

 

Once a fetus reaches full term and emerges at birth into the world as a separate human being, there is no question about its full moral standing—from my perspective this would include babies with the most serious birth defects, including anencephaly. Some bioethicists believe that a being must have interests to have full moral standing. Since babies with anencephaly, if they survive a short time after birth, have no brain, no capacity to experience pain or pleasure, and no future life, they have no interests. The latter may be true descriptions of babies with this disorder, but they are unequivocally individual human beings. And there is no reason, as the law currently supports, to justify killing or euthanizing the lives of these babies in my view. So can’t the same be said of a fetus from the moment of conception?

It is true that a human embryo is a biologically a distinct form of individual human life and because of that fact has moral worth and deserves respect. But there is a basic aspect of fetal life even after viability and prior to birth that is inescapable: the fetus is dependent on the mother for its life and is part of the woman’s body. There is no protecting the fetus prior to birth without controlling the bodies of pregnant women. At the same time, at the very least, abortion as I am defining my terms is morally concerning and even problematic. I realize many of my pro-choice friends will find that conclusion concerning, but it is simply a consequence of recognizing the moral humanity of fetal life. So the key question then becomes who should make this moral or ethical decision and how should abortion services be regulated under the law?

A moderate position that seeks to preserve as many values as possible in this conflict, it seems to me, will recognize elective abortion as a moral issue but will reject the notion that it should be restricted as a service under the law. For if the law seeks to protect fetal life by restricting abortions, ipso facto, it also seeks to restrict the liberty of the woman to control her body as she so desires. The idea of requiring a woman to keep an unwanted pregnancy is an assault to her dignity as free human being. We cannot pretend to live in a free society where men and women have equal moral worth if we do not extend full moral autonomy to both men and women equally.

I conclude abortion is a moral issue and like many moral issues they are decisions that individual free human people should make and should not be the business of government to regulate. But it is not trivial to recognize abortion as a moral issue. We should not only talk, but also act, like all human life as value. We can provide adequate healthcare to all people, which should include family planning, prenatal, and birth control services for woman. We should provide more day care for parents, particularly single parents and other support services to make having children easier.

In short we can be a society that acts like it values all human life, of which fetal life is a part. But the ethical position of valuing all human life in terms of ascribing full moral standing to individual human beings cannot extend individual fetal life if we are to full value women as autonomous human beings.

 

 

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

February 12, 2016

Pain Relief is an Ethical Issue

When patients lack capacity, physicians look to family and friends to step in and provide consent for treatment on behalf of the patient.  These surrogates, whether they were appointed by the patient as their health care agent or become health care surrogates by default under state law based on their relationship to the patient, have the right to receive information related to the care and treatment of the patient and have the corresponding responsibility to make health care decisions for the patient based on either the patient’s previously expressed wishes or her best interests.  What they don’t have, however, is the right to control and direct every minute aspect of the patient’s care in the hospital.  It would take several blog posts to discuss the conflicts that occur between surrogates and health care providers because of this (such as DNR orders, barriers to discharge, and demands for certain medications, to name a few), but perhaps the most concerning example of surrogate over-reach is the issue of inadequate pain management.

The use of pain medication can be difficult for both patients and providers, especially with the rate of opioid abuse in this country.  Patients and their families are often afraid of the possibility of addiction, while physicians are reticent to prescribe narcotics for fear of misuse.  Whether or not a patient is a “drug-seeker” is a common question that arises when physicians are deciding what to prescribe.  However, in the context of terminal illnesses – particularly at the very end of the illness – the shift in focus from curative to palliative care highlights the need for sufficient pain control in the face of nearly intractable pain.  It is in this context that denial of pain medication, or poor pain management, is most clearly an ethical issue.

I have often heard complaints from health care providers about how surrogates have refused to consent to pain medications, or insist that physicians give lower doses than medically appropriate.  When I ask how the provider responded to such requests, all too often the answer is, “I followed their direction.”  We are so used to turning to surrogates for consent for every treatment and procedure, but is it really within the surrogate’s authority to consent to or refuse pain medication?   Assuming there is no advance directive from the patient opposing adequate pain medication, do surrogates have the right to refuse it?  More importantly, is it ethical for physicians to withhold adequate pain medication at the direction of a surrogate despite obvious signs of pain in the patient?

While respect for autonomy is a bedrock principle in our society, and we would certainly honor the informed refusal of pain medication by a patient with capacity, this respect for autonomy does not mean we necessarily honor the directives of the patient’s surrogate to the same extent as we would the patient herself when it comes to pain control.  Without explicit direction from the patient, certain basic assumptions are made about what the patient would want: namely, relief of pain and suffering.  While questions of withdrawal of life-sustaining treatment or palliative surgery may properly be left to the surrogate, the provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence.  We have an obligation to do no harm to patients, and to the extent possible, to relieve suffering.  While the side effects of opioids should certainly be considered and discussed with the patient’s family, particularly as it may affect the patient’s awareness or respiration, if other palliative approaches are not sufficient to address the patient’s pain, these side effects should not preclude the use of pain medication.  Interventions aimed at pain relief should be given in the overall best interests of the patient, considering the risks and benefits.  Especially at the end of life, providing comfort to the patient should be of utmost importance, even if the surrogate objects.  When pain relief is an ethical issue, it is not an issue for the surrogate alone to decide.

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

 

January 28, 2016

My Child, Your Womb

Gestational surrogacy contracts have been in the news again recently as a gestational surrogate reports that the intended father, having discovered that she is expecting triplets, is demanding that she undergo selective reduction to abort one of the fetuses.  Situations such as these, while often not reported, are not necessarily uncommon.  In 2013, a gestational carrier was offered $10,000 to abort when a second trimester ultrasound discovered congenital heart and brain abnormalities.  Despite a well-established Constitutional right to privacy that includes a pregnant woman’s right to procure – or refuse – an abortion, surrogacy contracts routinely include provisions that not only prohibit a surrogate from having an abortion unless there is a medical need, but also give the intended parents sole discretion to determine whether the surrogate should abort where there is evidence of a physical abnormality or other issue.  Such provisions have not been tested in court, but would almost certainly be unenforceable based on the surrogate’s Constitutionally-protected right to reproductive autonomy.


In India, where there is an estimated $400 million surrogate tourism industry, women agree to be surrogates in exchange for $5,000-7,000, which is far more than they could make otherwise.  In many clinics, surrogates live in dormitories for the duration of the pregnancy and their food and medical care is provided by the clinic.  There are also reports that some clinics have policies against pregnancies of 3 or more fetuses – meaning that selective reduction may occur as a matter of course to reduce the number of fetuses to 2 or 1.  If this is in fact happening, are the surrogates (or even the intended parents) aware of what is happening?  Are they given a voice in the medical care and treatments they receive?  Or are the decisions made by the intended parents or the clinic, and simply imposed on the surrogate?


Surrogacy, as with other assisted reproductive techniques, has been promoted in the name of reproductive autonomy – the right and ability to have more options and exert more control over reproduction.  But in cases such as these, where surrogates are pressured legally, financially and socially to have an abortion, whose reproductive autonomy are we honoring?  While it may be the child of the intended parents, it is the uterus of the surrogate.  The intended parents have an interest in the healthy development and birth of their child, which can be affected by congenital abnormalities, surrogate behavior, or the presence of multiples.  The surrogate has an interest in her own bodily integrity, her own health, and the treatments or procedures performed on her, even in connection with the gestation of another’s child.  Where these interests conflict, whose rights are stronger: the intended parents of the child, or the woman carrying it? 


It seems unconscionable that a woman could be forced to undergo an abortion based on enforcement of a contract.  It is equally disturbing to think that an intended parent would be prevented from objecting to an abortion of his or her child because the surrogate was making the decision to abort.  While both of these decisions in the context of a commercial surrogacy arrangement may be considered a breach of contract, and therefore may have monetary damages, what is left in the aftermath?  A parent whose unborn child was aborted without the parent’s permission?  A surrogate who has been abandoned with a newborn she never intended to keep?  These consequences are far weightier than could be compensated for by money.

 

The problem with blending the rights of reproductive autonomy is trying to separate them again when there is a conflict.  A surrogate will always have the right to determine what happens to her body, which includes the right to have or refuse an abortion, even if the child belongs to someone else.  Is it possible, then, to simultaneously protect the reproductive rights of both the surrogate and the intended parents?  Or will there always be an inherent imbalance of reproductive rights and the potential for coercion in the enforcement of commercial surrogacy agreements?


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

January 8, 2016

OB Potpourri

This month’s issue of the medical journal Obstetrics & Gynecology (O&G) has a review of the four best ethics articles that appeared in their journal in the last year. Here are my comments (in italics) on their review (in quotes). Article title: “Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.” O&G‘s bottom line: “Opioid abuse is a chronic medical illness, not a... // Read More »
October 22, 2015

Truth Telling In Medicine: Problems Old and New

<p style="font-size: 11.2px; line-height: 19.04px;">The issue of truth telling in medicine was a lively concern in the early days of modern medical ethics during the 1970’s. A new moral awareness had emerge that provided a clear moral rejection of the paternalistic approach taken in the physician-patient relationship that prioritized the traditional values of beneficence and non-maleficence over truth telling. Of course the key development that fueled this new moral perspective as well as the growing passion for medical ethics was the newfound sense that arose beginning in the 1960’s that patients with capacity have a fundamental right both to refuse unwanted treatment and give voluntary informed consent to treatments they were considering. It became obvious to students of medical ethics that if patients are to be able to exercise their right to give voluntary informed consent they must receive a full and accurate disclosure of the relevant information necessary for them to make a decision.</p> <p style="font-size: 11.2px; line-height: 19.04px;">Up to the early 1960’s, patients coming into the health care system very well may not have had an opportunity to give voluntary informed consent. Giving patients this opportunity just wasn’t part of the medical culture. In the early 1960’s it was common for oncologists to not disclose a diagnosis of cancer; by the late 1970’s there was almost universal agreement that full disclosure was the expectation. The full moral force of the principle of respect for patient autonomy happened relatively quickly, especially after the Belmont Report of 1978, which articulated the basic principles of medical ethics (though non-maleficence was subsumed under beneficence). There is no question that the physician-patient relationship has been evolving ever since with new levels of expectations and involvement of patients and their surrogates. There is now universal agreement that physicians are expected to be truthful to patients and accurately disclose their medical condition, including diagnosis and prognosis. Without this first basic step of truth telling in disclosing the medical facts to the patient about their condition, patients cannot exercise their right to express their preferences and wishes about medical treatment and care goals, and specially give voluntary informed consent to medical interventions to treat their condition.</p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
June 8, 2015

Actions vs. Words: What counts most in understanding patient preferences?

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Clinicians striving to help patients achieve healthcare goals often encounter the perplexing dichotomy of the patient’s stated goals and preferences and actions to the contrary. Some of these challenges can be overcome with education and close follow up to help reinforce adherence to medical recommendations, but other times, these barriers are more enigmatic.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Take for example, a patient who requires hemodialysis to sustain life. She sometimes shows up for her outpatient dialysis, but more often does not show up and is admitted to the hospital for emergent dialysis several months in a row. In consultation with her providers she is adamant that she does not want to die, and knows that she needs the dialysis to remain alive. She is discharged, and the pattern continues. Liberal scheduling with the outpatient service, transportation, reminders are all offered. Psychological tests and support are provided, and yet, her action pattern of not adhering to the treatment plan continues. Again, she is advised it is acceptable to halt and she will be offered palliative care. She refuses, and says she wants to live and will sit for dialysis. What is her genuine preference? Should we honor these statements, or accept her actions as the more authentic expression of her wishes? Though this hypothetical example is quite familiar to renal care providers, the dynamic spans many scenarios leaving many practitioners with a dilemma about the practical limits of honoring verbalized wishes that are not supported by congruent actions.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
March 27, 2015

How to Get A Head in Life

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/ by Bonnie Steinbock, Bioethics Program Faculty An Italian scientist, Sergio Canavero, claims that he is two years away from performing the world’s first human head transplant, in which the head of one person would […]
March 23, 2015

Will Ariadne Lead Us Through the Maze of End-of-Life Healthcare?

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/   by Richard Koo, Bioethics Program Alum (MSBioethics 2011) and Adjunct Faculty About four years ago, Susan D. Block, M.D. posted a blog on Harvard Business Review’s website as part of a series of […]
March 6, 2015

Understanding the Latino Patient with Cancer

by Beatriz Lorena Hurtado, Bioethics Program Alumna (MSBioethics 2014) As a Latina working in healthcare I have always felt the responsibility to provide education about my culture, and to clarify cultural differences and misconceptions. It is always surprising to witness how eliminating misconceptions eventually translates into an increase in patient satisfaction, and less apprehension about […]
February 25, 2015

The Man Who Mistook His Life For A Hat

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012) Our society tends to put on pedestals the celebrities among us, particular upon their deaths. For author Oliver Sacks, it is no different except that he is not yet dead. He did, however, recently announce in the New York Times that metastasized tumors were found in his body. […]

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Published Articles (16)

AJOB Neuroscience: Volume 4 Issue 4 - Sep 2013

Autonomy in Neuroethics: Political and Not Metaphysical Veljko Dubljević

American Journal of Bioethics: Volume 10 Issue 12 - Dec 2010

The Encompassing Ethics of Bariatric Surgery

American Journal of Bioethics: Volume 10 Issue 12 - Dec 2010

Stuck in the Middle: The Many Moral Challenges With Bariatric Surgery

American Journal of Bioethics: Volume 10 Issue 9 - Sep 2010

Deidentification and Its Discontents: Response to the Open Peer Commentaries

American Journal of Bioethics: Volume 10 Issue 10 - Oct 2010

Invited Commentary: ?Rethinking Research Ethics,? Again: Casuistry, Phronesis, and the Continuing Challenges of Human Research

American Journal of Bioethics: Volume 10 Issue 7 - Jul 2010

Review of The Ethics of Consent, eds. Franklin G. Miller and Alan Wertheimer

American Journal of Bioethics: Volume 10 Issue 3 - Mar 2010

The Secret of Caring for Mr. Golubchuk

American Journal of Bioethics: Volume 10 Issue 3 - Mar 2010

The Case of Samuel Golubchuk and the Right to Live

American Journal of Bioethics: Volume 9 Issue 12 - Dec 2009

Response to Open Peer Commentaries on ?A Duty to Deceive: Placebos in Clinical Practice?

American Journal of Bioethics: Volume 9 Issue 12 - Dec 2009

A Duty to Deceive: Placebos in Clinical Practice

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