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Blog Posts (3217)

June 21, 2016

Organ Harvesting in China

On June 13, 2016 the House of Representatives passed HR 343, “Expressing concern regarding persistent and credible reports of systematic, state-sanctioned organ harvesting from non-consenting prisoners of conscience in the People’s Republic of China, including from large numbers of Falun Gong practitioners and members of other religious and ethnic minority groups.” )  In part, the bill “calls on the United States Department of State to... // Read More »
June 20, 2016

The Politics of Fetal Pain: Why This Is Not A Legislative Issue

I read with interest the recent blog by my colleagues Paul Burcher and Claire Horner entitled “The Politics of Fetal Pain”. In their blog they discuss the recent fetal pain bill passed in Utah, which “requires the use of general anesthesia on women seeking abortions at 20 weeks gestation or later.” At stake is the concern that fetuses may be capable of experiencing pain by 20 weeks, which has prompted 12 states to restrict or prohibit abortions from that point on, instead of 24 weeks, which is the current standard.

Burcher and Horner remind us that the issue of fetal pain has been a source of contention for some time, which has led to “several states restricting or prohibiting abortions 20 weeks or later on the basis of potential fetal pain.” The authors are very much aware of the possibility that anti-abortion advocates may be using this issue as a convenient means by which to place additional limits on abortion rights of women. Which is to say, anti-abortion advocates supporting these restrictions on women’s reproductive rights may be using the fetal pain issue as a means to restrict abortion rights. Even if they do have a bias in creating this law, Burcher and Horner still believe that the law itself is justified.

Though I would share a concern about the possibility of fetal pain, if I had reason to believe there were evidence to support it, I disagree that the appropriate next move ethically is to join forces with a legislative agenda of politicians whose interests go far beyond the issue of fetal pain. My worry is that such legislative actions in fact usurp the professional role of physicians as medical experts of scientific data to set appropriate standards for medical care.

I accept that the possibility of fetal pain at 20 weeks is a theoretical possibility. But to the extent I find such a claim plausible I would do so by placing my confidence in scientific evidence, which to date is questionable. The paper from which Burcher and Horner take their evidence about fetal pain comes from an author who makes it clear in his writing that he believes abortion is an act of unjust killing. This is not an unreasonable moral position nor does it mean that he is not accurate in his assessment of the medical and scientific evidence regarding fetal pain. But it does raise concerns about his ability to assess and write about data of fetal pain without bias. Is he following the evidence or is he interpreting the evidence to support his preexisting moral views? The answer is we just don’t know, in the same way we don’t know if the Utah state legislature is really concerned about the possibility of fetal pain beginning at 20 weeks or is their real goal to place additional restrictions on abortions?

I want to make it clear that people, including bioethicists, legislators, and the public at large, have every right to advocate, based on their understanding of the evidence, to ensure that fetuses do not suffer during abortions from 20 weeks and beyond. My only point is that such advocacy should not be expressed in laws that impose standards of care on how physicians practice medicine. Such advocates may retort, but why should I think that the medical profession or the scientific community is unbiased? Could it be the case that these professional bodies are abdicating their professional, moral obligations to reduce the possibility of human suffering? Of course that is a theoretical possibility. But in an era where the role of science is grossly misunderstood and under attack by many advocacy groups, those of us in bioethics must champion the standards of scientific research and judgment by medical professionals to produce evidence that is unbiased and reflects the best available understanding of important empirical questions, such as, can fetuses feel pain? This is not an ethical question, i.e. it has nothing to do with whether or not fetuses have moral standing as human beings—rather the question is purely a matter of getting the facts as clear as possible in determining at what point in the development of a human fetus is there a physiological basis for experiencing pain. This is exclusively the scientific issue about which scientific and medical experts must decide based on the best available evidence.

So where should we look for such an understanding of the data on fetal pain? The answer is we should rely on the experts on such matters as reflected in the opinion from the American Congress of Obstetricians and Gynecologists (ACOG), which concluded “fetal perception of pain is unlikely before the third trimester. Although ultrasound monitoring can show intrauterine fetal movement, no studies since 2005 demonstrate fetal recognition of pain.”

I hasten to make it clear that it is always possible current scientific opinions will need to be revised based on new data. There are many examples that bear out this point. But we should realize just how procedurally disruptive and even iconoclastic it is to impose standards legislatively onto medicine because, in effect, we don’t trust or have faith in the integrity of medical experts to be fair or unbiased themselves. For doing so indicts the institution within our democratic system whose defined role and responsibility is to be the arbiters of empirical disputes. The process, i.e. the scientific method they use is by definition one that has the least chance of bias. And without robust confidence in the scientific enterprise and the knowledge that is generated, bioethics loses its footing to make moral assessments and judgments. Thus I agree with the view of ACOG:

“Sound health policy is best based on scientific fact and evidence-based medicine. The best health care is provided free of governmental interference in the patient-physician relationship. Personal decision making by women and their doctors should not be replaced by political ideology.”

Committing ourselves to make decisions based on scientific evidence, both in individual cases and at the policy level, requires us to always stipulate that our knowledge today may not be getting things exactly right. Advocates for the possibility of fetal pain, and I may be one of them, should not be quiet. They have every right and perhaps an obligation to express their concerns. But to conclude that ACOG refuses to accept the possibility of fetal pain because of politics—the fear of having to possibly create new standards about which they may fear a backlash from prochoice advocates or that they really do not believe a fetus has full moral standing—is to lose trust and confidence in an essential democratic institution, and indeed risks becoming cynical and riding roughshod over the role of professional medical expertise.

Thus, I conclude the Utah bill was not an appropriate action for the legislature to take, even if there is eventually scientific evidence that supports their concerns. I understand that there are some medical concerns about which a state legislature may appropriately pass laws—assisted suicide or narcotics—if there is a clear and compelling public interest. But I submit, since there is no clear and compelling evidence, the issue of fetal pain is not one of them.

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.

June 20, 2016

Competition at Work!

Recently, pharmaceutical companies have been pricing many of their products at astounding values. A couple years ago, in fact, an amazing new hepatitis C drug came to market priced at about $90,000 per patient. But since that time, several other … Continue reading

The post Competition at Work! appeared first on PeterUbel.com.

June 20, 2016

Medical Devices after Cremation

This picture from NPR tells a huge story.  It depicts a hip replacement and other metal pieces from medical devices that survive the fire of cremation.
June 20, 2016

Peter Low - Limits of Medicine

This tomb in Glasgow caught my eye, especially this part: "When his phisicks force oft failed . . . his pleasant purpose then prevailed."
June 19, 2016

Where Do We Come From? What Are We? Where Are We Going? [EOL in Art 206]

Gauguin considered this 1897 work to be his masterpiece and the summation of his ideas. The painting should be read from right to left, beginning with the sleeping infant. 

Gauguin describes the various figures as pondering the questions of human existence given in the title; the blue idol represents “the Beyond.” The old woman at the far left, “close to death,” accepts her fate with resignation.


June 18, 2016

28th Annual MacLean Fellows Conference on Clinical Medical Ethics

June 18, 2016

Brain Death - Two False Assumptions

In this recent presentation Bob Truog argues that brain death suffers from two false assumptions. FALSE ASSUMPTION 1 We equate brain death with death of the human being.  Brain death is legally defined as the COMPLETE cessation of ALL functions o...
June 17, 2016

Best intentions, worst outcomes: Ethical and legal challenges for international research involving sex workers

Central America hosts a thriving sex work industry that is a key source and transit region for sex trafficking and undocumented migrants engaged in sex work. Sex workers – particularly those who are migrant – are at high risk for … Continue reading
June 17, 2016

Resource-based Thresholds for Futility in Neonatal Intensive Care

I am off, this morning, to see Dominic Wilkinson present "Resource-based Thresholds for Futility in Neonatal Intensive Care."  Here is his abstract:

In neonatal intensive care, disputes sometimes arise between families and clinicians over potentially beneficial life-prolonging treatment for a newborn infant. Parents strongly desire the treatment, yet health professionals judge that it would be futile. While professional guidelines support the concept of ‘medical futility’, there is no guidance on how to determine whether or when treatment would be futile. 

In this paper, we explore the application of cost-effectiveness thresholds (CET), used elsewhere in public health systems, to the determination of resource-based futility in newborn intensive care. We outline briefly the concept of futility, and of cost-effectiveness assessment. We then draw on CET to explore sequentially a series of clinical questions. When is a patient’s chance of survival too low to provide expensive life-support? How long is too long to provide intensive life-prolonging medical treatment? What level of quality of life is too low for life- saving surgery to be provided? 

This paper represents the first attempt to evaluate distributive justice based determination of futility in intensive care. It builds on careful analysis of existing empirical evidence as well as ethical argument. We identify and address major counterarguments to the use of cost-effectiveness in deriving futility thresholds for intensive care. 

Conclusions: our analysis identifies key normative questions for resource-based treatment limitation decisions as well as key empirical data necessary to inform such decisions.