Tag: double effect

Bioethics Blogs

End-of-Life Healthcare Sessions at ASBH 2017

The 2017 ASBH
conference
 in October 2017 includes over 400 workshops, panels, and
papers in bioethics and the health humanities.  Here are ones that pertain
to end-of-life issues.


THURSDAY, OCTOBER 19


THU 1:30 pm:  End-of-Life Care and Decision-Making in the ICU – Limited
English Proficiency as a Predictor of Disparities (Amelia Barwise)


Importance: Navigating choices in predominantly English-speaking care settings
can present practical and ethical challenges for patients with limited English
proficiency (LEP). Decision-making in the ICU is especially difficult and may
be associated with disparities in health care utilization and outcomes in critical
care. 


Objective: To determine if code status, advance directives, decisions to limit
life support, and end-of-life decision-making were different for ICU patients
with LEP compared to English-proficient patients. 


Methods: Retrospective cohort study of adult ICU patients from
5/31/2011-6/1/2014. 779 (2.8%) of our cohort of 27,523 had LEP. 


Results: When adjusted for severity of illness, age, sex, education, and
insurance status, patients with LEP were less likely to change their code
status from full code to do not resuscitate (DNR) during ICU admission (OR,
0.62; 95% CI, 0.46-0.82; p


Conclusion: Patients with LEP had significant differences and disparities in
end-of-life decision-making. Interventions to facilitate informed
decision-making for those with LEP is a crucial component of care for this
group.


THU 1:30 pm:  “But She’ll Die if You Don’t!”: Understanding and
Communicating Risks at the End of Life (Janet Malek)


Clinicians sometimes decline to offer interventions even if their refusal will
result in an earlier death for their patients. For example, a nephrologist may
decide against initiating hemodialysis despite a patient’s rising creatinine
levels if death is expected within weeks even with dialysis.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Educating the church about how to think about bioethics

Janie Valentine’s post on Monday about a Christian health sharing ministry considering the surgical treatment of ectopic pregnancy to be the moral equivalent of abortion points out a major concern related to the church and bioethics. This is particularly a concern regarding the evangelical Protestant church and bioethics. With its hierarchical structure the Roman Catholic Church has a way of connecting the well considered thoughts about bioethical issues that are expressed by Roman Catholic ethicists with the ministries of the church. Protestant churches, and evangelical Protestant churches in particular, have a significant disconnect between those who think deeply about and write about bioethical issues and those who are doing ministry.

The issue of whether to cover the costs of surgical treatment of ectopic pregnancy illustrates the need for people within the church to learn how to think about bioethics and other ethical issues. It is not that we need to have some established evangelical set of ethical positions on issues, but rather an understanding by people in the church of how to properly analyze and think about an ethical issue. Over centuries of thought Christian scholars have recognized the principle of double effect as a good way of analyzing moral dilemmas in which doing something that is good, such as saving the life of a woman with an ectopic pregnancy results in the unwanted bad affect of the death of an embryo. It is clear that we should not focus solely on consequences and do things that are wrong even to save a person’s life, but it is reasonable at times to do good things that have unintended but foreseeable bad effects.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Samaritan Ministries and Ectopic Pregnancies

As I was reading Laura Turner’s Buzzfeed essay about Christian health sharing ministries this past week, I was startled to discover that Samaritan Ministries, the insurance alternative my husband uses, does not cover expenses related to ectopic pregnancies.

In Section VIII of the Samaritan Ministries Guidelines, “Needs Shared by Members,” Ectopic Pregnancies is listed as the ninth item under “Miscellaneous Items Not Shared.” The guidelines state:

“Expenses related to the termination of the life of an unborn child are not publishable. The removal of a living unborn child from the mother which results in the death of the child is a ‘termination of the life of the child’ unless the removal was one for the primary purpose of saving the life of the child, or improving the health of the child. This means that the removal from the mother of an unborn child due to an ectopic pregnancy (outside the normal location in the uterus) is not publishable unless the member states they believed the child was not alive before the procedure. Considerations of the health or life of the mother does not change that the removal of a living unborn child from the mother may be a termination of life.”[1]

Ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in one of the fallopian tubes.[2]  The condition is highly dangerous to the mother, who is at risk of internal rupturing and blood loss.[3]  While there are different classifications of ectopic pregnancies and a few different methods of treatment, Turner approximates the cost of surgery to save the life of the mother to be around $15,000.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

What happens to the leftovers? Is compassionate transfer ethical?

by Katarina Lee

The Washington Post recently published an article discussing IVF and one woman’s journey in the creation of her child.[1] Unlike other articles that often focus on the process of IVF, Sarika Chawla highlighted an often forgotten and diminished aspect of IVF, the obligations to “left-over” embryos. Chawla discussed five options for these embryos: (1) destroy them; (2) donate them to medical research; (3) donate them to an infertile woman; (4) keep them frozen; and (5) engage in compassionate transfer. While Chawla did not address a sixth option in her article, it should be noted that there are also fertile women who will gestate “left-over” embryos out of a sense of moral and often religious obligation.

IVF not only poses financial and physical tolls on intended parent(s), but it places an enormous emotional burden on the parties involved. In the excitement and desire to have children, many individuals often over-look questions regarding “left-over” embryos. In any given round of IVF, several ovum are fertilized resulting in several embryos. While standards are consistently in flux, typically two embryos are transferred at a time. This leaves several frozen embryos as “back-up” if the previous transfers are unsuccessful. Many intended parent(s) choose not to address what will happen to the remaining embryos until after family completion, but by then they are left with embryos they often consider to be future children and siblings to their live-birth children. While the accurate number of frozen embryos is unknown due to lack of reporting requirements, in 2011, it was estimated that there were more than 600,000 in the US.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Euthanasia and Palliative Sedation Are Distinct Concepts–Intent Matters

December 16, 2016

(The Conversation) – Debate over euthanasia in Australia has been renewed by the recently failed bill to legalise it in South Australia, and the Victorian government’s announcement it will hold a conscience vote on assisted dying next year. As usual, parliamentary debates have spilt over into expert probing of current practices in end-of-life care.  From doctor and writer Karen Hitchcock to the Australian Medical Association, there seems to be broad consensus about the relevance of a doctrine called “double effect” in end-of-life care.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Observations from a recent discussion of doctor-assisted suicide

Early this past June, the Annual Meeting of the American Society of Clinical Oncology (ASCO) included an ethics session featuring a point-counterpoint discussion, with audience Q+A, of “physician aid in dying,” or, as I think more accurate, “physician-assisted suicide (PAS).”  Discussants were Dr. Timothy Quill, a palliative care specialist who is a past plaintiff in court cases seeking legal approval of PAS, and Dr. Daniel Sulmasy, an oncologist who is an outspoken opponent of PAS.   Both have written extensively on the subject.

I missed the session but only now was able to review it on ASCO’s “Virtual Meeting,” available only to subscribers.  I cannot summarize it fully but will just relay some observations from my listening.  I will say that the session lived up to its billing as a “thoughtful discussion,” one that demonstrates just how far our thinking has come (wandered?) on this matter.

I think it important to say that, although I consider Dr. Quill an adversary, his presentation clearly demonstrated concern for his patients.  Some of his noteworthy points:

  • ·       Although he calls PAS a “last resort,” he includes it in the umbrella of palliative care measures, and claims that the same issues of potential harms arise with all of them.  I’m not so sure; one can heavily sedate someone, not intending to kill him but accepting that risk (by the rule of “double effect”), and that is different from purposely helping that person kill himself.
  • ·       He emphasized that more patients ask about PAS than actually go through with it. 

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Special “Editor’s Choice” Issue of the Journal of Medical Ethics Now Online

by Brian D. Earp / (@briandavidearp)

On behalf of the Journal of Medical Ethics, I am excited to announce the publication of a special “Editor’s Choice” issue, now online at the journal website. In a rare turn for the journal, the entire issue made up of “Editor’s Choice” papers, with invited (peer-reviewed) papers from both up-and-coming and established scholars.

Editor-in-Chief Professor Julian Savulescu explains the significance of the issue: “Our self-imposed brief was to concentrate on excellent but less well-known scholars from a variety of perspectives, especially those who are young and up and coming, alongside some more established contributors.”

Although no particular topic assignment was given, Professor Savulescu remarks that “it is interesting that [the] contributions aggregate naturally around four perennial clusters: the concept of the good life, end of life, public health and new technologies (enhancement/selection).”

Here are some highlights from each contribution to the issue:

In “Prenatal screening and prenatal diagnosis: contemporary practices in light of the past,” Ana S. Iltis discusses genetic selection in the context of modern eugenics. As Savulescu notes: “She gives five reasons to believe this is not significantly different from old style, discredited eugenics of the late nineteenth and early twentieth century. Indeed, she argues convincingly that social goals, ‘public health’ and cost-effectiveness remain important drivers of genetic screening and testing programmes.”

Then, in “The ethics of sexual reorientation: what should clinicians and researchers do?” Sean Aas and Candice Delmas take on an argument that Savulescu, along with Dr. Anders Sandberg of the University of Oxford as well as myself (Brian Earp), have advanced with respect to the ethics of sexual orientation “conversion” therapy.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

How the death of a pregnant teenager has been manipulated

The case of Rosaura Almonte, pregnant teenager (16 years old) from the Dominican Republic who died of acute leukaemia after having been denied an abortion, has been widely reported on social media.  Her situation is being used to promote the legalisation of abortion in the country and as such, in our opinion, merits a broader reflection, since Rosaura’s story is undoubtedly the subject of objective manipulation in several media.

The pregnant teenager medical history

But let’s take one thing at a time. Firstly, we need to briefly summarise the young woman’s medical history, which is essential in order to make our ethical assessment. The history of course may not be as complete as it should be, medically speaking, since we only have information reported by social media.

As mentioned, Rosaura was a 16-year-old girl who was seven weeks pregnant when she was diagnosed with acute leukaemia (type not specified) on 12th July 2012.  A few days later, the possibility of an abortion was raised, arguing that it could aid the patient’s recovery; however, it was not performed, as abortion is banned in the Dominican Republic. Naturally, doctors then thought of giving her chemotherapy, which apparently was initially dismissed so as not to harm the health of the foetus. This however does not always occur, because chemotherapy used in the first trimester of pregnancy increases the risk of abortion, foetal death and malformations in only 10% to 20% of cases (Journal of Clinical Oncology, 30 November 2015). Generally speaking, the foetus is particularly vulnerable to developing teratogenic problems when the chemotherapy is applied between week 2 and week 8 of pregnancy.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Getting a Handle on CRISPR/Cas9 (Part 2)

Takeaways from Day 2 of the International Summit on Human Gene Editing. The challenge: Not devoting all of them to legal scholar and doctor of irony Barbara Evans.
  1. Barbara Evans’ scenario: Couple meets for a date. One says to other: BTW, I’ve had my genes edited. #FutureImplications
  2. Janet Rossant, Toronto Hospital for Sick Children: “It’s absolutely our responsibility” to engender public buy-in and trust.
  3. In France, UK, US, no plan to launch public debate on gene editing. “It might be a good idea.” (Jennifer Merchant)
  4. Listening & wondering: Is germ-line editing a distraction?  The breakthroughs and greatest uses will come with  somatic cells, which are much less ethically suspect. 
  5. Yes! Molecular biologist Thomas Reiss makes a case for accessible language (and uses it himself). #HealthLiteracy
  6. “What is needed is a very authentic form of public engagement,” requiring that“science learns to communicate with public.” (Keymanthri Moodley, S. Africa) 
  7. One concern in a “wild wild west” of gene editing: medical tourism.
  8. One concern if there’s a moratorium: “It will only limit the legitimate science” (Ephrat Levy-Lahad, Israel)
  9. International regulation would discourage medical tourism, but hard to respect social, cultural and moral/ethical differences among countries.
  10. An ethics question: Does principle of double effect have anything to say about the problem of off-target modifications?
  11. Public health disease burden in settings such as Sub Saharan Africa is high priority. Hepatitis B and HIV have treatments, not cures, possibly creating a moral imperative for somatic gene editing.
  12. Context: In a 6 billion character, 1.1-million

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

From Self-Interest to Morality: How Moral Progress Might Be Possible

One of the most stunning successes I have personally seen in my life is the emergence of the Effective Altruism movement. I remember when Will Crouch (now MacAskill) first presented 80 000 hours to our Graduate Discussion Group and Toby Ord was still a grad student. From their ideas a whole movement has emerged of brilliant young people galvanised into doing good. We are getting the brightest, best people of the current generation coming to Oxford to engage with the Centre for Effective Altruism. Almost every grad student I come across has some connection. Well done Will and Toby, and all those others who have contributed to establishing this movement

So I guess I should not have been surprised when during my visit to Harvard this week, a student contacted me from EA to give an ad hoc talk. I discovered there were cells all over the world and the movement had spread way beyond Oxford.

Anyway, I gave an impromptu talk and predictably there were many questions I could not answer satisfactorily. One the issues I covered was the need to create a new basic (or minimal) secular morality. This is necessary not only to decide what the goals of moral bioenhancement should be (my favourite current pet topic), but indeed how education should be revised and society ordered. Every society has a set of normative commitments. Ours are outdated, archaic and unfit for the challenges of a globalised, interconnected and technologically advanced world.

Since we were talking about Altruism, I said one part of a minimal morality which could be justified on either utilitarian or contractualist grounds is:

Duty of Easy Rescue: when the cost to you of some action is minimal, and the benefit (or prevention of harm) to another is great, you should perform that action.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.