the Electric Monk

Medical workers have a moral conscience like the rest of us. But consider this case:

A young woman, a University of Wisconsin-Stout student, on July 6, 2002, went to the Kmart in Menomonie [Wisconsin] to fill her prescription for birth control pills. Noesen asked if she intended to use the prescription for contraception. When she said she did, Noesen, a Roman Catholic, told her that filling it was against his religious beliefs. He refused to tell her how or where she could get the prescription filled. The woman took the prescription to a Wal-Mart Pharmacy, but when Noesen was called, he refused to transfer the prescription, later saying it would constitute participating in contraception.

In a separate case (apparently also in Wisconsin), a customer whose prescription for birth control was refused by an objecting pharmacist said that she was too traumatized by the incident to attempt to fill the prescription at another pharmacy. She said she subsequently became pregnant and had an abortion.

Should pharmacists have the right to refuse to dispense legally available drugs when doing so violates their strongly held religious or moral convictions? Does this right extend to all health professionals? The Bush Administration thought so: it sought to establish regulations that would cut off federal funding for “any state or local government, hospital, health plan, clinic or other entity that does not accommodate doctors, nurses, pharmacists and other employees who refuse to participate in care they find ethically, morally or religiously objectionable.” The Obama administration has since worked to rescind those regulations.

Obviously this is a difficult and complex array of moral issues, and we’d love to get your thoughts on it. To help get your ethical juices flowing, here is some food for thought:

1. If you are not inclined to grant pharmacists the right to refuse to fill birth control prescriptions, are you also not inclined to permit a doctor to refuse to assist in the suicide of a terminal cancer patient who is in tremendous pain and has only weeks to live (assuming for the sake of argument that this is legal)?

2. If you are inclined to grant pharmacists the right to refuse to fill birth control prescriptions, how do you square that with your (presumed) rejection of the right of a white health care professional to refuse to treat black customers/patients?

3. Does an anti-gun bookstore clerk have the right to refuse to sell “Guns & Ammo” to customer who wishes to buy it?

4. Assuming that conscientious objection to serving in the military when drafted ought to be permitted, is there a feature of the draft situation that is not present in the health care situation?

What do you think?

-Paul Kelleher

The trappings of human experience come in many guises: music, literature, fashion, and for some of us, drugs. A recent New Yorker article by Margaret Talbot argues that while LSD was the prototypical drug of the consciousness-expanding ’60s, the 2000’s are characterized by a very different type of drug: neuro-enhancers. Medications such as Adderall, Provigil, and Ritalin, intended to treat ADHD and other behavioral disorders, have found a very different use in enabling stressed college students and task-laden employees to handle their workload. A study from the University of Michigan’s Substance Abuse Research Center found that in 2004, 4.1 percent of American undergraduates had taken neuro-enhancers for non-clinical use. At some schools, the percentage was far higher–up to 25 percent.

Three major questions arise from Talbot’s piece.

From a scientific point of view, do these neuro-enhancers really “enhance” our abilities? Talbot writes that they can make you more efficient, but can’t help you become more creative.

Talbot’s observation, taken to its logical conclusion, suggests that the values of completion and competence, rather than excellence and creativity, have come to dominate our civilized lives. Does this presage a highly efficient, strung out, focus-less, pill-popping society that we don’t want to be a part of anyways? Or are we already living in it?

Perhaps most importantly, is there something ethically wrong with altering our brains by giving them the mental equivalent of steroids? If neuro-enhancers really do confer a significant edge, then do they unfairly benefit those who can afford to use them or are willing to use them without a prescription? What is the difference, if any, between the enhancing effects of these drugs and those of caffeine?

–Elsa Kim

Yesterday was the kick-off of yet another bioethics conference. From the perspective of an outsider like me–and a journalist to boot–”Ethical Issues in the Prioritization of Health Resources” seems like a hard sell. I struggle to imagine a less sexy title. (Perhaps “Academics Arguing about the Rights/Wrongs of Divvying Up Drugs and Doctors”?) But my prejudice was toppled by the following bizarre scene.

About 200 academics sat silently like parishioners in pews. Floating over their heads was a disembodied voice with a lilting Hispanic accent. It was Mexico’s Vice-Minister of Health, Mauricio Hernández, calling from his office to describe the difficult decision of how to stretch his limited budget to administer pneumococcal vaccines to his country’s children. The vaccine manufacturer recommends 3 doses, but it seemed to be more cost-effective to cut a corner from the standard of care and give only 2 doses. This is certainly the first time I’ve witnessed a politician on the phone with a packed room of academics, seeking their advice on a real-world, life and death dilemma.

Of course, deciding who should be given access to limited health resources is by definition a matter of life and death. But traditionally, philosophers who deal with the underlying ethics have not gotten their hands dirty with the real-world details. “Philosophers like us often say that we should learn about the issues from the experts who actually deal with them,” said Oxford bioethicist Roger Crisp. And rather than stopping there, “we should go on to try to make a positive difference.” This conference is supposed to be an opportunity for exactly this.

Crisp was the first speaker in a 3-man panel of academics who took the floor after the Vice-Minister. (Besides the Mexican vaccine dilemma, the conference learned about a dialysis machine shortage in Thailand and a new cancer drug that can extend life by a few months for an exorbitant cost. But more on those in a later post.) In contrast to the nitty-gritty of these real-world cases, the panelists battled it out on a very different plane–the abstract and esoteric world of moral theory. To give a sense of the flavor: Crisp added a new term to the menagerie of philosophical ‘isms (“sufficientarianism”); Alex Voorhoeve pondered whether it would be right or wrong to use a “philosophical laser” to prevent harm to one person from a plummeting meteor if not doing so would result in a greater benefit to another person; and JP Sevilla argued that redistributing people’s health (rather than money) was tricky because health is so “chunky”.

These are just caricatures of their arguments, of course. Abstraction is a necessary tool for teasing ethical issues apart. But the contrast between academic argument and real-world dilemma was dramatic. So I posed a real-world meta-question to the panel: Why does your work matter?

Voorhoeve considered his work in terms of national healthcare policies. “NICE is making some wrong decisions,” he said, referring to the ironically acronymed National Institute for Health and Clinical Excellence, the body that decides which drugs and treatments are not worth paying for in the UK. According to Voorhoeve, those decisions seem to derive ultimately from arguments made by another philosopher, All Souls don Derek Parfitt. So aside from the benefits to “mental hygiene,” he said, there are very practical reasons to get these philosophical arguments right.

With exquisite British self-deprecation, Crisp considered himself in the context of “all the philosophers over the centuries whose work is read and taken seriously.” Considering how vanishingly small that number is, he concluded, “I don’t think I matter.” But he went on to mount a poetic defense for the role of bioethics. “It’s like astronomy,” he said. The sky is filled with stars too dim to make out. “We’re trying to look deeper, helping each other to see a little farther.”

I was most touched by Sevilla’s reply. “What should I do to make the biggest difference for the benefit of all?” he wondered out loud. Public policy? Business? Even activism can have a more direct impact than academic bioethics. “The reason I do it is probably just that this is what I am best at,” he said. “Do I make a difference with these ideas?” He hopes so.

–John Bohannon

These days, nothing can stop you from becoming a parent, not even death. A woman recently celebrated in a New York courtroom after winning permission to harvest sperm from her dead fiance, just hours before the sperm’s 36-hour shelf-life had expired. “This was his wish,” she claimed. A woman in Texas was allowed to harvest sperm from her dead son in order to raise a “replacement child.” The sperm of a dead soldier was given to his Israeli parents so they could continue the family line, even though he left no will nor explicit consent. Being a dead parent has never been so easy.

Do dead men have rights when it comes to fatherhood? More generally, do people have a fundamental right to not be a parent, even after death? When it comes to dead men, after all, the responsibilities of parenthood are not a concern: They’re deadbeat dads by definition. So what exactly is at stake?

A confusing aspect of the right to not procreate is that it’s actually “a bundle of rights,” says I. Glenn Cohen, an assistant professor at Harvard Law School. In a recent paper, he argues that parenthood comes in three flavors: genetic, legal, and gestational. The man whose sperm was harvested becomes a genetic parent; the surrogate mother is a gestational parent; and the law might allocate legal parenthood to one, both, or even to third parties who become the child’s legal guardians. Do you have an equally protected right to not become each of these different types of parents?

According to Cohen, as a matter of constitutional rights, you don’t. The US constitution clearly protects a woman from becoming impregnated without her consent. And in certain circumstances involving reproductive technologies, it protects people from unwanted legal parenthood. But we are on much weaker constitutional grounds in the case of post-mortem fatherhood because this genetic parenthood does not carry with it legal or gestational parenthood.

But there are arguments to be made against harvesting sperm from dead men. In a second paper, Cohen explores some of the moral consequences. Arguing that harm is being done to the dead man “requires treading into contested philosophical waters,” he says, such as “whether death puts us beyond both benefit and harm.” But it certainly kicks up some financial dilemmas. For example, do posthumously conceived children get shares in any inheritance from the dead father? (If so, then sperm-harvesting could be as lucrative as gold-mining in some cases.) Also, harm could be done to society, for example by undermining norms for violating bodily integrity. (If harvesting dead men’s sperm becomes routine, what next?)

But do these concerns outweigh the interests of the women described in the first paragraph? Would you deny the recently bereaved girlfriend, wife, or mother?

–John Bohannon

In the fiery debate over taming the cost of US healthcare, there is a dirty word that no one wants to use: Rationing. When he was interviewed last week on the Daily Show, the president’s chief budget nerd Peter Orszag said that spiraling healthcare costs dwarf the banking crisis as a long-term financial threat. He carefully avoided suggesting that medical treatments or supplies might need to be rationed. But in a world with limited resources, rationing of some kind is inevitable. Consider one of the hardest cases of all: What should we do with limited Tamiflu stocks during an epidemic of bird flu?

The avian influenza virus has not mutated into a form that can spread epidemically, but public health experts warn that this could happen at any time. The only drug available to treat people with bird flu is Tamiflu (oseltamivir phosphate), but supplies are limited. At some point, hospitals could be forced to decide how to allocate what they have left. But who should be saved? And who gets to call the shots?

Harvard bioethicist Jim Sabin wrestled with this question last month during a seminar at the National Undergraduate Bioethics Conference. He painted a chaotic picture of hospitals using different allocation strategies at the same time. Hospital A keeps a stock of Tamiflu for staff who become exposed, to ensure that they will continue to be able to respond to the outbreak. Hospital B uses its remaining resources to try to save its sickest patients. In order to maximize the number of survivors, Hospital C reserves its drugs to treat patients who present within 48 hours of disease onset and are thus most likely to respond to treatment. Hospital D assumes that Tamiflu supplies will soon be depleted regardless of strategy, so it treats all probable and confirmed cases, regardless of severity. Finally, Hospital E is giving priority to younger patients.

Which hospital’s method should be adopted for the entire community? Or should hospitals be forced to unify their actions at all? If we can decide on the right strategy now, perhaps we can gain greater confidence that when the shots do need to be called, they’ll be called right. (Note: One strategy that Sabin left out is giving treatment only to those who can pay for it, which is the essence of US healthcare today.)
—Jennifer Marett

Would you abort an unborn child? What if it wasn’t yours?

Believe it or not, this is the question faced by a group of surrogate mothers in California this past week, and by a woman in Japan the week before that.

If you read Slate, you may have been following William Saletan’s commentary on these stories, which all have to do with the mixing of modern technology and age-old questions of body and ownership (personal organ sales anyone?).

In one case, couples in California working through a broker company hired surrogate mothers to have their children. The company lost all the money to bad investments, and found themselves unable to pay the already-pregnant surrogates.

By previous court ruling, the surrogate women, if they wanted to, could simply abort the fetuses. This would void their contract, but they weren’t being paid either way, and as emotionally gratifying as it may be, carrying their child to term could come with all sorts of expenses and dangers that they were no longer being compensated for.

What should the surrogate mothers have done? Do they have a moral obligation to continue bearing someone else’s child?

Would your answer change if the “surrogacy” was unintended? What if a woman undergoes in vitro fertilization (a way to get around infertility, among other uses) and the doctor implants the wrong embryo inside her? Is this woman obligated to keep her child? If this question seems easier than the one above, why?

In case you’re worried, all of the surrogates did decide to keep the children, although the woman with the mistaken embryo did not. The question stands, however — even if the women decided to terminate their surrogate pregnancies, would that have been wrong? Is this example a reason to disallow surrogate pregnancies altogether?

–Jue Wang

Have you ever suggested to a friend, even jokingly, that their favorite baseball or football player was on steroids? Have you ever gotten a positive reaction? The fact is, a lot of people would be very upset at the accusation that their idols were cheaters, as the use of performance enhancing drugs is restricted in athletics. It’s not fair, as the motivation for these restrictions outline, that one person should play better than another because they are taking steroids.

But why does “performance” have to be limited to athletic abilities? Theresa Lii of Brown University doesn’t think so. The off-label use of drugs such as Ritalin and Modafinil, collectively called “nootropics,” is rising. These cognition enhancing drugs are used to stay awake, boost productivity, and increase focus.

Suggest to the same friend that their use of Provigil makes them a cheater, because it’s giving them an extra edge in school or work. What kind of response do you think you would get then?

When do we draw the line between an acceptable performance enhancing drug and an unacceptable one? Do we draw one at all? If the purposes for these drugs aren’t really that different, should the same kind of regulations that are placed on steroids be placed on nootropics?
–Richard Blissett

Face transplantation presents a bioethical dilemma. Like other organ transplants, there is a risk that the body will reject it. To prevent this, patients are placed on immune-suppressing drugs, and often must continue this medication throughout the rest of their life. So face transplantation may lead to a shorter lifespan. But for the few people who so far have undergone the procedure, that is a worthwhile tradeoff.

Mary Rhee from the University of Maryland, Baltimore County, presented both the medical and the philosophical/psychological implications of this procedure today during the NUBC conference. On the philosophical/psychological side, the discussion began with the emphasis on the inherent “worth” of the face, in that it is an integral part of human identity. This is one reason why this is such a difficult bioethical issue, as a beneficial procedure that comes with so much baggage.

For some, the benefits far outweigh the loss of years of future life. Consider Isabelle Dinoire, a woman whose face was so severely mangled by a dog attack that she was largely unable to eat, drink, or even talk. Her wounds proved irreparable through the use of conventional reconstructive surgery. Hers is an easy case. But what of people who have facial scars that have no direct effect on their health and functions beyond social interaction?

Face transplantation is an excellent example of a core bioethical question. What is medicine’s purpose, to elongate life or to improve quality of life? Where should the balance be struck?
–Richard Blissett

At the end of his address at the National Undergraduate Bioethics Conference, Dr. Daniel Wikler posed a tough question to the audience. Two people need a liver transplant, one who is blind and one who is not. If there is only one liver available, who should receive the transplant?

According to a global health mantra, the sighted person should receive the transplant. This would amount to progress in global health, a small reduction in the burden of disease: A population of equal size that has one less person suffering from blindness is a healthier population.

Something about this answer feels repugnant, even for many who agree with the logic. There is no clearly desirable outcome in this situation. A human being will die regardless of the decision that is made. When facing such circumstances, perhaps the best we can do is to seek the lesser evil.

How would you decide who gets the liver? Save the blind person or the sighted? Or flip a coin?
–Kavin Sundaram

In 1997, a baby known as “Ashley X” was born. Like all babies she had limited control of her body and almost no ability to communicate. Tragically, Ashley would never acquire these abilities. She was born with static encephalopathy, an incurable neurological condition that left her severely disabled with the permanent mental ability of an infant.

The manner in which Ashley’s parents decided to deal with their daughter’s long-term care sparked a national ethical controversy. At the 2009 National Undergraduate Bioethics Conference today, this case was the focal point of a seminar presented by Christine Mitchell, the Associate Director of Clinical Ethics at Harvard Medical School.

"Ashley X" from her parent's blog http://ashleytreatment.spaces.live.com/blog/

Ashley’s parents, struggling to manage her care while giving her the best quality of life possible, opted to hormonally limit her growth, in part to make her easier to manage as she aged. Ashley’s uterus was also removed to preemptively eliminate the inconvenience/discomfort of a menstrual cycle.

Some questions that Mitchell raised with regard to this case were: 1) Were the actions of Ashley’s parents justified? If not, why not? 2) When, if ever, is it ok to use medical intervention to ease the burden on caregivers?

–Ashley Mrva