“He did not care if she was heartless, vicious and vulgar, stupid and grasping, he loved her. He would rather have misery with one than happiness with the other,” wrote Somerset Maugham in his famous 1915 novel Of Human Bondage. But what if the protagonist (clearly Maugham himself) could have taken a pill to rid him of his helpless passion? Would he? Should he? Would we have a novel which has been made into a film three times? Escaping from relationships is one of the issues that four authors, all from Oxford, including Julian Savulescu, discuss in a lead article in the American Journal of Bioethics.
Even though a love sterilisation pill is still fanciful, there have been some promising developments and the article provoked a good deal of discussion. A pill could be useful in a number of situations: allowing someone to escape an abusive relationship, adulterous love, unrequited love leading to suicidal thoughts, incestuous love (not that all incest is bad, they hasten to add), paedophilia, or love for a cult leader. They conclude that: “the individual, voluntary use of anti-love biotechnology (under the right sort of conditions) could be justified or even morally required. That is, in some cases, to deny its use would be inhumane.”
To the authors, a woman who wants to break with a beloved partner who has become violent and abusive is the clearest candidate for the break-up pill. This helps them to set four conditions for its use:
The love is clearly harmful;
The person wants to use the pill;
The pill would help a person follow higher order goals instead of lower order feelings;
There is no other alternative.
There are some contentious cases. What about homosexuality? In a sense, “reparative therapy” is a primitive break-up pill. The authors acknowledge that a pill could be misused, but they make no exception for homosexual feelings. We must “also respect the autonomous decision of each individual to engage in her own process of “becoming” who and what she seeks to be, in accordance with her personal goals and values. Therefore, we must conclude that even in the controversial case of homosexual love, it may be possible to justify the use of anti-love biotechnology in certain cases.”
Other academics commented on the article. Some of them pitched interesting scenarios if such a drug became available. Should soldiers take it to avoid developing friendly attitudes toward an enemy? Would we be poorer human beings if we no longer had to experience romantic heartache? Song writers might lose one of their most enduring themes. Pills could be used without consent to promote one-night stands – or to turn an affectionate boss against an employee. Parents could use a pill to quench a teen romance…. “The imminent development and availability of pro-love and anti-love agents will present a serious risk for unethical attempts to surreptitiously manipulate emotional and romantic feelings,” write two academics from Arizona State University.
There’s a great script for a film in here somewhere. But will it be Of Human Bondage IV or The Hangover Part IV?
Despite complaints from experts, more and more IVF clinics are using intra-cytoplasmic sperm injection (ICSI). Lisa Jardine, the outgoing head of the Human Fertilisation and Embryology Authority (HFEA), complained earlier this month that some clinics are using ICSI only because it is easier rather than because it is in the best interests of patients.
"We believe it is being used far too widely because it is procedurally easy," The Independent reported. "The scientists who advocate it already know that a boy born through ICSI is likely to have a low sperm count. So it is a little bit worrying that it is being rolled out so widely." Studies have shown that ICSI leads to more health problems for the children. It is also more expensive.
Writing in BioNews, Steven Fleming, of the University of Sydney, says in exasperation that the incidence of male factor infertility is only 30 to 40%, but that ICSI is being used to treat 53 to 68% of infertile couples in Australia, New Zealand and the UK. Presumably doctors believe that ICSI will result in higher pregnancy rates, but there is no convincing evidence for this.
"We know that babies born from ICSI have increased risk of some problems later in life and infertility is one of them," Allan Pacey, chairman of the British Fertility Society, told The Independent. "For these reasons we should be prudent over the use of ICSI. So let's use ICSI when it's needed, and not as some kind of guarantee against fertilisation failure, which is how some clinics approach it."
Some American politicians have discovered how to reconcile punishment and compassion: allow prisoners on death row to donate their organs. In Oklahoma Rep. Joe Dorman has suggested that extending someone else's life by becoming an organ donor is a way for criminals to redeem themselves. "It's Christian principles that if you can offer someone a chance of redemption, you should offer that opportunity," he said.
And in Ohio, Governor John Kasich deferred the execution of 40-year-old Ronald Phillips, who killed a 3-year-old 20 years ago, to see if it would be possible for him to donate his vital organs. “I realize this is a bit of uncharted territory for Ohio, but if another life can be saved by his willingness to donate his organs and tissues, then we should allow for that to happen,” he said.
Bioethicists derided the idea as impractical and immoral. Organs need to be fresh and functioning if a transplant is to be successful, but only execution with a bullet in the brain or the guillotine can guarantee this. Neither are likely to be used in the US. The prison would also have to build facilities to keep the prisoner-donor on life support until he (or she) is executed. " Are we ever capable of laying a stupid idea to rest in America?" asked bioethicist Art Caplan. "Apparently not."
As for the ethics, the American Medical Association does not condone doctor participation in executions in any capacity, much less organ transplants. And it would clearly be unethical for surgeons to remove vital organs from an otherwise healthy person. "It's a very, very dangerous topic from an ethical standpoint," a spokesman for the Oklahoma organ registry commented. "It just frames the whole thing wrong. This turns it into sort of a redemption kind of topic. That's not what donations are about."
A spirited debate arose in the US last week over the withdrawal of life support from a recently paralysed hunter. Tim Bowers, a 32-year-old newlywed from Indiana, suffered massive spinal injuries earlier this month after he fell from a tree during a deer hunting expedition. Bowers woke up in a hospital hours later, paralysed from the neck down and reliant on a breathing tube. After being asked by his family, a despairing Bowers asked doctors to remove his breathing tube. He died a few hours later.
Many bioethicists have argued Bowers was unfit to make the decision so soon after sustaining his injury. Arthur Caplan of NYU said, "initially after a terrible injury or a mutilating injury or a terrible burn, pain and disfigurement, everybody is like, 'I can't go on.' Almost a hundred percent say, 'I don't want to live like this." He suggested a cooling off period of a few weeks.
Bower’s sister said that Tim had once said he would never like to live his life in a wheelchair.
Outspoken disabilities activist Robert Anderson dismissed this “advanced directive”. "They never gave this young man a chance, he was not in the right stage of mind to make that type of decision. I always said I'd never want to live my life in a wheelchair either. Than I dove into shallow water at age 21 and broke my neck rendering me a quadriplegic. Life sure isn't easy but its definitely worth living."
The monolithic concept of autonomy may be fissuring, judging from recent articles in the bioethics journals. In debates over key issues at the beginning and end of life, autonomy has been an important criterion, often the only one, for settling problems. But as academics bat the ball back and forth, it seems that it is beginning to fray.
For example, writing in the Journal of Medicine and Philosophy, three Swedish academics contend that autonomy actually has three elements: competence, the ability to carry out plans, and authenticity. Competence, or decision-making ability, implies a capacity for making personal plans. But one must also possess efficiency, or the ability to put them into effect without external or internal constraints. Finally, truly autonomous decisions must be consistent with one’s own higher-order desires.
The question posed in this article is whether paternalism can be justified in order to enhance a patient’s “authenticity”. For instance, a person who wants to commit suicide immediately after a crippling accident could be restrained in order (paradoxically) to enhance his autonomy because later on he would want to live. A drug addict could be forced to take treatment to recover his true self.
The authors conclude that paternalism, except in a “weak” form is normally not justifiable. However, in an article in the Journal of Medical Ethics, Felicitas Kraemer, of Eindhoven University of Technology in the Netherlands, asks whether the concept of “authenticity” may be more important than autonomy. The focus of her interest is deep brain stimulation for Parkinson’s disease, which can restore control in a patient’s life but can also have bad psychosocial side effects.
She cites the example of a Dutch man whom DBS rescued from deep depression and physical and mental suffering. However, the DBS also made him so manic that he had been committed to a psychiatric hospital. There doctors gave him a choice: he could be “normal” and depressed, with the DBS switched off, but free. Or he could keep it switched on, making him manic, independent and happy – but institutionalised. He chose the latter.
“To be both autonomous and authentic was not possible for him,” comments Kraemer. “In the authentic state, he is no longer able to make any mentally competent, autonomous decisions in the future, and vice versa, when being mentally competent, he does not feel authentic. In this light, one could redescribe his dilemma as a dilemma between autonomy and authenticity.”
There seems to be a growing realisation among bioethicists that autonomy is not as simple as it seems. Perhaps it depends on what element is emphasised. This is not just an academic question, as issues like voluntary and involuntary euthanasia depend on it.
Concern about the steady expansion of the boundaries of euthanasia in Belgium is growing. The Belgian parliament is currently considering whether to extend the right to euthanasia to children and the demented, sparking considerable debate on the issue locally and overseas. One response has been the formation of Euthanasia Prevention Coalition Europe. The coordinator, a Welsh disability activist, Kevin Fitzpatrick, says:
“The UK, France and Germany are currently considering legislation, but overwhelming evidence from jurisdictions where euthanasia and physician-assisted suicide is legal, such as Belgium and the Netherlands, demonstrates beyond doubt, how quickly and easily euthanasia is extended to others, especially disabled people and elderly people. High-profile cases here have provoked international outrage leading commentators to think of Belgium as the new world leader in exploiting euthanasia against those with disabilities and mental health issues.”
The group recently held a press conference at the European Parliament in Brussels followed by a debate between Dr Jan Bernheim, an Belgian oncologist who was instrumental in legalisation and Alex Schadenberg, a Canadian who is the head of Euthanasia Prevention Coalition. See the video.
Lebanon: a country where there are sick people with money, healthy Syrian refugees without money, skilled doctors, and no effective government regulation. It's a perfect mix for black-market organ trafficking, according to Der Spiegel. The German news magazine interviewed an organ broker who was happily sourcing kidneys from young Syrians desperate for cash.
One of his clients was Raid, a 19-year-old former player for the Syrian national youth soccer team from Aleppo. Now he, his parents and his six brothers and sisters are all living in Beirut without an income. Raid sold his kidney for about US$7,000; the recipient will probably pay about $14,000. The broker, a 26-year-old named Abu Hussein, will get about $700 as a commission. He is one of five brokers working for a shady boss known as the Big Man. Business is booming: with one million destitute Syrians living in Lebanon, the price for a kidney is falling.
An independent report has highlighted ongoing violations of medical ethics at Guantánamo Bay and called on the Department of Defense (DoD) and the medical community to conform to ethical principles. The Task Force on Preserving Medical Professionalism in National Security Detention Centers claims that medical staff have been forced to act unethically.
“As a doctor who has been to Guantánamo and examined detainees, I am appalled that medical care there is controlled by command and security prerogatives,” said Vincent Iacopino, of Physicians for Human Rights, a member of the task force. “It is time for the administration to end the inhuman and degrading practice of force-feeding and restore the ability of medical staff to act independently and according to their clinical and ethical obligations.”
It discusses how medical personnel established and participated in torture. It also outlines how the DoD committed a number of ethical breaches, including improperly using health professionals during interrogations; implementing rules that permitted medical and psychological information obtained by health professionals to be used during interrogations; requiring medical staff to forgo independent medical judgment and force-feed competent detainees; and failing to adopt international standards for medical reporting of abuse against detainees.
The report also says that the CIA’s Office of Medical Services played a critical role in torture, including waterboarding. It had advised the Department of Justice that “enhanced interrogation” methods, such as extended sleep deprivation and waterboarding, were medically acceptable. CIA medical personnel were present during waterboarding, the Task Force claims.
“Putting on a uniform does not and should not abrogate the fundamental principles of medical professionalism,” said David Rothman, of the Institute for Medicine as a Profession, a sponsor of the report. “‘Do no harm’ and ‘put patient interest first’ must apply to all physicians regardless of where they practice.”
Adding to the criticism, more than 35 prominent doctors and public health professionals – including a former US surgeon general, six Nobel laureates, and 18 deans of public health and medical schools – have asked President Obama to end force-feeding at Guantánamo Bay. “Force-feeding undermines appropriate medical care and ethical responsibilities because physicians act as agents of command – a fundamental violation of professionalism,” they say in an open letter.
How can we ensure that doctors resist pressure to participate in unethical activities? Dr Craig Klugman, a bioethicist and medical anthropologist at DePaul University in Chicago, believes that medical students need much more training in ethics and character training. In a thoughtful post on the blog of the American Journal of Bioethics, he called for a reform of medical education.
“Medical education does not provide courses in moral courage, defying authority, or turning against the tide of one’s peers. In fact, medical education encourages group think, keeping your head down and knowing your place in the hierarchy, and seeking out the approval of your peers. Medical education itself has often been accused of encouraging a culture of bullying and abuse of medical students.
“In 2012, the Association of American Medical Colleges surveyed medical students and found that 47% experienced mistreatment including public humiliation, degrading language, and abuse of power (such as being asked to run superior’s personal errands). A 2012 study published in Academic Medicine found that over a 12-year period of time, a majority of students experienced mistreatment.
“That is enough time for the mistreated medical student to become the resident and even attending who mistreats her/his medical students. The bullied becomes the bully. The very traits that are ingrained into medical students through the hidden curriculum are the same ones that make them vulnerable to being used as instruments of the state to participate in torture and abuse.”
More revelations about the medical profession under the Nazis in this week’s Slate. A riveting article by Emily Bazelon demonstrates that medicine still has not acknowledged that some areas of anatomy still carry the taint of Nazi atrocities.
One of the conclusions of Nazi medicine even surfaced during the recent US election. Representative Todd Atkin, who was running for a Senate seat in Missouri, sank his campaign when he declared that research showed that women rarely conceived after rape. The claim caused a huge furore and led for calls for his resignation even from his own party.
Atkin’s claim was based on a 1972 essay by a Dr Fred Mecklenburg. He said that Nazi doctors sent women to the gas chambers to see if the stress of imminent death would affect ovulation. This was inaccurate, but a Nazi anatomist, Hermann Stieve, the head of the Institute of Anatomy at the University of Berlin, did study this issue by examining the bodies of executed political prisoners and criminals at nearby Plötzensee Prison. (Among them was an American woman married to a member of the German resistance, Mildred Fish-Harnack.)
All 31 anatomy anatomy departments in the territories occupied by the Third Reich used the bodies of executed prisoners. It seems that only one person ever resigned rather than work on them.
Stieve was never censured and continued in his position until 1952. He was unrepentant: “In no way do I need to be ashamed of the fact that I was able to reveal new data from the bodies of the executed, facts that were unknown before and are now recognized by the whole world.”
Bazelon describes several other doctors who did similar work. Anatomical illustrations from the Pernkopf Atlas are still in use even though the models were the corpses of dissected prisoners and possibly concentration camp inmates. German universities still hold specimens taken from Nazi victims. Some have studied their holdings and acknowledged them; others have done nothing.
Bioethicist Arthur Caplan has been at the forefront of efforts to identify the victims of Nazi doctors and to deal with tainted data. “If you use it, you had better be sure you don’t have any choice,” he said. “The purpose should be life-saving or very, very important. And you have to admit you are using it, but without giving credit to the person who gave you the tainted experiments. You say, ‘This came from a prominent German scientist under the Nazis.’ But you don’t recognize them by name.”
In a related area, bioethicist Gareth Jones and anatomist Maja Whitaker, both from New Zealand are campaigning to ensure that all bodies used by anatomists have been donated. At the moment, in many countries, unclaimed bodies are given to medical schools.