Bioedge
Thursday, July 28, 2016

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FROM THE EDITOR

What does Brexit mean for bioethics?” is our lead story today. Given that the Leavers were not expected to win and that the pundits have widely different views of the future of the politics and economies of the UK and the EU, it is unwise to be dogmatic on the issue.

However, the question highlights the importance of Britain in the world of bioethics. Britain is the home of utilitarianism, which is the dominant philosophy in bioethical discourse at the moment. The medical and scientific establishment is dominated by a utilitarian mindset which has set the agenda for debates on embryo research, stem cell research and assisted dying around the world. As one cynical writer commented, “when it comes to bioethics, Europe might be better off without Britain”.

There is something in this. Although I am handicapped by a big language barrier, my impression is that from Norway to Italy there is much more depth and diversity in bioethical discourse across the Channel. The Greens and the Christian Churches are much more influential, to say nothing of Continental philosophy, which despises utilitarianism as vacuous and naïve. If England (the pundits all agree that Scotland will secede) loses its biomedical industry to the EU, perhaps utilitarian bioethics will lose some of its funding and its influence. That would be no bad thing, I think.

******

Sorry, guys, but BioEdge will be taking a holiday during July. Our next issue will be in the first week of August. 

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2016-06-20 11:49 PM
What does Brexit mean for bioethics?
by Xavier Symons | Jun 25, 2016
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tags: bioethics, brexit, eu, european union, law, uk

It is tempting to provide an alarmist answer to this question. Yet it is wise to avoid the apocalyptic tone of recent media coverage and first to flag what is not going to change in UK biomedical ethics policy. 

As highlighted by a post on the Christian Medical Fellowship Blogs, the UK will not (or, at least, not yet) be leaving the Council of Europe (CoE) – this entity does not fall under the auspices of the EU. That the UK will remain in the CoE is significant, as this is the umbrella organisation for what is known as the Committee on Bioethics, an influential policy body that seeks to apply principles outlined in the Convention on Human Rights and Medicine to new issues in medical technology and research.

The European Court on Human Rights also falls within the purview of the CoE. Importantly, The ECHR has handed down significant decisions within the area of conscientious objection in healthcare. 

Yet some suggest the Brexit vote may effect disability rights legislation and regulations in the UK. EU directives about equal access and reasonable adjustment in the workplace have been described as a “double lock” on British legislation such as the 1995 Disability Discrimination Act. Disability advocates fear that the Brexit may in the long run lead to a loss of “hard won rights” for disabled people.

There are also significant concerns about the effects of Brexit on UK public health policies that are underpinned by legislation from the European Parliament. Writing in the Journal of Public Health earlier this year, Martin McKee and Michael J. Galsworthy of the London School of Hygiene and Tropical Medicine suggested that Brexit could negatively affect public health policy in areas ranging from environmental issues to anti-smoking policies and research ethics guidelines. 

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Getting down and dirty with bioethics
by | Jun 25, 2016
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tags: animal rights, animal welfare, bioethics

In its most expansive mode, bioethics deals with the biosphere, our responsibility for all living things. It is a bold writer who tackles this, which helps to explain why the purview of most bioethicists is humankind. Animals usually get short shrift.

However Charles Foster, barrister, travel writer, veterinarian, theologian, Oxford don, father of six and medical ethicist has published a fascinating, if sometimes stomach-turning, account of his attempt to reconnect with the animal world.

In his recent book Being a Beast, he tells how he lived as a badger, a fox, a swift and an otter. “Lived as” means “lived as”. Badger Foster lived underground, ate earthworms, scraped squirrel road kill off the tarmac and ate it with his 8-year-old son (cooked with wood sorrel and wild garlic, mind you). Fox Foster lived in London like urban foxes, scurrying down laneways and eating rancid pizzas.

Otters were his least favourite animal. They are pitiless killing and eating machines, consuming the equivalent of 88 Big Macs a day. A human counterpart would “stay up for a couple of nights, drinking a double espresso every couple of hours, before having a cold bath followed by a huge breakfast of still-twitching sushi and then a nap, and then keep repeating until I die.”

The lesson of the book, which is being praised as both bonkers and brilliant, is that humans need to engage with the natural world. In its own eccentric way, it is a serious and profound book:

“I’m angry at humans who act towards the natural world with a lack of empathy which, if displayed towards other humans, would be seen as frankly psychopathic. We have this ability to engage the natural world on so many more levels than we actually do. I’m incredibly happy being a human being, but I’m much happier having learned the lessons about being human that these other species have taught me.”

Even human beings cannot escape from their wilderness heritage: it is wired into their psyche through evolution. As a Cambridge graduate, he ought to know. Here is what his classmates were told at graduation:

“You’re about to leave Cambridge, gentlemen. Now, it may very well be true that the meek will inherit the earth, but my advice to you is this: Until they show some signs of making a serious bid for that position, trample all over them.”

Now, presumably, the mature Foster regards this as otter bosh. 

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British doctors reject neutrality on assisted dying
by | Jun 25, 2016
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tags: assisted dying, bma, uk

As one might expect, media coverage of assisted dying (aka assisted suicide or euthanasia or the right to die or dignity in dying) is skewed towards ringing-the-changes rather than steady-as-she-goes. In late May The Economist, an outspoken supporter, argued that the British Medical Association (BMA) should adopt a position of neutrality at its annual meeting. “[A] survey for The Economist last year showed that seven in ten Britons thought doctors should be allowed to help patients end their lives, subject to safeguards,” it contended.

However, when a proposal to adopt a neutral stance failed by a huge margin, 63% to 37%, on June 21, it was only reported by a few Christian and pro-life blogs.

The Chair of BMA Council Mark Porter said that this had been marked the eighth time in 13 years that the BMA had debated the issue: “nobody can credibly say this issue has been suppressed or obfuscated”.

The Royal College of Physicians, the Royal College of General Practitioners and British Geriatrics Society are all officially opposed to a change in the law along with 82% of members of the Association for Palliative Medicine

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The bioethics of Australia’s immigration detention policies
by Xavier Symons | Jun 25, 2016
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tags: australia, clinical ethics, law, torture

Australia’s asylum seeker policies have been subject to intense international scrutiny, even in the world of bioethics. A paper published this week in the Journal of Medical Ethics questions whether Australia’s mandatory detention and operational security laws prevent medical professionals from fulfilling their ethical duties.

Specifically, the authors of the paper – Dr John Paul Sanggaran, of the University of New South Wales and Dr Deborah Zion, of Victoria University – argue that the Australian Boarder Force Act 2015 prevents healthcare professionals who are working in detention centres from reporting human rights abuses such as the torture of detainees. Sanggaran and Zion write,

There is a documented history of issues having been raised by medical practitioners working within the system for years without progress let alone resolution…Significantly, the lack of transparency and informally sanctioned breaches of ethical practice are now accompanied by new laws that explicitly prohibit medical and healthcare practitioners from reporting, other than through demonstrably failed internal channels.

Healthcare workers, Sanggaran and Zion argue, are prevented from fulfilling basic ethical obligations to people in detention:

The role of doctors and other healthcare providers in detention is vital to maintaining any semblance of human rights, in particular the right to health, as other systems that uphold this right are absent… [Yet] Bearing witness by healthcare professionals presents a ‘dual loyalty’ conflict, whereby such persons are asked to subordinate the patient’s interests to the state or to their employer, thereby violating his or her human rights. The healthcare provider therefore finds him or herself in potential breach of a contractual obligation to remain silent.

The suggestion among asylum seeker advocates like the authors of this paper is that the Australian government should ratify the UN’s Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Part of this would involve the establishment of a National Preventative Mechanism (NPM) – a system of regular visits and reporting by independent bodies. NPM assessments, according to Sanggaran and Zion, “inform legislation and intervention, as well as act as deterrents in their own right. The transparency this provides should in and of itself act as a deterrent to human rights abuses.” 

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For some Canadian women, surrogacy is sacred
by | Jun 25, 2016
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tags: altruistic surrogacy, canada, commercial surrogacy, surrogacy

The motives for commercial surrogacy may seem relatively straightforward: woman does difficult and risky job; client hands over cash. But motivating women who are not closely related to a client couple for altruistic surrogacy seems more challenging.

Is a Canadian service called Sacred Surrogacy the way of the future in countries where commercial surrogacy is banned? Leia Swanberg, the CEO of Canadian Fertility Consulting, has created a program which draws upon shamanistic rites and fertility goddess worship to motivate her surrogates. Her four-week on-line course guides participants through their “surrogate journey in a sacred and beautiful way”. It includes sacred crystal essence, “crystal water to raise your surrogacy pregnancy vibration”, ayurvedic recipes, almond milk & honey ceremonial bath,” understanding your sacred milk” and fear release.

“Sacred surrogacy” offers quite a different way of looking at gestation. Rather than a commercial transaction, it is a participation in a sisterhood of fecund women:

A Surrogate is a woman who shares of herself by giving the ultimate gift of parenthood to another. It is a process in which you will carry a baby for a single, couple, gay, or straight family. You will be blessed as you join a sisterhood of women who will share in this beautiful journey with you.

Donors also share in the journey:

“Make no mistake about it, you are a heroine about to change a family’s life forever and that act is a reverent one, and should be noted as such. We have created a very special heartwarming mini program for you as you begin this journey, and we are honored to be able to offer you this acknowledgement for your gift of service.”

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UK Parliament to study freedom of conscience for doctors over abortions
by Xavier Symons | Jun 25, 2016
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tags: conscience, conscientious objection, uk

A new UK Parliamentary Inquiry into conscientious objection was launched this month, focusing specifically on the participation of healthcare professionals in abortion. 

The Parliamentary Inquiry into Freedom of Conscience in Abortion Provision, commissioned by Tory MP and outspoken abortion opponent Fiona Bruce, will consider the scope and import of section 4 of the UK Abortion Act (1967).  The so-called “conscience clause” of the act requires that “no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection”.

A call for ‘written evidence’ has been published on the Inquiry’s website, with submissions by July 16. The Inquiry committee is particularly interested in submissions regarding “good and bad practice in the use of the Conscience Clause”.

Christian Medical Fellowship Chief Executive Peter Saunders welcomed the announcement of the Inquiry and encouraged healthcare professionals to submit evidence:

This new consultation is timely. It provides a great opportunity for anyone with strong feelings on this issue, and especially those with experience of how the conscience clause works in practice, to provide input which may help to shape future law and regulations. It’s an opportunity well worth taking – especially for doctors and nurses.

 

 

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The ‘joy’ of fathering 22 donor kids
by Xavier Symons | Jun 25, 2016
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tags: art, sperm donation, us

The American tabloid media was abuzz this week with news that a New York mathematics lecturer had fathered 22 children through informal sperm donation.

Ari Nagel, a 42-year-old Kingsborough Community College academic, proudly told the New York Post about his exploits – including details of how he donates sperm in public toilets to desperate women who contact him over the internet.

Nagel said he finds satisfaction in helping families realise their dream of having children. “I get a lot of joy from seeing so many happy families that I was able to play a role in creating”, he told reporters.

Nagel says he sometimes fathers children by donating at fertility clinics, though others are conceived through informal sperm donation or intercourse.

Subsequent to his interview with the New York Post, papers revealed that Nagel himself is married with three kids. When questioned by the media Nagel’s wife said she was “livid”. Nagel was sued successful for child support by the mothers of the first five children he fathered.

In an interview with Slate, Gregory Zapantis, medical director of New York Reproductive Wellness, a fertility clinic, said that Nagel’s actions raise a host of medical, ethical and legal concerns:

“From a professional standpoint, I was appalled,” Zapantis said of his first reaction to the Post story. “Something like donor sperm is a complex process that requires considering social issues, ethical issues, and legal issues, and it seems like all of those things have not really been thought through carefully. In fact, it was approached in a very blasé and egotistical manner.”
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Facing a moral dilemma over driverless cars
by | Jun 25, 2016
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tags: utilitarianism

Driverless cars pose a quandary when it comes to safety. These autonomous vehicles are programmed with a set of safety rules, and it is not hard to construct a scenario in which those rules come into conflict with each other. Suppose a driverless car must either hit a pedestrian or swerve in such a way that it crashes and harms its passengers. What should it be programmed to do?

An article in Science this week shows that the give contradictory responses to scenarios like these. Researchers found that people generally take a utilitarian approach to safety ethics: They would prefer autonomous vehicles to minimize casualties in situations of extreme danger. That would mean, say, having a car with one rider swerve off the road and crash to avoid a crowd of 10 pedestrians. At the same time, they would be much less likely to use a vehicle programmed that way.

Essentially, people want driverless cars that are as pedestrian-friendly as possible -- except for the vehicles they would be riding in. "Most people want to live in in a world where cars will minimize casualties," says Iyad Rahwan, an associate professor in the MIT Media Lab. "But everybody want their own car to protect them at all costs."

People were strongly opposed to the idea of the government regulating driverless cars to ensure they would be programmed with utilitarian principles. They were only one-third as likely to purchase a vehicle regulated this way, as opposed to an unregulated vehicle, which could presumably be programmed in any fashion.

"This is a challenge that should be on the mind of carmakers and regulators alike," the researchers said. Moreover, if autonomous vehicles actually turned out to be safer than regular cars, unease over the dilemmas of regulation "may paradoxically increase casualties by postponing the adoption of a safer technology."

The result is what the researchers call a "social dilemma," in which people could end up making conditions less safe for everyone by acting in their own self-interest: "For the time being, there seems to be no easy way to design algorithms that would reconcile moral values and personal self-interest."

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Who’s telling the truth about China’s bioethics?
by | Jun 25, 2016
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tags: china, falun gong, organ trafficking, stem cell research, stem cell tourism

Somebody must be telling porkies about the state of ethics in China’s medical profession.

In Nature this week the head of the Guangzhou Institutes of Biomedicine and Health Duanqing Pei and former Nature journalist Douglas Sipp claim that China’s reputation as a “wild east” of stem cell therapies is undeserved. They paint a picture of a disciplined and ethical scientific fraternity.

“ … all too often the intimation is that Chinese scientists are free to do anything and are a step away from making designer babies. What is more, commentators, both in China and outside it, often assume that scientists and others in China have little concern about the fate of early human embryos. Even a cursory review of China's existing regulations, as well as its research and social norms, shows that this picture is fundamentally inaccurate.”

The authors say that China’s regulations are hidden behind a veil of ignorance due to the language barrier. But researchers operate with clear guidelines and firm regulation. “[I]n relation to the use of human embryos in research, China's approach has arguably been more effective and enabling than the legal patchwork seen in much of the world.”

On the other hand, doughty critics of China’s organ transplant industry accuse the government of "a new form of genocide that is using the most respected members of socieity to implement it". The International Coalition to End Organ Pillaging in China has released a 798-page report which claims that between 60,000 and 100,000 organs are being transplanted every year – far more than the official figures. What is the source? Falun Gong activists and their supporters in the West say that it is political prisoners and prisoners of conscience: Falun Gong members, Tibetans, Uighur separatists and house Christians.  

“What we’re trying to do is get the government, the party state in Beijing, to stop killing their own people for their organs,” David Kilgour, a human-rights activist and former Canadian MP, told the Toronto Globe and Mail. “An industrial-scale crime against humanity is going on in China.”

The authors of the report, who have written extensively on China’s organ transplants in the past, are David Kilgour, David Matas and Ethan Gutmann.

Their claims face an obvious problem: they cannot be proved. Nearly all the evidence is based on inferences from statistics gathered from transplant centres. The Chinese government has angrily denied all of the allegations. It states that from 2015 the government stopped using death row prisoners as sources for organ donation and that organ donation is completely voluntary.

And Jeremy Chapman, an Australian transplant surgeon and former president of the Transplantation Society, describes the estimates in this new report “pure imagination piled upon political intent.” He says that the figures have been fabricated by the Falun Gong.

Here’s a video about the report

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Interview: Dissecting the age of ‘do harm’ medicine
by | Jun 21, 2016
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tags: bioethics, interviews

Wesley J. Smith is one of America's leading commentators on bioethical issues, especially assisted suicide and euthanasia. His columns are published in the National Review and he is the author of 14 books. BioEdge interviewed him about his latest, Culture of Death: The Age of “Do Harm” Medicine.

*****

BioEdge: This is a thoroughly revised edition of a book you published 16 years ago. In your view, is there less respect for life in American medical culture now? Are there any bright spots?

Wesley J. Smith: There is less respect for human equality and the sanctity of life in healthcare generally, I fear, and not only in the U.S. Indeed, I changed the subtitle of the book to “The Age of ‘Do Harm’ Medicine” because it now grapples with developments outside the United States as well as in my own country. We are all connected, so that what happens in Canada impacts Australia, what happens in the USA can have a pull on South Africa.

I have observed in the 15 years since the first edition of Culture of Death, that throughout the developed world and the West we see a terrible and increasing disrespect for the intrinsic value of the most weak and vulnerable among us. Euthanasia has spread like a stain and grown increasingly toxic. For example, in Belgium medicalized killing is now coupled with organ harvesting—including of the mentally ill. Health care rationing, which is blatant and invidious medical discrimination, is a growing threat. Advocacy continues to discard the dead donor rule in organ transplant medicine, even proposals for the live-harvesting of patients with profound cognitive disabilities.

If there is a “bright spot,” it is to be found among the medical professionals—doctors, nurses, pharmacists, physicians assistants, etc.—who continue to resist these utilitarian bioethical agendas and work in the trenches of clinical medicine with an ongoing commitment to the wellbeing and equal value of all patients.

BioEdge: A serious problem in dealing with issues like stem cell research, surrogacy, futile care and so on is that people (including politicians) just don’t seem to be interested – at least until it touches them. How can we get voters and policy-makers to think about these issues more deeply?

Smith: It’s a difficult problem. The popular media is increasingly tabloid in its approach to reporting. It is the rare story that informs the general population about the threatening and radical ideas emanating from the academy, in the professional journals, and from among the leaders of the bioethical/medical establishments.

One of the purposes of the book is to help readers be forewarned of the potential threat they or their loved ones could face in a clinical setting—note, I don’t say will, but could—to enable them to mount a defense should an attempt be made to push a vulnerable patient out of the lifeboat.

Ironically, the media can be very helpful in such circumstances, because while the journalistic sector does a terrible job generally of reporting about bioethical issues—and are very boosting of assisted suicide—they often cast klieg lights on individual cases of medical oppression against particular patients, which can personalize the issue in such a way as to gain the attention and sympathy of the general public.

The great disinfectant of “light” can be very powerful at such times. Indeed, I am convinced this is why organ transplant medicine remains a generally moral and ethical enterprise. It is also the greatest defense against medical futility. Because the people generally reject such bad ideas and that acts as a popular bulwark against utilitarian incursions.

BioEdge: You have spent decades writing and debating about life issues. Amongst the hundreds of bioethicists you have read and interviewed, who represents represent the best and worst?   

Smith: There are several bioethicists whom I believe offer a splendid way forward in thinking about the complex issues with which bioethics grapples. First and foremost is the late Paul Ramsey. His concept of the “patient as a person,” was a crucial insight, indeed one that sparked one of the truly positive developments in bioethics, e.g., the right to refuse unwanted medical interventions. The problem we see in bioethics today is that many in the field want to treat some patients as non-persons.

I think Leon Kass brings a powerful intellectual advocacy for applying and analyzing bioethical issues through the prism of intrinsic human dignity, which was why his appointment by President George W. Bush to head the President’s Council on Bioethics met with so much criticism within the bioethics movement.

Dame Cecily Saunders, the great medical humanitarian who conceived the modern hospice concept is a great hero of mine. I was honored to interview her at St Christopher’s Hospice for the first edition of the book, and that material remains in this edition.

There are so many others worthy of mention. My friends William Hurlbut of Stanford quickly comes to mind, Jennifer Lahl of the Center for Bioethics and Culture, with whom I have worked closely, Richard Doerflinger, who helped me tremendously when I first became interested in the field, and my mentor in opposing assisted suicide, Rita Marker, head of the Patients Rights Council.

I hope it won’t hurt his reputation in the field, but I am fond of Art Caplan. We have crossed swords on more than one occasion and I often disagree with him. But he is very good on organ transplant issues. We co-authored a piece in USA Today calling for important reforms of hospice. I find him more open to contrary opinions than most, and willing to see the dangers in the policies he supports.

I disagree fundamentally with Thaddeus Mason Pope about everything, but respect his candor—he doesn’t sugarcoat the hemlock—and deeply appreciate the work he does in archiving various court cases involving bioethics around the world.

In terms of the “worst,” there are so many (he said with a chuckle)! Joseph Fletcher poisoned the field, in my view. Very toxic ideas, backed by magnificent persuasive writing skills. Peter Singer, whom I call “son of Fletcher,” popularized what I “personhood theory” in bioethics which devalues the intrinsic value of human life so invidiously. I am not a fan of Julian Savulescu, to say the least.

Sadly, I think one of the most influential, if crude, bioethical influences on society was Jack Kevorkian whose odious ideas of using euthanasia for utilitarian purposes and his more death-on-demand approach to assisted suicide have taken hold in places like Belgium and the Netherlands, and soon I fear, Canada. 

BioEdge: You describe bioethics as a kind of religion. What is the creed of this new faith?   

Smith: It is more an orthodoxy, I think. Unless a “bioethicist” has a modifier in front of her name, such as “conservative” or “Catholic,” most are very liberal politically, activist culture warriors, and utilitarian in their approach, either explicitly or in outcomes. The movement seems increasingly disdainful of religious belief as well. I think the most remarkable aspect of all of this is that the values of mainstream bioethics do not comport with the views of most people. And yet we are supposed to follow their “expert” lead in establishing crucial public policies and medical ethics. I think not.

BioEdge: Let’s peer into the future. What are the battles you are preparing for, the big issues?    

Smith: Assisted suicide and euthanasia are going to continue to be bioethical hot potatoes. Medical futility. Protecting medical conscience rights for health care professionals who wish to adhere to Hippocratic values is going to be huge internationally. I mean, if we are not careful, in 20 years one may not be able to find a doctor who would not be willing to kill you under some circumstances, which I find a very frightening prospect.

I think health care rationing will also become an increasing hot button issue in the US, particularly if Hillary Clinton is elected and the Affordable Care Act’s centralized control over American medicine becomes more centralized. And dealing with the ethical implications of CRISPR is going to be a daunting prospect.

BioEdge: In the new edition, you have added a chapter on transhumanism. Aren’t they just a bunch of harmless Trekkies?    

Smith: More akin to Star Trek’s tribbles, individually they are harmless, but if allowed to proliferate, could be deadly.

Like eugenics and bioethics before it, transhumanism is a top-down movement being driven from among the intelligentsia. I am not so much concerned about the development of transhumanist technologies or an actual “seizing control of human evolution”—as if we have the wisdom for such a task. But I think the values of the movement are explicitly anti-human exceptionalism, eugenic in outlook, would use genetic engineering to predesign offspring in the image and likeness of transhumanist goals, which would inhibit the individual freedom of designed progeny through the naked power of genetics.

On a more practical plain, transhumanist lobbying could divert resources away from practical concerns and toward quixotic or narcissistic quests. What is interesting is how transhumanism is becoming a materialistic religion, complete with prophets, eschatology, and a belief in eternal life in the here and now, rather than the great beyond.

How did Dylan put it? “You gotta serve somebody.” For transhumanists, that “somebody” is technology and the yearned for “singularity.” More like spitting into the howling winds of nihilism in my book.

BioEdge: I was pretty touched by your own experience with suicide, disability and care for the elderly. How have these experiences shaped your views?    

Smith: I got into this mess after a friend committed suicide under the influence of Hemlock Society literature. She killed herself on her 76th birthday, and I saw first-hand how the insidious Hemlock message convinced her that suicide was empowering.

I am currently taking care of my 98-year-old mother in my home, with serious Alzheimer’s. I have seen at very close quarters how devastating that disease is—it’s not just memory loss—and how easy it would be to manipulate her into a hastened exit. Coercion happens behind closed doors, which no “guidelines” can protect against.

I have been impressed with the importance of treating the dying as equals and “us” by my training as a hospice volunteer. The courage and fortitude of families I have observed caring for their dying loved ones regardless of the emotional cost touched me at a very fundamental place. The disability rights community has revealed, I think the power and dignity of resisting the dismissive and discriminatory attitudes too commonly seen in the medical context, which perceives the lives of people with disabilities are less worthy of total care than those of other people.

I especially appreciate their insistence that nobody should have to “earn” their moral value by possessing “characteristics” that those with the power to decide determine provide greater importance.

BioEdge: You can’t escape without a question about the US presidential election. Which of the presumptive nominees is more likely to wind back the “culture of death”?  

Smith: None of the above, I’m afraid. If Hillary Clinton becomes president she will accelerate current trends with great gusto, not only in the USA but internationally. I don’t think Donald Trump has thought—or much cares about—bioethical issues, and I am under no illusion that he will grapple with bioethics in any fundamental manner. However the election turns out, for issues I care most about, winter is coming. It’s just a matter of how cold that winter will be and how well we can insulate ourselves against the chill.

Wesley J. Smith is a lawyer and author who lives in San Francisco. He is the author of 14 books. The most recent is Culture of Death: The Age of "Do Harm" Medicine

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