Conscience claims, metaphysics, and avoiding an LGBT eugenic

Abram Brummet

Abstract

Novel assisted reproductive technologies (ART) are poised to present our society with strange new ethical questions, such as whether lesbian, gay, bisexual, and transgender (LGBT) couples should be allowed to produce children biologically related to both parents, or whether trans-women who want to experience childbirth should be allowed to receive uterine transplants. Clinicians opposed to offering such technologies to LGBT couples on moral grounds are likely to seek legal shelter through the conscience clauses enshrined in U.S. law. This paper begins by briefly discussing some novel ART on the horizon and noting that it is unclear whether current conscience clauses will permit fertility clinics to deny such services to LGBT individuals. A compromise approach to conscience is any view that sees the value of respecting conscience claims within limits. I describe and critique the constraints proposed in the recent work of Wicclair, NeJaime and Siegel as ultimately begging the question. My purpose is to strengthen their arguments by suggesting that in the controversial situations that elicit claims of conscience, bioethicists should engage with the metaphysical claims in play. I argue that conscience claims against LGBT individuals ought to be constrained because the underlying metaphysic—that God has decreed the LGBT lifestyle to be sinful—is highly implausible from the perspective of a naturalized metaphysic, which ought to be the lens through which we evaluate conscience claims.


Brummett A. Conscience claims, metaphysics, and avoiding an LGBT eugenic. Bioethics. 2018;00:1–9.

Hans Asperger, National Socialism, and “race hygiene” in Nazi-era Vienna

Herwig Czech

Abstract

Background

Hans Asperger (1906–1980) first designated a group of children with distinct psychological characteristics as ‘autistic psychopaths’ in 1938, several years before Leo Kanner’s famous 1943 paper on autism. In 1944, Asperger published a comprehensive study on the topic (submitted to Vienna University in 1942 as his postdoctoral thesis), which would only find international acknowledgement in the 1980s. From then on, the eponym ‘Asperger’s syndrome’ increasingly gained currency in recognition of his outstanding contribution to the conceptualization of the condition. At the time, the fact that Asperger had spent pivotal years of his career in Nazi Vienna caused some controversy regarding his potential ties to National Socialism and its race hygiene policies. Documentary evidence was scarce, however, and over time a narrative of Asperger as an active opponent of National Socialism took hold. The main goal of this paper is to re-evaluate this narrative, which is based to a large extent on statements made by Asperger himself and on a small segment of his published work.

Methods

Drawing on a vast array of contemporary publications and previously unexplored archival documents (including Asperger’s personnel files and the clinical assessments he wrote on his patients), this paper offers a critical examination of Asperger’s life, politics, and career before and during the Nazi period in Austria.

Results

Asperger managed to accommodate himself to the Nazi regime and was rewarded for his affirmations of loyalty with career opportunities. He joined several organizations affiliated with the NSDAP (although not the Nazi party itself), publicly legitimized race hygiene policies including forced sterilizations and, on several occasions, actively cooperated with the child ‘euthanasia’ program. The language he employed to diagnose his patients was often remarkably harsh (even in comparison with assessments written by the staff at Vienna’s notorious Spiegelgrund ‘euthanasia’ institution), belying the notion that he tried to protect the children under his care by embellishing their diagnoses.

Conclusion

The narrative of Asperger as a principled opponent of National Socialism and a courageous defender of his patients against Nazi ‘euthanasia’ and other race hygiene measures does not hold up in the face of the historical evidence. What emerges is a much more problematic role played by this pioneer of autism research. Future use of the eponym should reflect the troubling context of its origins in Nazi-era Vienna.


Czech H.  Hans Asperger, National Socialism, and “race hygiene” in Nazi-era Vienna. Molecular Autism 2018;9(29)

Divisions, New and Old — Conscience and Religious Freedom at HHS

Lisa H. Harris

January, the U.S. Department of Health and Human Services (HHS) announced the creation of its Conscience and Religious Freedom Division, explaining that it will allow HHS’s Office of Civil Rights to “more vigorously and effectively enforce existing laws protecting the rights of conscience and religious freedom” and will ensure that “no one is coerced into participating in activities that would violate their consciences, such as abortion, sterilization or assisted suicide.”1 Responses were as expected: religious conservatives hailed the new division as a needed intervention; public health and clinical leaders and advocates decried it, worrying about its impact on access to care and harm to patients.

HHS leaders’ comments to date suggest that they are uninterested in discrimination against health care providers whose consciences compel them to provide care, and uninterested in injuries to patients caused by care refusals. This framing makes conscience yet another issue dividing Americans, largely along partisan lines.


Harris LH.  Divisions, New and Old — Conscience and Religious Freedom at HHS. N Eng J Med 2018 Apr 12;378(15):1369-1371. doi: 10.1056/NEJMp1801154. Epub 2018 Mar 14

An effective referral is still a referral

Sanasi Jayawardena, Alexandra A Majerski

We are writing to respond to Dr. Steven Bodley’s letter: “Just the Facts on Effective Referral.” . . . The College of Physicians and Surgeons of Ontario’s (CPSO’s) effective referral policy for MAiD does not go far enough in protecting the religious freedom of physicians. . . It is unfortunate that the CPSO does not acknowledge that the provision of an “indirect” referral still renders the referring physician complicit. . . . medical students training in Ontario must now seriously consider taking their skills and talents to another province or jurisdiction in which they can practice their vocation in a manner that upholds their integrity. . . [Full Text]

Should lesbian couples have access to mitochondrial replacement therapy?

BioEdge

Michael Cook

“Three parent babies!!!!” was a shock-horror headline across the world when the UK was debating mitochondrial replacement therapy a couple of years ago. This is a technique to avoid passing on mitochondrial diseases from mother to child. There are different methods, but they involve combining the nuclear DNA of the mother’s egg with healthy mitochondrial DNA from another woman and fertilisation with sperm.

The government’s fertility regulator, the HFEA, explained that this was meant to “to avoid passing on serious genetic diseases to future generations”. Under existing legislation, MRT can only be used for this purpose.

Much of the opposition to the technique in a very heated debate was the unconventional matter of a child sharing two mothers, or at least, sharing the genes of two women. Many found this profoundly unnatural.

However, there is a group of women who might welcome this – lesbian couples. For them, it could be a way of creating a child with a shared genetic heritage.

Or so argue Giulia Cavaliere and César Palacios-González, of , King’s College London, in the Journal of Medical Ethics. Their reasoning is quite interesting. (It is spelled out a bit more simply in a blog post.)

First of all, against the headlines about “cures” for desperately ill children, they insist (as did many opponents of MTR) that no MRTs can be considered therapeutic as they do not cure children/embryos affected by mtDNA diseases, but they are rather a means to create children that are not affected by mtDNA diseases.

Second, they ask, if “cures” are not the reason for the existing legislation, what is? Their answer might have escaped the MPs who votes for it, but it fits:

the rationale to offer MRTs is to allow women at risk of transmitting mtDNA disease to have healthy children that are genetically related to them. The rationale, in other words, is to expand these women’s reproductive freedom …

Third, if reproductive freedom (and not the health of a child) is the most fundamental reason, then all women deserve to take advantage of MTR, not just the mothers of sick children. Lesbian couples are equally needy and deserving.

Providing access to MRTs to women at risk of transmitting a mtDNA disease and not to lesbian couples is in our view contrary to one of the tenets of morality, which demands to treat like cases alike. Denying access to MRTs to lesbian couples is morally unjustifiable in as much as it curtails the enjoyment of certain freedoms to a certain group without good reason, whilst allowing others to enjoy the very same freedoms.

Some bioethicists would call this the slippery slope in action. Others would respond that it is merely extending the inherent logic of the legislation. In any case, it certainly is an unexpected interpretation of the legislation.

This article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation. Commercial media must contact BioEdge for permission and fees. Some articles on this site are published under different terms.

Accessed 2018-03-28

 

Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States

Joseph K. Canner, Omar Harfouch, Lisa M. Kodadek, et al

Abstract

Importance

Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States.

Objectives

To investigate the incidence and trends over time of gender-affirming surgical procedures and to analyze characteristics and payer status of transgender patients seeking these operations.

Design, Setting, and Participants

In this descriptive observational study from 2000 to 2014, data were analyzed from the National Inpatient Sample, a representative pool of inpatient visits across the United States. The initial analyses were done from June to August 2015. Patients of interest were identified by International Classification of Diseases, Ninth Revision, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation.

Main Outcomes and Measures

Demographics, health insurance plan, and type of surgery for patients who sought gender-affirming surgery were compared between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014.

Results

This study included 37 827 encounters (median [interquartile range] patient age, 38 [26-49] years) identified by a diagnosis code of transsexualism or gender identity disorder. Of all encounters, 4118 (10.9%) involved gender-affirming surgery. The incidence of genital surgery increased over time: in 2000-2005, 72.0% of patients who underwent gender-affirming procedures had genital surgery; in 2006-2011, 83.9% of patients who underwent gender-affirming procedures had genital surgery. Most patients (2319 of 4118 [56.3%]) undergoing these procedures were not covered by any health insurance plan. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased by 3-fold in 2014 (to 70) compared with 2012-2013 (from 25). No patients who underwent inpatient gender-affirming surgery died in the hospital.

Conclusions and Relevance

Most transgender patients in this national sample undergoing inpatient gender-affirming surgery were classified as self-pay; however, an increasing number of transgender patients are being covered by private insurance, Medicare, or Medicaid. As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them.


Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, Haider AH, Lau BD. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg. Published online February 28, 2018. doi:10.1001/jamasurg.2017.6231

 

Physicians are not solely responsible for ensuring access to medical assistance in dying

Diane Kelsall

Patients’ rights to access to medical assistance in dying (MAiD) trumps the religious rights of physicians under the Canadian Charter of Rights and Freedoms  –  or so says the Ontario Superior Court of Justice. But ensuring equitable access to health care is a societal responsibility and does not rest solely on the individual physician. Surely there is a way forward that ensures access for patients requesting MAiD without trampling on physician rights enshrined in law.

 


Kelsall D.  Physicians are not solely responsible for ensuring access to medical assistance in dying. CMAJ February 20, 2018 190 (7) E181; DOI: https://doi.org/10.1503/cmaj.180153

Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

G. Bravo, C. Rodrigue, M. Arcand, J. Downie, M.-F. Dubois, S. Kaasalaine, C.M. Hertogh,S. Pautex, L. Van den Block

Abstract

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.


Bravo G, Rodrigue C, Arcand M, Downie J, Dubois M-F, Kaasalaine S, Hertogh CM,  Pautex S, L. Van den Block L. Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs. 2018 Jan 3. pii: S0197-4572(17)30319-1. doi: 10.1016/j.gerinurse.2017.12.002.

Is there any difference between euthanasia and palliated starvation?

BioEdge

Xavier Symons

While euthanasia and assisted suicide are currently illegal in most countries, the practice of voluntarily stopping eating and drinking (VSED) is seen by some as an ethically and legally permissible alternative. VSED refers to seriously-ill patients refusing to eat and drink for a sustained period of time with the intention of bringing about their own death.

Yet a new paper published in BMC Medicine argues that VSED is ethically indistinguishable from assisted suicide, and should be subject to the same legal regulations as more salient cases of assistance in dying.

The paper, lead-authored by Ralf J. Jox of the Institute for Ethics, History and Theory of Medicine at the University of Munich, argues that “supporting patients who embark on VSED amounts to assistance in suicide, at least in some instances, depending on the kind of support and its relation to the patient’s intention”.

While VSED does not involve an invasive or aggressive act like many other means of suicide, the authors write that “VSED should [nevertheless] be considered as a form of suicide, as there is both an intention to bring about death and an omission that directly causes this effect”. Doctors who assist patients in VSED — by encouraging them, or promising pain-relief if VSED is undertaken — are potentially instrumental in the deaths of the patients, as the suicide would not occur without them, and they share the patient’s intention of inducing death.

The authors of the paper conclude that the same legal prescriptions or regulations that apply to physician assisted suicide should also apply to VSED.

“[We] maintain… that future ethical discussions on assisted suicide require consideration of medically supported VSED, and vice versa…Thus, the widely held position by palliative care societies, professional bodies of physicians, legal scholars, and ethicists to disapprove of assisted suicide but approve of and even promote medically supported VSED appears inconsistent”.


This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

 

Accessed 2017-08-11

 

The status of the human embryo in various religions

William Neaves

Abstract

Research into human development involves the use of human embryos and their derivative cells and tissues. How religions view the human embryo depends on beliefs about ensoulment and the inception of personhood, and science can neither prove nor refute the teaching of those religions that consider the zygote to be a human person with an immortal soul. This Spotlight article discusses some of the dominant themes that have emerged with regard to how different religions view the human embryo, with a focus on the Christian faith as well as Buddhist, Hindu, Jewish and Islamic perspectives.


Neaves W. The status of the human embryo in various religions. Development 2017 144: 2541-2543; doi: 10.1242/dev.151886