L’euthanasie au Canada: une mise en garde

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français

Euthanasia in Canada: a Cautionary Tale

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

We are Canadian physicians who are dismayed and concerned by the impact  – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public  – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . . Continue reading in the World Medical Journal | Français

Doctors Have an Alarmingly High Suicide Rate, and No One Is Sure How to Help Them

Gizmodo

Ed Cara

Medical doctors are more likely to die from suicide than members of any other profession in the US, suggests new research presented this week at the annual meeting of the American Psychiatric Association. And worse than that, few interventions seem to have helped make these suicides less common.

Studies have consistently shown that doctors die from suicide at a higher rate annually than people in any other profession, and some research has found that a majority of medical professionals suffer from serious work stress and burnout. But the authors behind this latest work wanted to not only get a clearer picture of how often these deaths happen, but whether any programs have successfully helped lowered rates. So they examined relevant, peer-reviewed studies dealing with both issues over the past 10 years. . . [Full Text]

Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Valerie Fleming Lucy Frith, Ans Luyben, Beate Ramsayer

Abstract

Background

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.

Method

We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.

Results

Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n =  58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.

Conclusions

We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.


Fleming V, Frith L, Luyben A, Ramsayer B. Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons. BMC Medical Ethics. 2018;19:31. doi:10.1186/s12910-018-0268-3.

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