Medical Euthanasia in Canada: Current Issues and Potential Future Expansion

Psychiatric Times

Mark S. Komrad

Dr Mark Komrad explores the relatively new Medical Aid in Dying (MAID) law in Canada, and how it may be on the verge of opening medical euthanasia to certain qualified psychiatric patients, similar to practices in Belgium and The Netherlands (see A Psychiatrist Visits Belgium: The Epicenter of Psychiatric Euthanasia).

He also brings out specific worries about the emerging ethical and legal trends in Ontario, to stop conscientious objecting physicians from refusing to refer cases of patients seeking euthanasia to colleagues who might be willing to provide it.

Dr Komrad is a clinical psychiatrist and an ethicist. He just finished a 6-year tenure on the APA Ethics Committee and also serves on the APA Assembly. In those contexts, he helped to craft the current current APA position on Medical Euthanasia for non-terminally ill patients [PDF]. He is also on the teaching Faculty of Psychiatry at Johns Hopkins, Sheppard Pratt, and the University of Maryland. Dr Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor any of the institutions where he is on the faculty. . . . [Go to Psychiatric Times for Podcast]

 

HHS rules prevent providers from being forced to do things that violate moral convictions

The Hill

Reproduced with permission

Diana Ruzicka*

In the April 4, 2018 article, HHS rule lowers the bar for care and discriminates against certain people, nursing leaders, Pamela F. Cipriano and Karen Cox, wrote that the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Proposed Rule: Protecting Statutory Conscience Rights in Health Care; Delegations of Authority expands the ability to discriminate, denies patients health care and should be rescinded. These accusations are unfounded and the rule should be supported.

What the rule does is “more effectively and comprehensively enforce Federal health care conscience and associated anti-discrimination laws.” It is not an effort to allow discrimination but an effort to prevent it by enforcing laws already on the books and gives the OCR the authority to oversee such efforts. This is something that nursing should encourage because it supports the Code of Ethics for Nurses (code).

The code reminds us that, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence and continue personal and professional growth.”

It is precisely because nurses are professionals who hold themselves to these standards that patients have come to see nurses as persons worthy of their trust, persons in whose hands they are willing to place their lives. Being granted by the public this weighty and solemn responsibility is humbling and must never be taken lightly. Thus the nurse’s duty to practice in accord with one’s conscience, to be a person of wholeness of character and integrity, is recognized by the.

It is odd that, despite supporting a nurse’s duty to conscience and the right to refuse to participate in an action to which the nurse objects on the grounds of conscience, Cipriano and Cox insist that the nurse, must assure that others make the care available to the patient. This suggests a failure to recognize that referring the patient to someone who will do the objectionable act in place of the nurse can make the nurse complicit.

The culpability of complicity is well recognized in law and ethics, as an accomplice is liable to the same extent as the person who does the deed. Thus, to make a referral and be complicit in an act to which the nurse conscientiously objects, also violates conscience. We doubt nursing leaders actually support this, as the consequences would be chilling.

When persons are made to violate their conscience, to set it aside, to silence it, moral integrity is eroded and moral disengagement progressively sets in. To move from caring for our fellow human beings to acting on them in ways that our conscience tells us we should not, requires powerful cognitive manipulation and restructuring to free ourselves of the guilt associated with this violation of our deeply held moral or religious beliefs.

Moral disengagement has frightening negative consequences, namely a pernicious dehumanization of persons, including oneself and of society as a whole. Rather than a nurse being someone of moral courage, ethical competence and human rights sensitivity, as our code directs, a nurse would have to be someone who is willing to surrender their conscience to expediency, powerful others, or whatever happens to be permitted by law at the time and place.

No longer would patients find that nurses are persons they can trust. It is precisely because nurses practice in accordance with their conscience that the public continues to grant them high scores on honesty and ethics.

None of this is to say that nurses may abandon patients. By promptly seeking a transfer of assignment that does not involve the objectionable act or by transferring the patient elsewhere without making a referral, the nurse continues to uphold the code by “promoting, advocating for and protecting the rights, health and safety of the patient [and, at the same time,] preserving wholeness of character and integrity.”

Clearly, refusal to care for a patient based on an individual attribute is unjust discrimination and has no place in nursing or health care. But that is not what the rule does. It protects the right to object to being forced to participate in an act that violates a person’s deeply held moral convictions or religious beliefs and from discrimination as a result of one’s refusal to participate in such an act.

To call for rescinding the rule, whose purpose is to protect this fundamental human right, would be short-sighted and could make unjust discrimination more likely and harm not only nursing but also the patients we serve.

 

Discrimination isn’t always wrong

America

John J. Conley

Is discrimination always wrong?

To listen to the current national debate on the topic, it would appear to be so. Virtually all international human-rights covenants categorically reject discrimination on the basis of race, religion and gender. Even contemporary professional philosophers tend to treat discrimination as an unalloyed evil. The University of Chicago’s Brian Leiter has led a very public philosophical campaign to eliminate religious exemptions to anti-discrimination laws and to declare unethical religious practices that appear to be discriminatory, especially in the area of gender and sexual orientation.

But our crusade against discrimination seems to rest on a fundamental confusion. There is a difference between discriminating against someone because of the group to which he or she belongs and discriminating against someone on the basis of his or her actions. . . . [Full text]

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.

Oklahoma Officials Endorse Nitrogen Executions As ‘Humane,’ But Some Medical Experts Aren’t Sure

Stateimpact Oklahoma

Quinton Chandler

Oklahoma wants to go where no state has gone before: Executing death row inmates with nitrogen gas. Officials say nitrogen will bring quick, painless deaths, but the research is slim — and it has never been used in U.S. executions.

The case for nitrogen hypoxia sounds simple. Nitrogen is already in the air we breathe, but, as long as humans get the right mix, nitrogen is safe. The state wants to make death row inmates breathe pure nitrogen.

State Sen. Ervin Yen, R-Oklahoma City, is a cardiac anesthesiologist who signed his name to the bill that made nitrogen hypoxia a legal execution method in 2015. He says the inmates would die from “lack of oxygen,” not exposure to nitrogen. . . [Full text]

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)

Tongue splitting, bodily harm, and human dignity

BioEdge

Xavier Symons

Contemporary cosmetic surgery has become a tool for realising bizarre personal fantasies. Sometimes it also leads to significant bodily harm. “Tongue-splitting” is an operation whereby a person’s tongue is split from the tip to as far back as the underside base. The operation has become a common alteration for body-modification enthusiasts, who say it heightens their sense of taste and touch.

Some jurisdictions, however, have enacted a ban on the procedure. The operation can be painful, and can temporarily impede one’s capacity for speech.

In a recent post on the blog Practical Ethics, UK lawyer Charles Foster considers the legality and ethics of the procedure.

Foster discusses the case of R v BM, where a Wolverhampton tattooist was found guilty of inflicting grievous bodily harm on a patient after splitting their tongue. Even though the customer consented, the court found that consent was not a defence against having inflicted grievous bodily harm.

Foster argues that the ruling represents a defence of basic human dignity, which transcends the ambit of personal autonomy:

[The ruling] is a salutary reminder that there are limits to the law’s protection of personal autonomy. Factors other than autonomy are in play in the criminal law. I have argued elsewhere that the primary factor (and the foundational factor in the criminal law – in which all other factors, including autonomy, are rooted) is human dignity.

Indeed, Foster argues that in harming another, one does violence to one’s own human dignity:

One might say that X causing injury to Y is doubly culpable because in doing so X outrages not only Y’s dignity but also his own (X’s) dignity…dignity is ‘Janus-faced’.


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.

Physician warns of threat to freedom of conscience in Ireland

The Irish Times

Andrew O’Regan

Sir, – I have a number of concerns relating to conscientious objection and abortion.

The recently published heads of Bill define termination of pregnancy as “a medical procedure which is intended to end the life of the foetus”.

If the referendum is passed, this is the procedure that will be available on demand for any reason up to 12 weeks and after 12 weeks on vague health grounds.

First, it is of great worry to Irish practitioners that doctors, nurses and midwives cannot avoid participation in abortion in an increasing number of jurisdictions, including Sweden, Iceland, Finland and Bulgaria.

Second, in the UK supreme court, two midwives lost their battle to be treated as “conscientious objectors”, and to be excused from participating in abortions.

The midwives were told that while they could refuse to carry out the procedures themselves, they were obliged to delegate these duties to other staff and to supervise the staff during the abortions.

Many doctors and nurses consider that if their conscience prevents them from intentionally ending the life of the foetus, they should not be required to supervise and organise this same act.

The legislation proposed if the Eighth Amendment is repealed will oblige GPs and other healthcare professionals who conscientiously object to transfer care to another doctor and to inform the patient in writing that they may seek review of the objecting doctor’s decision.

Third, in 2013 a resolution to restrict the right of doctors and nurses to conscientious objection was narrowly defeated in the European Parliament. Some Irish MEPs voted for this. In the recent Dáil debates some politicians argued against a doctor’s right to avoid participation in abortion.

We have seen how one political party expelled a number of members for voting with their consciences in 2013 and how another party suspended one of the youngest female TDs in Dáil Éireann for exercising her conscience in a vote last month.

Fourth, some academic campaigners have been arguing for the removal of conscientious objection across Europe, claiming that it can be used as a “subtle method for limiting access to abortion”.

Finally, under Minister for Health Simon Harris’s plans for abortion, GPs and others will not be entitled to conscientiously object to participating in the intentional destruction (not delivery) of the foetus where there is a risk to the life or health of the patient in an emergency.

No evidence has been produced to show that intentional destruction of the foetus is necessary to avoid risks to the life or health of a pregnant patient.

I would urge GPs and our colleagues from other disciplines who are also in the front line of patient care to inform themselves fully of the implications for the practice of medicine should this referendum be passed. – Is mise,

Dr ANDREW O’REGAN,

(General Practitioner and Senior Lecturer),
Killarney,
Co Kerry.

UN Bureaucrats Push Full Steam Ahead for Abortion, Slam Breaks on Euthanasia

Experts a seek to limit freedom of conscience for  medical professionals

Center for Family and Human Rights

Stefanno Gennarini

NEW YORK, April 13 (C-Fam) “Sexual and reproductive health and rights are integral to the dignity of women and girls,” said Deputy High Commissioner for Human Rights Kate Gilmore at a gathering of UN experts and bureaucrats in Geneva last month.

Gilmore invited some thirty international experts of two UN human rights treaty monitoring committees to “confront” the UN General Assembly and “defy” UN member states which have repeatedly refused to recognize an international right to abortion.

“This is not a time for optimism. This is not a time for hope. This is a time for courage,” Gilmore said. Egging on the experts, she said that the limitations that member states had placed on their power and resources were a “pernicious intentional effort to counter your authority, to minimize the reach of your responsibilities, and dilute the authority with which you speak.” . . .[Full Text]

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