October-December, 2006
December
A 67 year old Spanish woman who had fertility treatment in Latin America gave
birth to twins in Barcelona. [BBC
News]
The potential for conflicts of conscience in end of life care is illustrated in
the case of Peirgiorgio Welby. Welby suffered from muscular dystrophy and, from
1997, had relied upon mechanical ventilation to breathe. In April, 2006 he lost
the ability to use a computer mouse, which had facilitated communication, and he
made a public request that his respirator be disconnected so that he could die.
A judge ruled that he could order the respirator to be disconnected, but that
Italian law would then require doctors to resuscitate him. Eventually, an
anaesthetist, apparently violating instructions from others, disconnected Welby'
s respirator at his request. No attempt was made to resuscitate him, and death
was pronounced about forty minutes later.
Catholic teaching does not require the use of extraordinary or excessively
burdensome measures to prolong life, noting, however, that while treatment may
be considered burdensome, life must not. Thus, the disconnection of a mechanical
ventilation would not necessarily constitute euthanasia. However, it appears
that Welby's public advocacy of euthanasia and repeated references to ending his
life caused some Church officials to treat his death as a form of euthanasia,
and Welby was denied a Catholic funeral because he had "repeatedly and publicly
affirmed his desire to end his own life." [BBC
News, 22 December, 2006] The decision remains controversial among Catholics.
The UN
Convention on the Rights of Persons with Disabilities, just adopted by the
General Assembly, includes a provision (Article 25f) that forbids
"discriminatory denial of health care or health services or food and fluids on
the basis of disability." This is being interpreted by a number of organizations
to prohibit the practice of withdrawing nourishment (artificial nutrition and
hydration) from persons in persistent vegetative state, which has common in
countries like Britain and the United States. The Convention also refers to
"sexual and reproductive health", the first time the phrase has been accepted in
an international treaty. Abortion advocates typically use the phrase to include
abortion, and, for this reason, the Holy See will not sign the convention.
Despite public opposition, a "command paper" from the British government
indicates that laws and regulations will be changed so that a child's need for a
father will no longer be considered relevant to applications for artificial
reproductive techniques. This will facilitate the insemination of single women
and lesbians who do not want a relationship with a man. Sex-selection for
non-medical reasons will continue to be banned, but the selection of
tissue-matched embryos to supply tissue for a sibling suffering a
life-threatening illness will be permitted. The production of chimeras (embryos
combining human and animal cells) will be allowed, but the reproductive
techniques that would produce embryos from genetic material from a woman alone
will be forbidden. Other changes will affect sperm donors, children conceived by
IVF, and surrogacy. The health minister asserts that the aim of the revisions
"is to pursue the common good through a system broadly acceptable to society." [The
Telegraph] Since a number of the provisions are morally controversial, it
remains to be seen what effect they will have on health care workers who do not
share the minister's understanding of the common good.
The BBC reports that it has obtained video footage of the post-mortem
examination of 30 deceased newborns in the city of Kharkiv, Ukraine. The video
shows that organs, including brains, have been stripped, and the dismemberment
of some bodies. According to a senior British forensic pathologist,
dismemberment is not standard post-mortem practice. The BBC speculates that the
video may be evidence of harvesting stem cells from bone marrow.[BBC]
A woman who lapsed into a coma following a massive brain haemorrhage in 1993 and
has been in a persistent vegetative state since will be deprived of nutrition
and hydration as a result of a court ruling. The National Health Services Trust
has been given permission to withdraw all life sustaining 'treatment', which, in
British law, includes food and fluids. [The
Guardian] The case illustrates the problem faced by conscientious objectors
to euthanasia, since the woman was not dying and the sole purpose for
withdrawing nourishment is to cause her death.
Canadian Physicians for Life has pointed out that some vaccines (like the
infant vaccine PENTACEL, used against diphtheria, tetanus, pertussis, polio and
Haemophilus B) are derived from tissue from aborted foetuses, while others (like
PEDICEL) do not. "This presents a serious moral dilemma to those who might view
the use of such abortion-related vaccines as a form of cooperation with an
immoral act," the organization says. While both vaccines are approved in Canada,
only PENTACEL is marketed in the country and publicly funded in childhood
vaccination programs. CPFL has asked federal and provincial governments to
provide a choice between the two vaccines and "ensure the supply of vaccines
from non-objectionable sources."[
CPFL
News Release] [
Vaccines
developed from aborted foetal cells]
November
Catholic Charities of the Dioceses of Albany and Ogdensburg, Servants of Relief
for Incurable Cancer, Our Lady of Consolation Geriatric Care Center, the
Carmelite Sisters for the Aged and Infirm, Bishop Ludden High School, Delta
Development of Western New York, the Temple Baptist Church and the First Bible
Baptist Church are appealing a
ruling by the New York Court of Appeals. The Court upheld a state law
requiring all employers, without exception, to include contraceptive coverage in
drug benefit plans for employees. It is being suggested that, if the ruling is
not overturned, prescription drug benefit plans may be cancelled completely by
objecting institutions.
The British Pregnancy Advisory Service wants the law in the United Kingdom
changed so that two doctors no longer have to approve an abortion, and wants
nurses to dispense abortifacient drugs to women during the first nine weeks of
pregnancy. The chief executive of the service acknowledged that 40% of abortions
are a consequence of contraceptive failure, including the failure of the birth
control pill, and that abortion is considered a "backup" for failed
contraception. [The
Guardian] A change in the law that resulted in an increase in demand for
abortion or dispensing of abortifacient drugs by nurses would likely have an
adverse impact on conscientious objectors.
Lord Falconer, Lord Chancellor of England, has issued guidelines for the
application of the Mental Capacity Act that state that a health care worker who
refuses to abide by the terms of a "living will" may be charged criminally or
liable to civil penalties. Criminal prosecution could result in imprisonment.
Concern among conscientious objectors arises from the legal definition of
"treatment" to include artificial nutrition and hydration. Since patients can
legally refuse treatment, patients (or proxies) can refuse nutrition and
hydration in order to cause death. The guidelines are reported to recognize
conscientious objection, but require an objecting physician to transfer a
patient to a colleague willing to carry out the instructions. A conflict could
still arise if the transfer had to be initiated by the objecting physician
rather than by the patient or proxy. [Evening
Standard]
16 November, 2006
Despite the suggestion of the Royal College of of Obstetricians and Gynaecology,
a report published by the Nuffield Council on Biothecs "unreserverdly" rejected
euthanasia for newborns "even when that life is 'intolerable.'" [2.37,
Critical Care Decisions in Fetal and Neo-natal Medicine: Ethical Issues].
The Council recommended that babies born at 24 to 25 weeks gestation should
not receive disproportionately burdensome treatment, noting that most babies
born at less that 25 weeks gestation will die. At 23 weeks it held that it is
very difficult to predict the outcome of intervention, stating that physicians
are not legally obliged to initiate or continue what they consider to be futile
care at this state. The Council recommended that intensive care should be
provided to babies in the 22nd week of gestation only in exceptional cases, when
parents insist upon it and physicians agree that it is in the baby's best
interest. The Council viewed attempts to resuscitate babies below 22 weeks
gestation as experimental, and insisted that it not be attempted outside an
approved research programme following the normal protocols.
The report also referred to the issue of conscientious objection:
Paragraph 4.34 If a doctor or other health professional has a
conscientious objection to termination of pregnancy, they have the right
under the Abortion Act 1967 to refuse to participate in such procedures.
[Although not in a situation when the termination is needed to save the life
of or prevent severe permanent injury to the pregnant woman.] and refer the
patient to another doctor.[citing Mason JK and Laurie GT (2005) Mason and
McCall Smith's Law and Medical Ethics, 7th Edition (Oxford: Oxford
University Press).] This right of conscientious objection to participating
in terminations is supported by the BMA. [citing British Medical Association
(1999) The Law and Ethics of Abortion] However, research suggests
that, while midwives involved in feticide felt that the right to object was
genuinely available, consultants typically saw this right as theoretical.
[citing Graham R, Rankin J, Haimes E and Robson S (2006) Providing
feticide: An exploration of health professional perspectives J Obstet
Gynaecol 26 (Supp. 1): S14 -16.]
Paragraph 8.41 It is unrealistic to envisage legislation in the UK
which did not offer doctors a right to refuse to practise euthanasia on
grounds of conscience. When analogous rights of conscientious objection are
granted in other legislation, it is clear that the objector is required to
refer his or her patient to another clinician. The difficulty of moving a
baby already gravely ill may either render any 'right' to euthanasia
impracticable, or render the right to conscientious objection meaningless.
[, citing General Medical Council (2001) Withholding and Withdrawing
Life-prolonging Treatments: Good practice in decision-making, paragraph
28.]
The Council's view regarding an obligation to refer is not uncontested [See
Conscientious objection and referral;
Joint Committee on Human Rights].
A federal appeals court upheld the dismissal of a lawsuit brought by the
National Family Planning and Reproductive Health Association against the "Weldon
Amendment." The Weldon Amendment is a clause in federal law that prohibits
the federal government from providing certain kinds of federal aid to states
that discriminate against medical professionals who decline to participate in
abortions. [ADF
News Release]
The Fifth Circuit Court of Appeals in Chile has upheld a lower court decision
that allows the morning-after pill to be dispensed to minors without parental
consent, and a bill has been introduced to legalize abortion during the first 12
weeks of pregnancy. The developments suggest the likelihood of conflicts of
conscience among some health care workers in the country.
Two different research teams in Britain have applied for permission to fuse
human cells with animal eggs. One team wants to produce chimeric embryos that
will be about 99.9% human and 0.1% animal in order to obtain stem cells from the
embryos for research. The embryos would be destroyed after 14 days. The other
wants to inject human skin cells into cow eggs to study how adult cells can be
"reprogrammed" into primitive cells. The research is controversial, but a
precedent for it is said to be the accepted practice of using human sperm to
fertilize a hamster egg to test the quality of the sperm. The resulting embryo
is destroyed at the two cell stage. [The
Telegraph]
Professor Lord Robert Winston, who introduced pre-implantation genetic
diagnosis (PGD) of embryos conceived
in vitro, now believes that it is
acceptable to use the technique to select embryos for sex. He had previously
held that it should be used only to identify embryos having a serious genetic
disorder. Current regulations permit sex selection only in the case of
conditions inherited only by one sex. Britain's Human Fertilisation and
Embryology Authority (HFEA) cites surveys showing public opposition to sex
selection running at about 80%. [
Sunday
Herald]
The Royal College of Obstetricians and Gynaecology has recommended that
euthanasia be seriously considered for severely disabled infants, arguing that
"a very disabled child can mean a disabled family." The recommendation was made
to the Nuffield Council on Bioethics during its inquiry into the ethical issues
raised by the policy of prolonging life in newborn babies. The College qualifies
the recommendation as a call for debate rather than legalization. [Sunday
Times] Adoption of the practice would be of concern to physicians opposed to
it for moral or ethical reasons.
October
The Catholi Cardinal Archbishop of Bangkok and an assistant monk at
the Buddhist Suan Kaew Temple both spoke out against abortion in response to a
conference organized by Thammasat University's Faculty of Social Administration
on legalization of abortion. The conference asserted that abortion was "not a
moral issue." [Asia
News] The outright denial of a legitimate moral perspective on the issue and
the possibility that a change in the law could adversely impact those who have a
different view give reason for concern about freedom of conscience in the
country.
Danish women travel to Spain to undergo abortions up to week 32, or eight months
into a pregnancy. The legal limit for abortions in Denmark is 12 weeks (with the
possibility of later abortions upon application): in Spain, 24 weeks. German,
British and Spanish women also use the private facility for abortions that would
not be legal in their own countries. The disclosure, made in a television
documentary, caused shock among doctors and politicians, indicating that
conflicts of conscience can arise even among health care workers generally
supportive of a controversial procedure. [Sapa-dpa]
Ms. Kathy Sinnott, a Member of the European Parliament from Ireland, noted that
the European Parliament had rejected amendments to a budget provision that would
have stopped funding of programmes that include coercive abortion, involuntary
sterilization and infanticide. [Ms
Sinnott's office, 26 October, 2005]
Further to the arrest of four Israeli physicians (
Israeli
physicians arrested for illegal experiments), a police Chief Superintendent
has told the Knesset Labour and Welfare Committee that eight more are under
investigation. [
Haaretz]
According to a news report in Britain's Sunday Times, the Royal College of
Obstetricians and Gynaecologists is expected to recommend that birth
certificates be denied to babies born at less than 22 weeks gestation. This
would currently affect about 300 babies each year, including about 50 born alive
during or after failed abortions. The Society would prefer that they be
classified as "pre-viable" and that their live-births not be officially
recognized. [Sunday
Times]
Most Rev Anthony Fisher OP, an auxiliary Catholic bishop in Sydney, Australia,
states that Catholic hospitals in the country will refuse to co-operate in
treatment involving the use of products from embryonic stem cell research. The
statement illustrates how conflicts of conscience can arise as a result of
artificial reproductive technology, even though they may not occur among the
researchers directly involved. [LifeSite, 20 October, 2006 ]
By a 6-to-0 decision, the New York Court of Appeals dismissed an appeal against
rulings by the State Supreme Court and the Appellate Division, that upheld a
statute requiring the Roman Catholic Church and other religious organizations to
cover the cost of contraception for employees. Eight Catholic and two Baptist
organizations had sought to broaden a "religious employer" exemption to include
religious schools, hospitals and social service organizations. The New York
State Catholic Conference is considering an appeal. [New
York Times] [Ruling]
A man who attempted to asphyxiate his wife was placed on probation for three
years by Quebec judge. The judge asserted that Andre Bergeron acted "out of
love," and his lawyer has suggested that the judges remarks and sentence signal
the need to change the law. A Quebec woman convicted of assisting in her son's
suicide received the same sentence earlier this year. [
Western
Catholic Reporter] It is unlikely that future sentences in the province will
depart significantly from this standard. Acceptance by the legal profession of
the notion that euthanasia and assisted suicide are acts of love and compassion
will likely make it difficult for conscientious objectors to avoid involvement
with the procedures should they be legalized.
While acknowledging that freedom of conscience of pharmacists ought to be
respected, the Head of Professional Ethics of the Royal Pharmaceutical Society
asserts that an objecting pharmacist or other staff member "must advise the
patient of an alternative source for the service requested." [
Daily
Telegraph] To require the objecting pharmacist to facilitate the provision
of the drug would be problematic for a number of objecting practitioners. [See
Referral: False Compromise]
A resolution prepared for the Annual General Meeting of the College of
Pharmacists of British Columbia one 25 November, 2006, appears to have opened an
avenue for dialogue on the subject of freedom of conscience for pharmacists. The
resolution asked that the College propose a more appropriate forum than the
Annual General Meeting for the discussion of important ethical issues. The
governing College Council has now suggested that a representative of
conscientious objectors in the profession meet with the College's Ethics
Committee over the next few months to discuss the issue.
The proposed resolution followed repeated rejection of policy proposals
intended to ensure respect for freedom of conscience and religion for
pharmacists. The College of Pharmacists of British Columbia has been
particularly hostile to the concept. In 2000, its ethics committee issued a
bulletin that impugned the integrity of conscientious objectors, making
accusations the College had no evidence to support. [See
Project Report 2001-01].
A 37 year old woman complained to the media that she had been refused the
'morning after pill' at a Lloyds Pharmacy in Green Arbour Road, Thurcroft. She
suggested that he should find a different line of work. A local Director of
Public Health agreed that a pharmacist could refuse to provide a drug for
reasons of conscience, but was obliged to tell the patient where to obtain it.
Lloyds is supporting the exercise of freedom of conscience by the pharmacist [This
Is London]. The circumstances related in the news article suggest that some
improvements could be made in communicating with patients in these
circumstances.
Dr. Christopher James Doig of the University of Calgary, Alberta, has
voiced opposition to organ transplants based upon the criteria of donor cardiac
arrest rather than donor brain death. The former criteria (DCD), used in the
first organ transplants, were replaced in North America by brain death criteria
(DBD), but in June of this year the Ottawa Hospitla announced that it was
returning to the earlier practice. Dr. Doig asserts that returning to the
earlier criteria " is a major change in end-of-life practice and
poses significant ethical problems for end-of-life decision-making in
intensive care units (ICUs). His concern is that the treatment of severely
brain-injured patients will be compromised because of pressure to harvest their
organs. Of particular interest is his reference to research showing a wide
variation in practice in Canadian intensive care units in the withdrawal of
life-sustaining treatment. He believes that "the possibility of conflicted
decision-makingin a controlled DCD program is more than a theoretical
possibility." [CMAJ]
Dr. Doig's concerns and the differences in practice noted indicate the potential
for conflicts of conscience among health care providers. A letter responding to
his comments emphasized the importance of adopting DCD in order to save lives,
but acknowledged the need to develop "consistent end of life protocols" across
the country. [CMAJ letters]
This would not necessarily resolve conflicts of conscience, especially if the
protocols reflect only the views of a predominant secular ethical establishment.
Four senior doctors at Kaplan Hospital in Rehovot and the Hartzfeld Geriatric
Hospital in Gedera have been arrested during an investigation of hundreds of
illegal and unethical experiments on elderly patients over several years.
Allegations include causing "wrongful death through negligence, abuse of
helpless victims, aggravated assault, fraud, violation of a statutory obligation
and interference in an investigation." Some of the illegal experiments were
reported in professional journals and formed the basis of the reputations of
some of those accused as geriatrics experts, and some of the experiments had not
medical or scientific value. There are indications that responsibility for the
experiments extends beyond the physicians arrested.[Haaretz]
The story demonstrates the need for health care workers to develop conscientious
convictions independent of an established ethos in a profession or institution,
so that they will be better able to recognize and respond appropriately to
unethical practices. It also illustrates the potential for conflicts of
conscience among health care workers practising in an ethically compromised
institution or profession.
Acting on what appears to be a belief that children do not need fathers, the
number of single women obtaining IVF has doubled in the past five years, while
IVF treatment for lesbian couples has increased fourfold. [Sunday
Telegraph]
Mary Hanna, who describes herself as a "devout Coptic Orthodox Christian,"
agreed to serve four years in the US military on active service and four years
in the reserves so that the US Army would pay for her medical education. The 30
year old anaesthesologist joined the army in 1997, at which time she had no
religious objections to military service. However, she said, she experienced a
growth of religious interest after the death of her father in 2003 and submitted
an application for conscientious objector status after being ordered to report
for active duty in August, 2006. The application was approved by her superiors
but denied by the Conscientious Objector Review Board. A federal judge has now
ruled in her favour. Her lawyer states that she is willing to repay the army the
$184,000.00 invested in her education.
Responding to the latest report of Catalonia's Consultative Bioethics Committee
on euthanasia, an association of Christian doctors released a statement that
said: "We doctors do not want to be executioners." [Zenit]
British scientists are seeking approval to create embryos by fusing human cells
with animal eggs in controversial research which will boost stem cell science
and tackle some of the most debilitating and untreatable neurological diseases.
Three British research teams plan to submit applications to the Human
Fertilisation and Embryololgy Authority seeking permission to replace nuclei in
rabbit and cow eggs with human cells. The result is expected to be embryos that
have a full set of human genes with animal genes contained in mitochondria:
chimeras that are 99.9% human and 0.1% animal. [The
Guardian]
Several articles in the Journal of Medical Ethics discuss the use of pvs
patients as experimental subjects. Some authors assert that they would be
especially useful in studies of the long-term effects of animal organs
transplants.
- R Sparrow
Right of the living
dead? Consent to experimental surgery in the event of cortical death.
J. Med. Ethics, Oct 2006; 32: 601 - 605.
- S Curry
Living patients in a
permanent vegetative state as legitimate research subjects. J. Med.
Ethics, Oct 2006; 32: 606 - 607.
- H Draper
Research and patients in a permanent vegetative state. J.
Med. Ethics, Oct 2006; 32: 607
- J Thompson
Relatives of the
living dead. J. Med. Ethics, Oct 2006; 32: 607 - 608.
- N Levy, A Ravelingien, J Braeckman, F Mortier, E Mortier, and I
Kerremans
Respecting rights ...
to death. J. Med. Ethics, Oct 2006; 32: 608 - 611.
A South African nurse who alleges that she was forced to resign because she
refused to participate in abortion [See "South
African nurse denied position"] has been given leave to proceed against the
Health Department in the Labour Appeals Court. The Health Department claims that
conscientious objectors are forced to participate in abortion only in an
'emergency situation.'