Taking Sides: Clashing Views on Bioethical Issues

Unit 1 Medical Decision Making

Issue 1. Is Informed Consent Still Central to Medical Ethics?

YES:: Robert M. Arnold and Charles W. Lidz, from “Informed Consent:: Clinical Aspects of Consent in Health Care,” in Stephen G. Post, ed., Encyclopedia of Bioethics, vol. 3, 3rd ed. (Macmillan, 2003)

NO:: Onora O’Neill, from Autonomy and Trust in Bioethics (Cambridge University Press, 2002)

Physician Robert M. Arnold and professor of psychiatry and sociology Charles W. Lidz assert that informed consent in clinical care is an essential process that promotes good communication and patient autonomy despite the obstacles of implementation. Philosopher Onora O’Neill argues that the most evident change in medical practice in recent decades may be a loss of trust in physicians rather than any growth of patient autonomy. Informed consent in practice, she says, often amounts simply to a right to choose or refuse treatments, not a deeper and more meaningful expression of self-mastery.

YES:: Leslie J. Blackhall, Gelya Frank, Sheila Murphy, and Vicki Michel, from “Bioethics in a Different Tongue:: The Case of Truth-Telling,” Journal of Urban Health (March 2001)

NO:: Mark Kuczewski and Patrick J. McCruden, from “Informed Consent:: Does It Take a Village? The Problem of Culture and Truth Telling,” Cambridge Quarterly of Healthcare Ethics (2001)

Leslie J. Blackhall, Gelya Frank, and Sheila Murphy, from the University of Southern California, and Vicki Michel, from the Loyola Law School, advise clinical and bioethics professionals facing truth-telling dilemmas to make room for the diverse ethical views of the populations they serve. Philosopher Mark Kuczewski and bioethicist Patrick J. McCruden argue that by insisting on informed consent or an appropriate waiver process, the health care system respects cultural differences rather than stereotyping them.

YES:: Paul Antony, from “Testimony before the Senate Special Committee on Aging, United States Senate” (September 29, 2005)

NO:: David A. Kessler and Douglas A. Levy, from “Direct-to-Consumer Advertising:: Is It Too Late to Manage the Risks?” Annals of Family Medicine ( January/February 2007)

Paul Antony, Chief Medical Officer of Pharmaceutical Research and Manufacturers of America (PhRMA), asserts that direct-to-consumer advertising can be a powerful tool in educating millions of people and improving their health through better communication with physicians, better adherence to medication regimens, and more active involvement in their own health care. Physicians David A. Kessler and Douglas A. Levy contend that as a result of direct-to-consumer advertising, consumers ultimately take medicines they may not need, spend money on brand medicines that may be no better than alternatives, or avoid healthy behaviors.

Unit 2 End-of-Life Dilemmas

Issue 4. Have Advanced Directives Failed?

YES:: Henry S. Perkins, from “Controlling Death:: The False Promise of Advance Directives,” Annals of Internal Medicine (vol. 147, 2007)

NO:: Elmer D. Abbo and Angelo E. Volandes, from “A Forced Choice:: The Value of Requiring Advance Directives,” The Journal of Clinical Ethics (Summer 2008)

Physician Henry S. Perkins believes that advance directives promise patients a say in their future care but actually have had little effect because they are based on an unrealistic assumption of more control in unforeseeable crises. Physician and attorney Elmer D. Abbo and physician Angelo E. Volandes acknowledge the criticisms of advance directives as they have been used but argue that the solution lies in requiring them, not abandoning them.

YES:: Robert W. Donnell, from “A Bright Line,” Medscape (October 3, 2006)

NO:: Mary Faith Marshall, from “Oh, the Water . . . It Stoned Me to My Soul,” University of Minnesota Bioethics Examiner (Summer 2006)

Physician Robert W. Donnell believes that the medical profession must apply moral absolutes in matters of life and death, no matter what the conditions, and one of those absolutes is never to administer fatal doses of medication. Philosopher Mary Faith Marshall argues for compassion, not absolutism, when tragic choices have to be made.

YES:: Marcia Angell, from “The Supreme Court and Physician-Assisted Suicide—The Ultimate Right,” The New England Journal of Medicine ( January 2, 1997)

NO:: Kathleen M. Foley, from “Competent Care for the Dying Instead of Physician-Assisted Suicide,” The New England Journal of Medicine ( January 2, 1997)

Physician Marcia Angell asserts that a physician’s main duties are to respect patient autonomy and to relieve suffering, even if that sometimes means assisting in a patient’s death. Physician Kathleen M. Foley counters that if physician-assisted suicide becomes legal, it will begin to substitute for interventions that otherwise might enhance the quality of life for dying patients.

YES:: Steven H. Miles, from ““Informed Demand for ‘Non-Beneficial’ Medical Treatment,” The New England Journal of Medicine (August 15, 1991)

NO:: Felicia Ackerman, from “The Significance of a Wish,” Hastings Center Report ( July–August 1991)

Physician Steven H. Miles maintains that physicians’ duty to follow patients’ wishes ends when the requests are inconsistent with what medical care can reasonably be expected to achieve, when they violate community standards of care, and when they consume an unfair share of collective resources. Philosopher Felicia Ackerman contends that it is ethically inappropriate for physicians to decide what kind of life is worth prolonging and that decisions involving personal values should be made by the patient or family.

Unit 3 Choices in Reproduction

Issue 8. Is Abortion Immoral?

YES:: Patrick Lee and Robert P. George, from “The Wrong of Abortion,” in Andrew Cohen and Christopher Heath Wellman, eds., Contemporary Debates in Applied Ethics (Blackwell, 2005)

NO:: Margaret Olivia Little, from “The Morality of Abortion,” in Bonnie Steinbock, John D. Arras, and Alex John London, eds., Ethical Issues in Modern Medicine (McGraw-Hill, 2003)

Philosopher Patrick Lee and professor of jurisprudence Robert P. George assert that human embryos and fetuses are complete (though immature) human beings and that intentional abortion is unjust and objectively immoral. Philosopher Margaret Olivia Little believes that the moral status of the fetus is only one aspect of the morality of abortion. She points to gestation as an intimacy, motherhood as a relationship, and creation as a process to advance a more nuanced approach.

YES:: Jean Toal, from Majority Opinion, Cornelia Whitner, Respondent, v. State of South Carolina, Petitioner ( July 15, 1997)

NO:: Lynn M. Paltrow, from “Punishment and Prejudice:: Judging Drug-Using Pregnant Women,” in Julia E. Hanigsberg and Sara Ruddick, eds., Mother Troubles:: Rethinking Contemporary Maternal Dilemmas (Beacon Press, 1999)

Jean Toal states the Majority Opinion in a case involving a pregnant woman’s use of crack cocaine, the Supreme Court of South Carolina ruled that a state legislature may impose additional criminal penalties on pregnant drug-using women without violating their constitutional right of privacy. Attorney Lynn M. Paltrow argues that treating drug-using pregnant women as criminals targets poor, African American women while ignoring other drug usage and fails to provide the resources to assist them in recovery.

Unit 4 Children, Adolescents, and Bioethics

Issue 10. Should Adolescents Be Allowed to Make Their Own Life-and-Death Decisions?

YES:: Robert F. Weir and Charles Peters, from “Affirming the Decisions Adolescents Make About Life and Death,” Hastings Center Report (November–December 1997)

NO:: Lainie Friedman Ross, from “Health Care Decisionmaking by Children:: Is It in Their Best Interest?” Hastings Center Report (November–December 1997)

Ethicist Robert F. Weir and pediatrician Charles Peters assert that adolescents with normal cognitive and developmental skills have the capacity to make decisions about their own health care. Advance directives, if used appropriately, can give older pediatric patients a voice in their care. Pediatrician Lainie Friedman Ross counters that parents should be responsible for making their child’s health care decisions. Children need to develop virtues, such as self-control, that will enhance their long-term, not just immediate, autonomy.

YES:: Sarah E. Shannon, from “In Support of the Ashley Treatment,” Pediatric Nursing (March/April 2007)

NO:: Teresa A. Savage, from “In Opposition of the Ashley Treatment,” Pediatric Nursing (March/April 2007)

Nurse Sarah E. Shannon believes that ethically and legally parents have the right and duty to make decisions and to care for their family members who are unable to do so themselves and that we should not abandon parents of severely developmentally disabled children to the harsh social and economic realities that are barriers to good care. Nurse Teresa A. Savage believes that children like Ashley should have independent advocates, preferably persons with disabilities, to weigh the risks and benefits of proposed interventions.

YES:: R. Alta Charo, from “Politics, Parents, and Prophylaxis—Mandating HPV Vaccination in the United States,” The New England Journal of Medicine (May 10, 2007)

NO:: Gail Javitt, Deena Berkowitz, and Lawrence O. Gostin, from “Assessing Mandatory HPV Vaccination:: Who Should Call the Shots?” Journal of Law, Medicine and Ethics (Summer 2008)

Law professor R. Alta Charo believes that objections to requiring that 11- to 23-year old girls be vaccinated with an FDA-approved vaccine for human papillomavirus focus not on public health but on concerns that recognizing the reality of teenage sexual activity implicitly endorses it. Law professors Gail Javitt and Lawrence O. Gostin and physician Deena Berkowitz believe that, given the limited data and experience, and the fact that HPV does not pose imminent and significant risk to others, mandating HPV vaccine is premature.

Unit 5 Genetics

Issue 13. Is Genetic Enhancement an Unacceptable Use of Technology?

YES:: Michael J. Sandel, from “The Case Against Perfection,” The Atlantic Monthly (April 2004)

NO:: Howard Trachtman, from “A Man Is a Man Is a Man,” The American Journal of Bioethics (May/June 2005)

Political philosopher Michael J. Sandel believes that using genetic technology to enhance performance, design children, and perfect human nature is a flawed attempt at human mastery, and banishes appreciation of life as a gift. Physician Howard Trachtman says that the medical community should embrace enhancement as a never-ending quest for health that recognizes that perfection can never be achieved.

YES:: Henry T. Greely, Mildred K. Cho, Linda F. Hogle, and Debra M. Satz, from “Thinking about the Human Neuron Mouse,” The American Journal of Bioethics (May 2007)

NO:: William P. Cheshire, Jr., from “The Moral Musings of a Murine Chimera,” The American Journal of Bioethics (May 2007)

A five-person working group at Stanford University, led by Henry T. Greely, a law professor, believe that in some situations and with safeguards it is ethical to proceed with experiments that implant human brain cells in mice. Physician William P. Cheshire, Jr., argues that good intentions can lead to mixed consequences, and that on balance the creation of mice with human brain cells might alter society’s assumptions about human cognition and the special status of human nature.

Unit 6 Human Experimentation

Issue 15. Should Prisoners Be Allowed to Participate in Research?

YES:: Institute of Medicine Committee on Ethical Considerations for Revisions to DHHS Regulations for Protection of Prisoners Involved in Research, from Ethical Considerations for Research Involving Prisoners (June 2006)

NO:: Silja J.A. Talvi, from “End Medical Experimentation on Prisoners Now,” inthesetimes.com (September 26, 2006)

The Institute of Medicine Committee believes that the current protections for prisoners rely too much on their vulnerability as a category and should be revised to consider the potential risks and benefits of each study, thus allowing prisoners to participate in some kinds of research. Silja J. A. Talvi, an investigative journalist, believes that all prison research should end because prison medical care is so poor and there is such a high potential for abuse.

YES:: Editorial Board, USA Today, from “Our View on Experimental Medicines:: If All Else Fails, Let the Dying Try Unapproved Drugs,” USA Today (August 21, 2007)

NO:: George J. Annas, from “Cancer and the Constitution—Choice at Life’s End,” The New England Journal of Medicine ( July 26, 2007)

The Editorial Board of USA Today believes that dying people should have the right to take drugs that are still in the approval process if conventional medicines have failed to help them. Law professor George J. Annas argues that there is no Constitutional right to demand experimental interventions, and that fully open access would undermine the FDA’s ability to protect the public from unsafe drugs.

Unit 7 Bioethics and Public Policy

Issue 17. Does Military Necessity Override Medical Ethics?

YES:: Michael L. Gross, from “Bioethics and Armed Conflict:: Mapping the Moral Dimensions of Medicine and War,” Hastings Center Report (November/December 2004)

NO:: M. Gregg Bloche and Jonathan H. Marks, from “When Doctors Go to War,” The New England Journal of Medicine ( January 6, 2005)

Political scientist Michael L. Gross argues that war brings military and medical values into conflict, and that military necessity often overwhelms a physician’s other moral obligations, such as relieving suffering. M. Gregg Bloche, a physician and lawyer, and Jonathan H. Marks, a British barrister, stress that physicians remain physicians even in the military and that there is an urgent moral challenge in managing the conflict, not denying it.

YES:: Thomas H. Murray, from “Doping in Sport:: Challenges for Medicine, Science and Ethics,” Journal of Internal Medicine, vol. 264, 95–98 (2008)

NO:: Julian Savulescu, Bennett Foddy, and Megan Clayton, from “Why We Should Allow Performance Enhancing Drugs in Sport,” British Journal of Sports Medicine (December 2004)

Social psychologist Thomas H. Murray contends that performance-enhancing drugs affect the individual athlete’s integrity because using banned substances is a dishonest behavior and corrupts a victory. Philosopher Julian Savulescu and research colleagues Bennett Foddy and Megan Clayton argue that legalizing drugs in sport may be fairer and safer than banning them.

YES:: Robert D. Truog and Franklin G. Miller, from “The Dead Donor Rule and Organ Transplantation,” The New England Journal of Medicine (August 14, 2008)

NO:: Robert M. Veatch, from “Donating Hearts after Cardiac Death:: Reversing the Irreversible,” The New England Journal of Medicine (August 14, 2008)

Physician Robert D. Truog and ethicist Franklin G. Miller argue that the “dead donor rule”—the principle that donors must be declared dead by neurological standards—should be replaced by a practice that allows organ removal from dying patients whose hearts have stopped but who are not yet brain-dead. Philosopher Robert D. Veatch believes that there are practical difficulties in declaring a person’s cardiac function “irreversible” and suggests instead amending the definition of death to refer to the loss of higher-brain functions that are responsible for consciousness.

YES:: Donald W. Herbe, from “The Right to Refuse:: A Call for Adequate Protection of a Pharmacist’s Right to Refuse Facilitation of Abortion and Emergency Contraception,” Journal of Law and Health (2002/2003)

NO:: Julie Cantor and Ken Baum, from “The Limits of Conscientious Objection—May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?” The New England Journal of Medicine (November 4, 2004)

Law student Donald W. Herbe asserts that pharmacists’ moral beliefs concerning abortion and emergency contraception are genuinely fundamental and deserve respect. He proposes that professional pharmaceutical organizations lead the way to recognizing a true right of conscience, which would eventually result in universal legislation protecting against all potential ramifications of choosing conscience. Julie Cantor, a lawyer, and Ken Baum, a physician and lawyer, reject an absolute right to object, as well as no right to object, to these prescriptions but assert that pharmacists who cannot or will not dispense a drug have a professional obligation to meet the needs of their customers by referring them elsewhere.

YES:: Lawrence O. Gostin, from “Law and Ethics in a Public Health Emergency,” Hastings Center Report (March–April 2002)

NO:: George J. Annas, from “Bioterrorism, Public Health, and Human Rights,” Health Affairs (November/December 2002)

Law and public health professor Lawrence O. Gostin states that the threat of bioterrorism makes it imperative to reframe the balance between individual interests and society’s need to protect itself so that the common good prevails. Law professor George J. Annas contends that taking human rights seriously is our best defense against terrorism and fosters public health on both a federal and global scale.