Tag Archives: bioethics

Public Health and Respect for Personal Autonomy

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Applying ethical principles to the medical field has proven complex, as highlighted by James Childress in his writings on the complexities of adhering to respect for personal autonomy.[1] The philosophical discipline of bioethics is not narrowly tied to medicine, but expands to cover medical anthropology, medical sociology, health politics, health economics, research, public health policy, and more.[2] Public health aims at improving the health of the community as a whole, and public health initiatives usually involve preventative measures that prolong life and promote health. Generally, public health policy concerns itself with health based on population-level health analysis.  Thus, how do ethical principles change when the policy is focused on net benefit for the community, instead of focusing on individual community members?

Concentration on the group needs and health leads to thinking that often forgets about individual rights, but ethical principles of the individual need to be remembered when applying public health policies. Historically, individual rights are becoming increasingly recognized, and in the medical field, consent is a twentieth-century phenomenon.[3] As medicine increasingly recognizes individual rights, it is a logical extension for public health as a discipline to acknowledge analogous rights.

In bioethics, consent is rooted in the ethical principle of respect for personal autonomy, but this principle is complex and limited in application. Childress in “The Place of Autonomy in Bioethics” presents the scope of applicability of the principle of autonomy in medicine. He argues that first and foremost respect for autonomy of persons differs from people who are not autonomous such as children (unspecified age range) and the insane. Also, respect for autonomy must coincide with other necessary ethical principles such as beneficence and care, and in certain circumstances, ethical principles can outweigh or override one another. Thus, under certain circumstances the principle of respect for personal autonomy may be infringed upon, and specifically, the realm of public health needs to consider if policies made for the benefit of the group reasonably infringe upon the personal autonomy of group members.

The political cartoon depicts the modern-day anti-vacccination “epidemic.” This so-called epidemic is happening parallel to increasing focus on individual rights. Our generation will have to consider how much public health can infringe upon personal autonomy of our society’s citizens. (Source: http://theweek.com/cartoons/index/228275/the-anti-vaccine-epidemic)

This past September, 750 students in Winston-Salem, NC faced suspension after not adhering to state vaccination policies for the Tdap vaccination that protects against tetanus, diphtheria and whooping cough or pertussis.[4] Cases of mandatory vaccinations represent paternalistic interventions where interference with an individual’s liberty may be justified by reasons such as welfare, happiness, values, interests, and needs of the person being coerced. Mandatory vaccination initiatives are public heath measures that override rights of respect for personal autonomy for the sake of containing and preventing infection and disease. In context to this case, paternalism functions off the principle of beneficence. Mandatory vaccinations highlight the conflicts between moral principles, and under these circumstances, I think beneficence overrides each group member’s autonomy. While privacy and confidentiality can still be protected, controlling the spread of disease and preventing illness in community members is a moral call to action for vaccination. While it may be easier to fully respect the autonomy of an individual patient than an entire population, public health policy still should not deprive individuals of their rights without thoughtful consideration. Following Childress’s logic, are all group members considered equally autonomous thus infringement upon personal autonomy is the same? Or, based on group status does infringement on personal autonomy have different implications? In modern times, awareness of personal rights is increasing within bounds; therefore, it is important for public health to grasp and debate these ethical concerns. A new interpretation could view mandatory consent as a prior consent based on group membership, and thus interference is the price of group membership.[5]  Such a viewpoint believes that the individual’s interests are still considered, but an individual is accepting his or her role as a group member. Future public health policies could work to understand the line between respect for personal autonomy and social responsibility, and from there, public health can define its realm of action and control.

Sources:

[1] Childress, J. F. “The Place of Autonomy in Bioethics”

[2] Benatar, D. Bioethics and health and human rights: a critical view. Journal of Medical Ethics. 2006 January; 32(1): 17-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563274/

[3] Veatch, R. M. “Abandoning Informed Consent”

[4] http://www.journalnow.com/news/local/article_b770c0ca-2484-11e3-93a9-001a4bcf6878.html

[5] Hall, Spencer. Should public health respect autonomy? Journal of Medical Ethics. 1992. 18: 197-201.

Why is (Respect of) Autonomy Important?: Possible Cultural Preconceptions Surrounding the Argument for Autonomy

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When discussing biomedical ethics, we frequently favor the right of the patient to decide. This emphasis and respect for autonomy can overrule any number of other considerations. Therefore, I ask the following: Why is (respect of) autonomy important? A typical answer, and likely my own response, would include the importance of the individual’s right to make his/her own decisions. It is an exceedingly important component of any medical decision, and not to be taken lightly. The individual has final say because the body/mind in question is their own.

While reading J. F. Childress’ article “The Place of Autonomy in Bioethics”, I was struck by the potentially confounding factor of socioculturally different views on the importance of autonomy. As a product of American society, I have been raised to believe that the rights and privileges of the individual are paramount. Our culture and, indeed, most of Western thought, is centered on the idea that individuality (and the individual’s conception of that individuality) is to be encouraged. Given the dominance of Western thought in philosophical inquiry, particularly bioethical inquiry, it makes sense that a discussion of bioethics would take into consideration autonomy, the right of the individual to make his/her own decisions.

Free will is another Western presupposition that comes into play when discussing autonomy, the idea that we are the deciders of our own outcomes. Though I do not seek to undermine either of these ideas (free will and the importance of individuality), I think it is important to acknowledge and address the ways in which these ideas shape our dialogue. The reasoning behind the emphasis placed on autonomy is founded in the belief of both free will and individual importance. Should a society, religion, culture, etc. manifest a rejection of either of these principles, autonomy would, in that community, cease to be a worthwhile focus in bioethical conversation.

At the risk of bastardizing, oversimplifying, and/or misrepresenting my argument, I will lay out a general description of what I mean: If we reject the philosophical idea of free will, then our autonomous decisions (whether medical or not) become unimportant – free will is founded in self-determination and without it, predetermination negates the significance of choice. If we reject the sociocultural weight with which we measure individuality, if we cease to believe that the rights of the individual outweigh other considerations, then the value of the individual’s decision is called into question: if the individual is insignificant, why does their opinion and consequent decision matter?

Given that there exist many communities in the world in which one (or both) of these ideas is rejected, I believe reflection on the preconceived significance of free will and individuality under which we discuss autonomy is important to fully understand why our particular society and culture holds autonomy to be important. This type of reflection allows us to transcend our preconceived notions and the potential dangers that arise from not understanding or acknowledging our accepted cultural and philosophical biases.

In short, though I personally believe that a patient’s right to autonomy is exceedingly important, I must acknowledge that a) others- particularly those whose opinions have been shaped by different worldviews – may very well disagree with that opinion,  and b) my reasoning behind that opinion is founded in my own sociocultural and philosophical views on free will and the value of the individual.

Word count: 557

Works Cited:

Childress, James F. “The Place of Autonomy in Bioethics.” Arguing About Bioethics. By Stephen Holland. Hoboken: Taylor and Francis, 2013. Loc 8698-897. Kindle.

The role of equal access in genetic enhancement: A contradiction.

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In “The Case Against Perfection: What’s Wrong with Designer Children, Bionic Athletes, and Genetic Engineering”, Michael J. Sandel asks us as readers to consider the inherently present repercussions of allowing genetic enhancement to run rampant in our society. While many of his arguments and counterarguments are sound, I found there to be a glaring inconsistency that arose in Sandel’s contemplation of the relevancy of social structure and class in genetic enhancement.

In his section on memory enhancement, Sandel brings up the point that many people worry about the danger of cognitive enhancement leading to two different classes of human beings: those with access to these enhancements, and those without. He even goes so far as to posit that this unfair distribution might, if the cognitive enhancement were to become evolutionary, lead to the division of humanity into two subspecies – enhanced versus natural. This argument is quite an interesting one, as it asks us to picture a futuristic world far removed from our own. Sandel asks “is the scenario troubling because the unenhanced poor would be denied the benefits of bioengineering, or because the enhanced affluent would somehow be dehumanized?” (Holland loc. 2999). He illegitimizes this as a core argument for the immorality of genetic engineering by saying that “the fundamental question is not how to ensure equal access to enhancement but whether we should aspire to it in the first place.” (Holland loc. 2999).

Later in the essay, in his argument on our societal meritocracy, Sandel argues that genetic enhancement would ruin our perception of giftedness as just that – a gift that we are fortunate to have, and would instead encourage the mindset that our new genetically-enhanced abilities are entirely our own, leading us to feel no sense of gratitude for our abilities or sympathy toward those people without our abilities. The contradiction upon which this post is centered stems from Sandel’s claim here that “A lively sense of the contingency of our gifts – a consciousness that none of us is wholly responsible for his or her success – saves a meritocratic society from sliding into the smug assumption that the rich are rich because they are more deserving than the poor.” (Holland loc. 3241). The rather obvious implication here is that genetic engineering would lead to a stratification of society based on the “haves” and the “have-nots”. This dualist idea of “the rich and the poor”, those who can afford genetic enhancement and those who cannot, is strikingly similar to the argument he presented earlier and promptly dismissed.

While both of these arguments speak to the importance of class consideration in the development of an educated opinion about the ethicality of genetic enhancement, I am troubled by Sandel’s dismissal of the first point while taking seriously the second, as the two are very closely related: he uses the same foundation of argument, that genetic enhancement polarizes social structure, to make each point. Why is there a discrepancy in his consideration of these two points? He struck the first point from his core argument because the question on which he was focusing was not “how to ensure equal access” (loc. 2999), but in the second point, which is mentioned near the very end of the article, he points to inequality of access as a serious ethical consideration. It seems to me that, for the sake of consistency, Sandel needs to reconsider his view on the importance of ensuring equal access to genetic enhancement. Is provision of equal access a part of the fundamental question of the morality of genetic enhancement?

 

Sandel, Michael J. “The Case Against Perfection: What’s Wrong with Designer Children, Bionic Athletes, and Genetic Engineering.” Arguing About Bioethics. Ed. Stephen Holland. London: Routledge, 2012. Loc. 2935-3263. Kindle Edition.

Cloning: hard cases can make bad laws

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The reality of cloning is now a global phenomenon, and as technologies improve the possibility of human cloning becomes more plausible. The use of cloning to manufacture, as mentioned by both Leon Kass and David Elliot in Arguing about Bioethics, exists in the realm of animal technologies, and eerily, China is now cloning pigs on an “industrial scale” (www.bbc.co.uk/news/). The photo below depicts the mass production of pigs that is now possible due to genetic cloning. Therefore, there is only a short time until human cloning is efficient and safe enough to enter the market place. Interestingly within the United States, individual states take different stances on cloning, and cloning boundaries are blurred across the nation. (www.ncsl.org, bdfund.org ). As technological advances further blur lines, there needs to be conversation on the moral boundaries of cloning as a form of “assisted reproduction,” and critical engagement is necessary to translate moral standards into public policy that will govern scientific procedures.

(http://www.cntvna.com/Culture/2014-01/23/cms131796article.shtml)
(http://www.cntvna.com/Culture/2014-01/23/cms131796article.shtml)

Cloning takes the discussion of human experimentation another step further, and challenges the ethical line of human subject experiments. The first cases of cloning would be all encompassing biological, genetic, social, and procreation experiments. Science has already taken baby steps towards further human experimentation such as cloning through techniques like prenatal genetic screening and parental genetics testing. This brings up debates about selection, the power of positive selection, and what can be categorized as too much selection (Holland 153) David Elliot in “Uniqueness, Individuality, and Human Cloning” presents a weak objection to the manufacturing argument, and instead he argues, “It can simply be a choice to have a child of one’s own in the only way possible” (Holland 153). Elliot’s counterargument against the manufacturing objection highlights defendable and seemingly reasonable motivations for cloning, such as infertility or genetic diseases, and he overlooks unreasonable motivations for positive selection, such as for control over sex, intelligence, or beauty. This reasoning treads a dangerous path, and the President’s Council on Bioethics warns “hard cases can make bad laws” (bioethics.georgetown.edu). Therefore, it is essential to look beyond the logical and sensible cases that seem to necessitate cloning, to cases of inappropriate and dangerous motivations. Difficult life circumstances relating to fertility can blind a society, or an individual, of the moral implications of bringing new life into this world (bioethics.georgetown.edu).

Thus, evaluation of cases of cloning will involve prudence. There are recognizable and defendable motivations to clone in order to produce a child, but no one can articulate how much control and design selection amounts to a product, rather than a child. Tough cases can make bad laws, and it will be a societal test for how justifications like those presented by Elliot will affect public policy and laws.

Joyelle Flemming in her previous blog post brings up interesting considerations about the repercussions of cloning on the future. While in time our generation or future generations may come at accept cloning as a form of reproductive assistance, how will this impact future generations and the relationship of science and society? Cloning conversations must address the implications on the future and how man-made selection through cloning will effect the development of the human species as well as the world. While there is no perfected cloning technique to date, considerations of the morality of cloning should address cloning in context to the present as well as projected techniques.

 

Sources:

Elliot, David. “Uniqueness, individuality, and human cloning.” Arguing about Bioethics. London: Routledge, 2012. Print.

“Human Cloning Laws.” Human Cloning Laws. National Conference of State Legislatures, Jan. 2008. <http://www.ncsl.org/research/health/human-cloning-laws.aspx>.

“Human Cloning and Human Dignity: An Ethical Inquiry — Full Report.” PCBE: Human Cloning and Human Dignity: An Ethical Inquiry — Full Report. The Presidents Council on Bioethics, July 2002. Web. <http://bioethics.georgetown.edu/pcbe/reports/cloningreport/children.html>.

Kass, Leon R. “Why We Should Ban the Cloning of Humans: The Wisdom of Repugnance.” Arguing about Bioethics. London: Routledge, 2012. Print.

Nikas, Nikolas T. “Human Cloning Laws: 50 State Survey.” Bioethics Defense Fund, 19 May 2011. Web. <http://bdfund.org/wordpress/wp-content/uploads/2012/07/CLONINGChart-BDF2011.docx.pdf>.

Shukman, David. “China Cloning on an ‘industrial Scale'” BBC News. BBC, 14 Jan. 2014. Web. 26 Jan. 2014. <http://www.bbc.co.uk/news/science-environment-25576718>.