Taking Sides: Clashing Views on Bioethical Issues, Expanded

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.

YES: Angela Fagerlin and Carl E. Schneider, from “Enough: The Failure of the Living Will,” Hastings Center Report (March–April 2004)

NO: Susan E. Hickman, Bernard J. Hammes, Alvin H. Moss, and Susan W. Tolle, from “Hope for the Future: Achieving the Original Intent of Advance Directives,” Hastings Center Report (November–December 2005)

Psychologist Angela Fagerlin and law professor Carl E. Schneider believe not only that living wills have failed to live up to their advocates’ expectations but also that these expectations were unrealistic from the start. Susan E. Hickman, Bernard J. Hammes, Alvin H. Moss, and Susan W. Tolle, multidisciplinary specialists in end-of-life care, recognize the limitations of traditional advance directives but argue that newer processes of introducing advance directives can achieve their original aims.

YES: American Medical Association, from “Sedation to Unconsciousness in End-of-Life Care,” Report of the Council on Ethical and Judicial Affairs (June 2008)

NO: Margaret P. Battin, from “Terminal Sedation: Pulling the Sheet Over Our Eyes,” Hastings Center Report (September–October 2008)

The American Medical Association affirms that in cases of extreme suffering the physician’s duty to relieve pain and suffering includes palliative sedation—using drugs that result in unconsciousness and may hasten death. Philosopher Margaret P. Battin believes that palliative or terminal sedation is an unsatisfying compromise that offers no greater protection against abuse than do institutional safeguards established for direct physician aid in dying.

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: 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.

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: Joseph E. Balog, from “The Moral Justification for a Compulsory Human Papillomavirus Vaccination Program,” American Journal of Public Health (April 2009)

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

Health science professor Joseph E. Balog believes that a principle-based approach to moral reasoning leads to the conclusion that compulsory HPV vaccinations for teenage girls can be justified on moral, scientific, and public health grounds. 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.

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: Gregory E. Kaebnick, from Prepared Statement before the U.S. House of Representatives Committee on Energy and Commerce (May 27, 2010)

NO: Christopher J. Preston, from “Synthetic Biology: Drawing a Line in Darwin’s Sand,” Environmental Values (February 2008)

Philosopher Gregory E. Kaebnick believes that the potential societal benefits of the new technology of synthetic biology are too great to delay its use. Christopher J. Preston, an environmental ethicist, warns that synthetic biology is a threat to the concept of “natural” that has guided moral thinking about the environment in North America.

YES: Emil J. Freireich, from “Should Terminally Ill Patients Have the Right to Take Drugs that Pass Phase I Testing?” British Medical Journal (September 8, 2007)

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

Physician Emil J. Freireich believes that patients with advanced cancer and limited life expectancy should have the same privilege as all individuals in a free society. 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.

YES: Neal Dickert and Jeremy Sugarman, from “Ethical Goals of Community Consultation in Research,” American Journal of Public Health (July 2005)

NO: Eric T. Juengst, from “Community Engagement in Genetic Research: The ‘Slow Code’ of Research Ethics?” in Bartha M. Knoppers, ed., Populations and Genetics: Legal and Socio-Ethical Perspectives (Koninklijke N.V., 2003)

Neal Dickert and Jeremy Sugarman, physicians and ethicists, propose ethical goals for evaluating community consultation in research, which they believe will protect communities as well as individuals from harm. Philosopher Eric T. Juengst asserts that community consultation can provide researchers with cultural insights and assist in recruiting participants but not offer protection for communities.

YES: Sara Rosenbaum and Jonathan Gruber, from “Buying Health Care, the Individual Mandate, and the Constitution,” The New England Journal of Medicine (July 29, 2010)

NO: Glen Whitman, from “Hazards of the Individual Health Care Mandate,” Cato Policy Report (September/October 2007)

Law professor Sara Rosenbaum and economist Jonathan Gruber contend that the provision of the health reform legislation requiring individuals who are not covered by an employer health plan to pay a penalty if they do not buy health insurance is constitutional and the only way that access to health care can be assured for all. Economics professor Glen Whitman argues that the individual tax mandate is based on false assumptions about the level of uncompensated care and is likely to drive up costs rather than result in savings.

YES: Sally Satel, from “Kidney for Sale: Let’s Legally Reward the Donor,” Globe and Mail (March 10, 2010)

NO: The Institute of Medicine Committee on Increasing Rates of Organ Donation, from Organ Donation: Opportunities for Action (2006)

Psychiatrist Sally Satel contends that a regulated and legal system of rewarding organ donors will not only save lives but also stop the illegal trafficking that offers no protections for poor people around the world. The Institute of Medicine Committee argues that a free market in organs is problematic because in live organ donation both buyers and sellers may not have complete or accurate information, and selling organs of dead people raises concerns about commodification of human bodies.

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 “Making Sense of Fairness in Sports,” Hastings Center Report (March–April 2010)

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 the ban on performance-enhancing drugs should continue because it furthers the true meaning of sports—which is to compare athletes on their natural talent and abilities. 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: 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: Alzheimer’s Association, from “Alzheimer’s Association Statement Regarding Biomarkers,” August 11, 2010.

NO: Kenneth Covinsky, M.D., from “Caution on Diagnosing Preclinical Alzheimer’s Disease,” Hastings Center Bioethics Forum (July 15, 2011)

The Alzheimer’s Association, a voluntary health organization devoted to care, support, and research on the disease, believes that the identification of biomarkers is a positive step toward being able to intervene before clinical symptoms appear, allowing more time for planning. Geriatrician Kenneth Covinsky asserts that it may never be appropriate to recommend widespread use of the label of preclinical disease because of the challenge of distinguishing between risk for disease with the disease itself.

YES: Rajeev Raghavan, M.D., and Ricardo Nuila, M.D., from “Survivors—Dialysis, Immigration, and U.S. Law,” New England Journal of Medicine, June 9, 2011

NO: James Dwyer, Ph.D., from “When the Discharge Plan is Deportation: Hospitals, Immigrants, and Social Responsibility,” Bioethics, vol. 23, no.3, 2009.

Rajeev Raghavan and Ricardo Nuila, physicians who work with end-stage renal disease patients, argue that standardized coverage for dialysis treatments would alleviate the burden on taxpayers where the most undocumented residents live and would improve these patients’ health, allowing them to return to work. James Dwyer, a philosopher and bioethicist, looks at another response to treatments for immigrants—deporting them. While he opposes deportation, he asserts that placing the financial responsibility on individual hospitals or regions is unfair.