I’ve become more and more interested in the role of the medical humanities beyond medical ethics, and the implications that the conclusions drawn in the humanities may have for medical practice.  Perhaps the analyses the humanities provide can hold some normative force, particularly if these perspectives uncover valuable perspectives which would otherwise go unrecognized.

But who should be studying the medical humanities?  For humanities students, medical history, ethics, and even portraiture provide interesting and fruitful topics, but how much scope should be given for these ideas in the medical curriculum?  Perhaps tomorrow’s doctors could benefit from greater opportunities to explore these ideas, but unless they choose to do so in a separate course, how can space be made in the curriculum?

Sokol discusses the value of a greater knowledge of the history of medicine amongst medical students, and radically (for a medical ethics and law lecturer, at least) proposes making space in the core curriculum for history by dispensing with ethics, a hasty suggestion which requires further analysis.

How much time and space in the curriculum can be justified for non -clinical subjects is an important issue for medical educators, and I agree the history of medicine does have a contribution to make to make in terms of its potential impact on the development of a doctor as a person with an awareness of their place and relationship with the progress of the discipline as a whole.  This is an admirable goal, and could help to “foster a sense of perspective and continuity, and a spirit of reflective inquiry” (Sokol D BMJ 2007: 1186), and arguably improve practice too.  However, surely ethics is equally capable of developing these qualities, if not more so.  One joy of studying philosophy in general, and ethics in particular; I think, is the dialectic – or engagement with the ideas of the great thinkers of the past.

Sokol suggests that the lessons of ethics could be subsumed into the history class, but I am far more sceptical of this.  History should not and cannot replace ethics.  This is because how things have been done in the past is not sufficient guidance for future practice.  Medical ethics’ strength is its ability to deal with problems associated with novel technologies that a history lesson may not resolve.

Ethics is important for medical practice because it provides a toolkit to aid clinician’s decision making, providing analytical skills ideal for problem solving and developing the ability to consider and evaluate all relevant perspectives in a challenging situation.  It also provides a basis for support or questioning of the framework for medical practice provided by the law.

History shouldn’t replace ethics because it cannot match it in these significant respects.  Good Doctors will be able to evaluate and improve their practice by employing ethical concepts – whether this is the four principles, or considering what a virtuous doctor would do in the situation, for instance.  And this, indirectly, means better patient care.  Learning what doctors did in the past and why and how practice has developed over the centuries can be instructive, but for different reasons.

I propose a more suitable role for the history of medicine in undergraduate medical education.  The consideration of the history of medical ethics is much neglected, particularly with regard to certain periods in history such as the 18th Century.   The roles for history and ethics are not mutually exclusive, and together they could complement and reinforce one another successfully.  The history of medical ethics did not begin with the 1960′s Harvard Brain Death Committee, as it has been claimed (by Kuhse and Singer, no less).  Nor was there no consideration of medical ethics between Hippocrates et al in Ancient Greece and the resurgence of the area in the twentieth century.

Physicians and writers such as Thomas Percival and John Gregory in the 18th century, were doing medical ethics as we do it today (McCullough), and their contribution, and others like it, deserve greater recognition.  (I hope to contribute to that analysis in the near future).

A greater awareness of the history of medical ethics would be valuable for ethicists and medics alike, as it would help to inform our ideas about the question of where medical ethics is going next.

See:

D Sokol 2007: A perforated education BMJ 335: 1186 (08/12/07)

LB McCullough, and Baker, Porter and Porter on 18th Century Medical Ethics.

http://humanitiesandhealth.wordpress.com/

The  law on abortion has hit the headlines again.  Later this month, the Chair of BPAS (the British Pregnancy Advisory Service) is challenging the Department of Health over the location where an early medical abortion can legally take place.

This is because the law on Abortion is now vastly outdated.  When the original Act was passed (in 1967), a clause was needed to restrict the place where an abortion could take place, as a safeguard (Abortion Act 1967 1.3/3(1)a) because later, surgical abortions were more common.  Now medical technology has improved and earlier, medical abortions can occur safely in or out of a hospital or clinic context.

Contrary to popular belief, abortion is still technically illegal in the UK, except in circumstances where particular grounds can be met.  Women in the UK still do not legally have the ‘right to choose’ , although this is something that many campaigners would like to see change.  The limit on the place where an abortion may occur now forms a restriction to women’s choices without providing a significant safeguard.

Of course if the woman wishes to remain in a clinical context after taking the second part of the medication needed, she should be able to do so, and in some cases this may be appropriate, or indeed necessary (especially after later abortions).  But within the first 8 weeks or so, the opportunity to finish the process at home could provide women with a more private and comfortable experience, which I think should be facilitated wherever possible.

The Abortion Act is in need of revision in several respects; for instance the 24 week time limit for ground 1(1)(a) is frequently criticised in light of the changing threshold of foetal viability.  Access to abortion still relies upon two registered medical practitioners forming the belief, in good faith,  that one of the grounds has been met.  So it is the doctor’s judgement, rather than the woman’s choice, that is recognised in law and this seems contrary to the spirit of how it is enacted.  It would be more consistent to recognise how the law is really interpreted in practice, and this is why it should be changed.

If the change that BPAS is advocating goes through, the law will be more consistent with other countries around the world and would draw less of a distinction between abortion and miscarriage, and between abortion and other medical treatments, when such a distinction is unwarranted.  It is high time that the problem of how the law should be interpreted should be resolved.

The recognition that the place where an abortion occurs need not affect the reason for it, nor the quality of medical care and support that a woman receives, would be a small but significant shift towards a legal recognition of a woman’s right to choose, especially in the case of early medical abortion.  As the Department of Health itself recognises, where abortion is legally permitted, it should be as easily accessible as possible.  BPAS are acting as advocates for many women who would like to see this change to the law, and for this they should be praised.

Links:

• BPAS’ account of the challenge: http://www.abortionreview.org/index.php/site/article/905/
• http://blogs.independent.co.uk/2011/01/13/the-case-for-%E2%80%98home-abortions%E2%80%99/
• Ann Furedi on the BBC: http://www.bbc.co.uk/news/health-12173743

It has been argued, by the likes of Peter Singer, that the recognition given to the relevance of moral proximity is mistaken.  Because utilitarianism is morally impartial, it states that we must treat all sentient beings equally, and so it makes no moral difference whether a person affected by our action is a stranger on the other side of the world or our best friend.  But this makes acting morally difficult to the point of impracticality.  It makes morality very demanding, and although this may be correct, it requires further justification.  Not only that, but it fails to recognise how the partiality we feel for the people close to us could actually be morally praiseworthy.

For example, it is suggested that it is morally equivalent for a person who fails to send money to charity for famine relief to send a poison food parcel amongst the aid packages, because they are just as directly responsible for the deaths that result in either case.  This is one argument for the view that killing and letting die are morally equivalent.  And although it is correct that decisions we make can affect people that we never meet, who matter just as much morally as our friends, there are important and morally significant differences  which cause me to doubt this conclusion – such as over the certainty of the outcome, the identifiability of the victim and so on. From a naive perspective, the stranger just does not matter as much to us.  Is this something that morality should seek to capture or overcome?  Reciprocity may form another morally significant distinguishing feature of such situations.  If the person does not give to charity because they wish to buy a present for a friend instead, how is this act to be morally evaluated?  Both the donation or the gift would be acts of kindness, but can choosing to buy the gift be justified?  How could a stranger’s life be weighed against a friend’s happiness?  A utilitarian would have to attempt the task but it would be an extraordinarily difficult one for a moral agent to have to make in a real situation.

Reciprocity is an intriguing moral concept because of its ambiguity.  Firstly it seems that reciprocating the kindnesses of others would be a morally permissible, even praiseworthy thing to do.  And reciprocity requires a certain degree of proximity.  But perhaps this a morally immature view, because reciprocity is not sufficient for a moral action.  The motive or intention behind the action is also relevant, for instance.  Possibly reciprocal behaviour is not even necessary for a moral action, but it is sometimes relevant.

But if this is so, how can it be determined when the principle of reciprocity is relevant and when it isn’t, and when it can be a useful moral guide?

I wondered about the significance of this for the virtue of love, as one example, as identified by Comte-Sponville in his excellent Short Treatise on the Great Virtues (Vintage: 2003).  Some loving relationships are by their nature reciprocal, such as the parent-child relationship.  But it can never be a duty to love someone in return, nor would it be moral to do so if it wasn’t sincerely meant.  And reciprocation is not strictly necessary for love, because the strength and value of love is not lessened for it’s being unrequited.  Would reciprocity help us to discover how to love ‘excellently’?  There are some circumstances in which it will be morally significant, perhaps in the small, yet significant every day interactions with others in our life.  But virtues such as love morally surpass reciprocity; it is morally virtuous to be generous, kind, and loving to those we encounter without hope or expectation of the behaviour being returned.

The play follows a man’s journey as he comes to terms with his infertility and chooses whether to have a child via donor conception.    When he (Richard) meets a teenage girl (Kate), on a park bench, he is able to confide to her feelings that he cannot speak about with anyone else.  She helps him to realise what having a child via donor conception could be like and once he’s able to voice his fears, his concerns are confronted and allayed.  The relationship between the characters was mesmerising, and so vividly realised.  The story is witty and sensitively told; the actor’s performances were subtle, nuanced and thought provoking, and it was imaginatively staged, too.

The representation of issues like these in fiction is really valuable when it is done so well, and so clearly well informed by the real experiences of families formed by donor conception.  Unlike popular documentaries made on bioethical topics by several major broadcasters (which I intend to discuss in more detail in another post) the fictional portrayal of the dilemma from the perspective of the person making a real and life-changing decision about the use of a particular kind of A.R.T, and the possible consequences for all affected by it, presents a much more powerful human story than the poorly researched, scientifically simplistic and ethically scanty documentaries which seem to satisfy television broadcasters.

Perhaps this is because it allows the issues involved to be raised, whilst still allowing the audience to consider their own views and responses to the scenario, encouraging emotional engagement, and philosophical reflection, without excessive manipulation risked by a biased report of the facts.  The play reinforced my own views about the importance of parental honesty about children’s origins because of their need for genetic truth, but also made me reconsider my views on egg sharing (more on which later).  This is also why I think the inclusion of fictional philosophical works on this blog is justified, fine examples like this demonstrate superbly the value of fiction to good philosophy.

• The HFEA is currently undertaking research in preparation for a review of its policies about gamete donation, including compensation and how the shortage of donor gametes can be addressed.  If you have been affected by donor conception and would like to contribute to the consultation you can contact the Authority (see the link for details).
• The Donor Conception Network is a support group for families created by donor conception.

A C Grayling: Descartes

Matthew Stewart: The Courtier and the Heretic (about Leibniz and Spinoza)

Edmonds and Eidinow: Rousseau’s Dog and Wittgenstein’s Poker

Ray Monk: Wittgenstein

Amir D Aczel: Descartes’ Secret Notebook

Simon Critchley: The Book of Dead Philosophers

They are all excellent, and Critchley makes a special effort to include a more representative cross-section of the people who have contributed to the history of ideas, however the list of philosophers profiled in this selection does prompt the question ‘where are all the women?!’  I have been frequently frustrated by the omission of female philosophers from all periods of history from books about the history of ideas, and therefore the philosophical canon.  (Although there are some excellent books seeking to redress the balance such as the Rereading the Canon series).  I hope that this balance will be further resolved in future.

1. Marcus Aurelius: Meditations

2. Boethius: Consolations of Philosophy

3. The Correspondence Between Rene Descartes and Princess Elisabeth of Bohemia

4. Plato’s Republic

5. Sophie’s World: Jostein Gaarder

6. Descartes’ Meditations

7. Human Identity and Bioethics: DeGrazia.

8. Hipparchia’s Choice: Le Doeuff

9. After Virtue: MacIntyre

10. Reasons and Persons: Parfit

After http://www.guardian.co.uk/books/philosophy+series/toptens

There are some particularly important issues surrounding Reproductive Tourism, which includes patients travelling for services such as fertility treatment, abortion and surrogacy.  These areas are under-researched and there is not a great deal of data available about the motivations and experiences of those who seek treatments like these abroad.  However, a motivation specific to reproductive tourism is the shortage of egg donors in the UK.  In other countries where the law is different, donors are paid (they can only be compensated in the UK), and so more donor gametes are available.  There are many ethical issues surrounding the exploitation of donors, and coercion and possible lack of voluntariness in egg sharing practices.   Comparing the UK law with other countries allows an exploration of alternative policies which could provide an ethical response to these challenges.

European citizens are entitled to be treated in other jurisdictions, and people who travel for services that are unavailable in their home country do not break the letter of the law.  But they may in some circumstances, for example in travelling for social sex selection, break the spirit of the law (Veronica English, BMA¹).

Health tourism of this kind raises issues and challenges for the UK regulator, the HFEA.  Its remit does not extend to clinics outside of this country, but it can address the reasons that patients seek treatment abroad.  There is a real and urgent need to resolve the UK donor gamete shortage, shorten waiting lists and recommend fair prices for treatment.  Many of the problems here originate in inequity in access to fertility treatment, and in the payment and anonymity of donors.  The demand for treatments which are illegal or unavailable here should give us pause to reconsider their availability here.

When UK patients are treated abroad, there is a need to research the foreign system extensively, including the legal implications as well as the facilities of the particular clinic where they hope to be treated.  For instance, areas of significant legal variation include laws about the acquisition of parenthood and citizenship of babies born abroad as a result of surrogacy.  The UK regulator could serve as an appropriate forum for sources of such information and factors that potential tourist patients should consider.

However, reproductive tourism does not only concern IVF treatment in Europe.  An illuminating comparison can be drawn with the provision of abortion to Irish women in Great Britain².  In Ireland abortion is illegal and in light of the dangers of ‘backstreet abortions’, the state relies on travel to meet the demands of women seeking a termination of pregnancy.  The statutory response in Ireland has been to allow the provision of balanced information about the options for pregnant women seeking advice, and allow women to access termination services elsewhere, whilst retaining the formal prohibition.

This has been widely criticised as inconsistent, and unfair to the women who have to suffer the stress and delay associated with travelling for treatment.  However Ruth Fletcher provides a more hopeful interpretation: the support provided to women travelling for a termination at the points of exit and return (in the form of information beforehand and aftercare when necessary), has contributed to the political demand for reform to resolve the inconsistency.  Therefore access to treatment abroad may act as a catalyst for change.

¹HFEA ELAC Ethics and Law Horizon Scanning Seminar 24/02/10.

² Fletcher R 2010 ‘Abortion Tourism: Governing Reproduction in Transnational Times‘ Lent Lecture KCL 25/02/10.

Links

http://www.transrep.co.uk/index.php

http://www.hfea.gov.uk/infertility-facts.html#1254

http://www.hfea.gov.uk/fertility-clinics-treatment-abroad.html

There are sixteen factors which suggest prosecution is in the public interest and six factors which suggest it is not.  This guidance was much needed and should offer some reassurance to legal professionals, those who wish to commit suicide but cannot do so without help, and their families.  Although the new policy does not guarantee immunity from prosecution if the factors are met, neither is it the case that a prosecution would automatically follow even if the law were broken, and a criminal offence committed.  Any prosecution would have to meet the criteria of evidence and public interest.  The law on suicide has been critiqued for its inconsistency since suicide itself was decriminalised in 1961.  Why should assisting a legal act be a crime?

The law as it stands intends to protect the vulnerable and Keir Starmer’s comments on the new policy suggest that a more successful balance may be achieved in future, as each case will considered on its own merits.  By focusing on the ‘motivation of the suspect rather than the characteristics of the victim’, a moral assessment provides part of the basis of the decision as to whether a prosecution would be in the public interest.  You can read the press release from the CPS here.

It is encouraging that there is now public recognition that it is not obligatory or praiseworthy to demonise and punish relatives of people who are seriously (or terminally) ill and desperate to end their lives with dignity and in a manner and means of their own choosing, but who cannot do so without help.  I want to highlight a couple of the factors mentioned in the new policy guidance and discuss how they might be interpreted.  One of the factors outlined against prosecution is that the suspect had a compassionate motive and was not motivated by personal gain.  This is a crucial recognition because we cannot evaluate actions without knowledge of motives.

It may still be difficult for ‘suspects’ to meet the conditions; especially in light of having to prove that they were not motivated by personal gain when they might incidentally, in fact stand to gain by the person’s death that they assist.  This might be relatively common where close relatives are involved.  But hopefully this factor can be interpreted so that victims do not have to exclude the person that assists them from their wills, for instance, because the focus is on motivation, as that would seem grossly unjust and a clumsy demand for proof of motivation.

Another problem may arise in the interpretation of the requirement that the victim had Mental Capacity (i.e. the decision making ability) to make an informed choice about suicide.  Because of the degenerative nature of many of the conditions that people who request assisted suicide have, this may be a problem.  By the time the request for assisted suicide is carried out, they may no longer have mental capacity.  The guidance is slightly ambiguous as to whether the Mental Capacity is required at the time of the decision, at the time of the suicide, or both.  Requiring mental capacity at the time of the decision is an important safeguard but I hope this does not discriminate against people with mentally, as opposed to physically, degenerative or damaging conditions.

There is still some way to go to the legalisation of voluntary active euthanasia, as this new policy does not change the law on euthanasia or assisted suicide.  It will be interesting to see how the factors are interpreted in practice; but I am hopeful because the policy of the CPS  is now clarified that will bring some reassurance to the people that need it most until such a time as the law is changed by Parliament.  It also ensures that prosecutors’ decisions about whether a prosecution is in the public interest will not be arbitrary, but instead consistent, and based upon all of the relevant factors in each particular case.

Links:

http://www.cps.gov.uk/publications/prosecution/assisted_suicide_policy.html

http://www.guardian.co.uk/society/2010/feb/02/terry-pratchett-assisted-suicide-tribunal

He suggests modern political events such as the MP’s expenses scandal show that acting virtuously is  just as important as following rules, or perhaps even more so, contrary to the suggestion of deontology.  Virtue Ethics provides a critique of rule based approaches to moral behaviour.

Longley describes the resurgence of Virtue Ethics but he is also right to highlight that it has ‘never really gone away’.  Virtue Ethics accords well with ordinary thought patterns.  Philosophers such as MacIntyre, Foot and Hursthouse have developed what the classical philosophers began, and have been very influential in the ‘comeback’ of Virtue Ethics.

As Longley indicates, we need the virtues.  Geach also said ‘men need the virtues as bees need stings’.  The classical virtues are wisdom, justice, courage and temperance.  And Longley describes that these virtues have practical applications in the modern world.  This is interesting and important and I intend to discuss this in more detail in future, but one application that Longley identifies is the relevance of the virtues to Cognitive Behavioural Therapy (CBT).   Virtue Ethics depends on the notion that there is an ideal, or desirable moral character and that it is attainable.

This has implications for the ‘will to believe’, as discussed by William James.  I’ve always been unconvinced by the idea that practising a certain way of behaviour will make it true for that person, so that they will acquire new beliefs that they didn’t have before.  For example, religious belief could perhaps be acquired by worshipping and praying until the person comes to believe it.  But I think it always requires a ‘leap of faith’, which someone that has (rational) reason not to believe in God will not make.  Perhaps religious belief is a special exception; because this idea seems far more plausible with a character trait like courage, as Longley suggests.  Longley indicates that Virtue Ethics depends on the idea that admirable character traits can be cultivated through practice in this way, and although I think this conception of Virtue Ethics is debatable, it may be a useful description and also presents the possibility of this kind of self-improvement in a new light.  Longley highlights some presuppositions of a Virtue approach, but I think these are not problematic. This also has other significant practical implications which I will discuss further in future, but the formation of a Good Character will be crucial to approaching practical dilemmas from a Virtue Ethics perspective.