Worst case bioethics

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21 – 24 August, 2012


Max Stern Yezreel Valley College, (YVC)
Nazareth, Israel


Organised by:

The European Society for Philosophy of Medicine and Healthcare

(ESPMH) and the Max Stern Yezreel Valley College, Nazareth, Israel


Identifying the worst case scenarios – how to conceptualize events outside of normal human experience in trauma victims following a disaster

Ahmad, Ayesha

The psychologically fragmented individual, suffered by the effects and consequences of a disaster, offers a particular challenge to the responding medical practitioner. How may such trauma be understood? For example, Norris et al (2002) reviewed literature on the psychosocial consequences of a (natural) disaster, concluding that over a third of studies described individuals who suffered from severe distress including diagnosable disorders.

First, an ontological distinction will be made between a trauma that occurs (in)ternal to an individual and a trauma that occurs (ex)ternal to the individual. Natural disasters are unlike other forms of trauma because the individual can suffer from the destruction of property, and the disintegration of their lifestyle and livelihood. However, in this paper, I refer to phenomenological aspects, which are apparent during a rupture of the land.

Second, the paper will lead on to discuss an individual’s psychological symptoms as part of a symbiotic relationship with their land; the Other. This allows for a re-framing of the individual’s situation as a transformative narrative rather than a pathology. In turn, the question is then begged about the applicability of a Post-Traumatic Stress Disorder diagnosis.

In the context of the ‘worst case/s of bioethics’, the examination here conforms to exploring the ethical implications of diagnosis. This is in contrast to many of the discussions that are similar in nature in the sense that they refer to the treatment of the individual in the emergency medical setting following a natural disaster. However, in the case of the traumatized individual, I argue that our first ethical consideration lays with the diagnosis,

rather than the treatment, of the individual. In order to develop this argument, this paper is strongly focused on the nature of an individual’s (psychological) distress – finally concluding that the focus on the individual’s rupture of experience will accommodate an ownership of their being-in-the-world (their territory) and an understanding of their altered narrative (their landscape) following the (named) disaster.
Are “Undue Inducements” a Problem for Benefit Sharing?

Arnason, Gardar

When medical research is conducted in resource-poor countries, the results are often primarily for the benefit of health care systems to which the research participants have little or no access. In such cases the research participants carry the burdens of participating in the research, while patients in developed countries enjoy the benefits. To correct this injustice, various benefit sharing frameworks have been proposed. One of the main problems for benefit sharing is how to avoid the problem of undue inducements. If people in resource-poor countries are offered significant payments or health care services which they would otherwise not have access to, the fear is that they might be “unduly induced” to participate in the research. One argument against benefit sharing is that offering any significant benefits to research participants will result in undue inducement, which is prohibited by most international research ethics guidelines. In this paper I discuss the meaning of “undue inducement” and in what ways inducement may be perceived to be ethically problematic. I argue that the problem of undue inducements is insignificant and should not be used as an argument against benefit sharing frameworks.

Hospital under Fire—Ethical Considerations

Bar-El, Yaron

In 2006, Rambam Medical Center (RMC), the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks. This extreme situation posed serious ethical dilemmas, which the hospital's leadership had to address. Immediately after the Second Lebanon War started on July 12, 2006, RMC was notified of an emergency condition and took the necessary measures to prepare for a mass casualty situation. Shortly after, when missiles began falling within close proximity of the hospital (approximately 60 missiles fell within half a mile of the hospital), it became obvious that the situation was completely different from previous mass casualty events because the hospital itself, patients, staff, and visitors were under constant serious threat.

Faced with an unprecedented situation, the hospital leadership made several major decisions that determined their actions throughout the war, as follows: The hospital’s first priority would be delivery of emergency surgical and medical services to the injured from the battlefields and home front. The RMC staff already had years of experience dealing with mass casualty situations, hence, this decision seemed natural and was received with no reservations.

All elective medical and surgical services to the civilian population would still be provided. Although over a third of the civilian population had left the bombarded areas and moved to safer areas of the country, those remaining still needed medical services. This need was intensified since the war situation led to closure of many ambulatory clinics, dental clinics, pharmacies, and peripheral dialysis services. For many days, patients could receive medical services and supplies only through hospitals. This decision required working fully staffed, every day, exposing employees to danger while in, or on the roads coming to or leaving the hospital. Some of the measures taken to reduce this threat included providing underground lodging for staff and their children, and providing shrapnel proof vehicles for transportation.

Danger to patients, staff and visitors, would be reduced as much as possible. Wards facing north, and the top three floors, were evacuated to unused underground spaces and corridors. Injured soldiers and civilians were transferred to other hospitals in safer areas as soon as their conditions allowed. Unfortunately, due to the shortage of shielded spaces, not all wards and patients could be relocated to safe areas. This situation led the RMC leadership to modify construction and renovation plans which were at an advanced stage; a much larger sheltered area was added and funds were allocated for that need. A new fortified Emergency Room has since been constructed and the new underground parking lot was re-planned to serve also as a fortified emergency underground 2,000-bed hospital.

Modern warfare will continue to involve civilian population and institutes. Hospitals must be prepared to function and deliver treatment while under fire and other threats. Many functional and ethical dilemmas arise in these situations, dilemmas that should be recognized, researched, and explored in advance.
Extreme side effects and emergencies: The principle of the double effect (PDE) meets human rights.

Barilan, Y. Michael

The principle of double effect has developed in Catholic moral theology and won acceptance in traditional medical ethics as an instrument for dealing with difficult moral dilemmas such. However, some key conceptual problems within the PDE have remained controversial. Two key questions are whether the PDE is applicable when the minor effect is inevitable, and whether it is applicable when the minor effect violates what we would refer today as |an extreme side effect" or a violation of a human right (e.g. the effect is a loss of life).

In this presentation I will recreate the PDE, incorporating in it contextualization as well as the requirements of informed consent, Michael Walzer's notion of "double intention". Reformulated thus I will examine the applicability of the PDE to dilemmas of severe side effects, military medicine and major public health initiatives. The presentation is based on a section from a new book, "Human dignity, human rights and responsibility: the new language of bioethics and bio-law" by MIT Press.

Non Battlefield Military Medical Ethics in Israel - the perspective of responsibility

Barnea, Rani

While battlefield emergency medicine has its own ethical issues and dilemmas (regarding soldiers of both sides of the conflicts and local population as well), the ethics of routine peacetime military medicine involves its own special set of problems.

In our research we studied military documents and conducted interviews with military physicians in order to reconstruct the moral ethos and values of Israel's medical corps.

Israel's armed forces and public medicine have evolved together during the mid 20th century with the construction of the Zionist national entity eventually becoming the sovereign state of Israel. This has embedded social and community values and morality in the professional ethos of the IDF's (Israeli army) medical corps. While non-obligatory professional western armies around the world define the medical corps' chief role in terms of preservation of combat power, the professed objectives of the Israeli medical corps are more complex. The IDF consider itself "the peoples' army", thus absorbing civil values and over-spilling military values to the civil society. The symbiosis between military and civil life in Israel (which has also been a target of much criticism) does not allow the full militarization of the military medical service.

The military system is characterized as a "total institution" that creates and protects the vulnerability of its soldiers at the same time. We suggest that the moral foundation of the connection between the army and its soldiers is constructed of two core moral principles - contractarianism (as in Rawlsian model) and responsibility. Our research and thesis strives to define the boundaries of military medical responsibility based on conflicting needs and interests characterizing military medicine.

Too severe to transmit to offspring? Reflections of mutation carriers on hereditary cancer and reproductive decision-making

Bateman, Simone; Dekeuwer, Catherine

Genetic testing used in conjunction with reproductive technology has considerably expanded the reproductive options open to persons susceptible of transmitting to their children a genetic mutation associated with a serious disorder. In the past, choice was restricted either to taking the risk of transmitting the familial disease to their offspring, or to not conceiving one’s own children and eventually adopting a child or, more recently, conceiving a child with donor gametes. Genetic testing can now be carried out on the fetus (prenatal diagnosis – PND) and even on the in vitro embryo (preimplantation genetics diagnosis – PGD). However, in case of a positive result, the only form of “prevention” is the termination of the pregnancy after PND and the discarding of affected embryos after PGD. Because these are morally and socially controversial solutions to the problem, many countries restrict access to PND and PGD to diseases considered as particularly serious, even though there may not always be agreement as to what or who defines a disorder as “severe”.

In the context of such debate, little attention has been given to the reproductive concerns, plans and choices of the carriers of a mutation themselves. What are their thoughts concerning the acceptability of taking the risk of transmitting a mutation to the next generation? What is their opinion concerning PND and PGD as reproductive options in such circumstances? These questions are all the more difficult to answer when the presence of a mutation is associated with an increased risk but not a certainty of developing a disease.

Drawing on the results of a study done in France that investigates the way in which carriers of a mutation associated with hereditary cancer reflect on their reproductive decisions, we would like to show how their thoughts on reproductive decision-making are modulated by their personal evaluation of the seriousness of the disease. Although carriers may refer to the medical criteria used in making such an evaluation, they do not necessarily endorse the idea that some diseases are objectively more serious than others. By comparing the responses of carriers of an early onset (retinoblastoma) and a late onset (hereditary breast and ovarian cancer) disease, we would like to show that the evaluation of the seriousness of any one disease may be variable among carriers, that the factors affecting this evaluation are related to the characteristics peculiar to each disease and their perceived impact on what carriers define as a normal family life. This will influence their decision to have or not to have children, including whether or not to take extraordinary measures to have them.
Cosmopolitain altruism - the Cyprus case

Beck, Stefan

Transnationally operating transplantation systems, international networks of biobanks and the altruism of donors afford a "culture of giving" that transcends national borders. Based on empirical data from an ethnographic study on practices of bone marrow transplantation in Cyprus it will be argued that we are currently witnessing an emergent cosmopolitan citizenship that implicitly or explicitly questions national biopolitical regimes.

On medicine in political conflicts: Bone marrow transplantation to Gaza children in Israel

Birenbaum-Carmeli, Daphna

Decades of occupation and political upheavals have left Gaza healthcare system unable to provide many common procedures including life-saving ones. Seriously ill Gazans are thus referred by the Palestinian Authority to treatments abroad, often to Israel. In this paper I look at Gaza children who undergo bone marrow transplantation in Israel. Due to financial limitations, the Palestinian Authority funds only transplantations from kin donors. The transplantation thus draws a line between Israeli children to whom the world donor repository is open, and Gaza children in similar medical conditions, who are confined to their family circles. This difference, which coincides with the confinement of Gaza patients and their attendants to the hospital premise and with their continuous stay in the hospital for month long treatments, due to movement restrictions, will provide the backdrop for some ethical questions on medical treatment in a foreign country that is greatly responsible for the patients’ very need to seek therapy abroad.
Ethical issues in providing healthcare during war, pandemics and disasters - The role of physicians in war preventive measures against terrorism: bioethical issues

Borgo, Melania; Picozzi, Mario

Today, the concepts of soldier and war are changed because of the terrorism and the war on terrorism. The enemy is no longer another defined State: now he is invisible, doesn’t follow the usual rules of armed conflict and, sometimes, he doesn’t wear a uniform so that it will be always more difficult to understand where he is and what he does. In the traditional warfare, the soldiers were not responsible for their actions and they knew that if they had killed an adversary they would not be prosecuted, except that if they had committed serious crimes against humanity. Now, instead, the other is unpredictable, he is able to do everything also against civilians; the soldiers are no longer afraid of suffering the same fate as their enemies because they know that the others don’t have sophisticated weapons and a big numbers of soldiers as they have. In a context like this, it is possible to think back to introduce, another time, some practices that had been excluded from the international law after many Declarations. From the literature we can deduce that there are two different measures to be evaluated to prevent terrorism, but both generate bioethical issues. On one side, to rebalance the warfare after the acts of terrorism and to obtain information to prevent future actions like this and save lives, some States contemplate to using, as in the past, enhanced interrogation techniques as torture, but is it right that the lives of many are saved while the dignity of some is violated? And then, if those preventive measures have to be an exception how to avoid abuses? Is not likely that, in this way, also the violence more stringent will be justified? On the other side, instead, sTraduci da: italiano

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Alphaome States choose to limit the freedoms of its citizens to provide them more safety, but it is reasonable to restrict the rights of some to ensure more security to other? In Israel, for example, to protect the society against possible terrorist attacks the Palestinian ambulances (PRCS) should be controlled quickly to allow them to easily reach the hospital, but, many times, they have to wait, at the check point, an Israeli vehicle of the Magen David Adom (MDA) whereby the patients will be transferred according to the method of “back-to-back”. This causes many delays and even medical risks in certain cases. How to guarantee the protection of the lives of some, without denying the best cares to others?

The doctrine of double effect: Resuscitating practical wisdom in palliative care ethics

Braude, Hillel

In this paper I shall analyze how phronesis may be applied in the liminal context of palliative care ethics through the Doctrine of Double Effect (DDE). Aristotelian practical wisdom or phronesis is considered by many philosophers of medicine to provide the foundational moral framework for medical ethics. Defined as the moral and intellectual virtue that disposes one habitually to choose the right thing to do in a concrete moral situation, phronesis provides an approach that takes into account the variability of individual patients. Relying on phronesis allows medical ethicists to apply various philosophical principles to the fluid changing context without slipping into moral relativism. Similarly, one would expect that phronesis would provide the appropriate moral framework for palliative care ethics. For example, in their Palliative Care Ethics: A Companion for all Specialties, Randall and Downie argue that phronesis is necessary to determine the intrinsic and extrinsic aims of palliative care. However, it is questionable how best to apply phronesis in the context of palliative care that is characterized by liminality. The anthropological concept of liminality refers to transitional states in the human life cycle characterized by the overturning of accepted norms and values. The heightening of human contingency in liminality means that even phronesis might not by itself provide an adequate moral framework for palliative care ethics, evidenced most clearly in the DDE. Rooted in the Catholic natural law tradition, the DDE states that an equivocal action is morally legitimate provided that the good and not harmful effect is intended, even though the unintended harmful effect may be foreseen. DDE has been used to justify the administration of high doses of opioid analgesics in order to relieve pain and other severe symptoms even at the risk of hastening death. DDE allows physicians to administer adequate palliative care to patients while still being opposed to physician-assisted suicide and euthanasia. As exemplified in the palliative care context, DDE was formulated in the attempt to deal with situations of radical moral uncertainty. DDE arises in instances where prudential reasoning, distinguishing between a virtuous and non-virtuous act, is at an impasse. In other words, the need for DDE arises because of the impossibility of using phronesis in order to determine the good means to a particular end. The apparatus of prudential reasoning is jammed because of the “ontological uncertainty” that comes to exist regarding the consequences of one’s actions. DDE provides a solution to this impasse by arguing that even though the act of killing is wrong, if it is an unintended consequence of an action intended to alleviate distress, then it is not considered killing. Through analyzing the mechanism of DDE in palliative care I shall demonstrate in this paper how DDE operates through temporarily suspending prudential reasoning while simultaneously providing a mechanism for its resuscitation.

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