In his presidential address to the Seventieth Session of the Indian
Philosophical Congress, Dr. Rajendra Prasad points out that ethical principles
do not determine the possibility or impossibility of anything they are relevant
to; rather, they determine its desirability or undesirability. These principles
are relevant to individuals, their groups, their actions, motives, intentions,
attitudes, plans and policies, projects and projections... Ethical goodness is
foundational to all other kinds of goodness in the sense that its presence in
any one of them heightens the latter’s natural or distinctive value, and its
absence in the latter or the latter’s having been polluted with some ethical
evil, does the contrary. A necessary component of our ethical concern is a
concern or care for the welfare of others...
That an ethical consideration has the primary, or an overriding authority, is
clear from the fact that no non-moral consideration can take away or curtail the
moral rightness of an action, if the latter is otherwise morally right. The
moral rightness of an action can be a very good ground - some would say the best
ground - for attributing to it some other kind of rightness, say political
rightness. No action can or should be said to be right - even from a religious
point of view - if it is morally wrong. In fact, one of the methods quite often
adopted by religious reformers to improve or purify the functioning of a
religion is to suggest dropping or modifying those of its prescriptions or
proscriptions which they consider morally wrong, unjustified or insignificant.
The Human Genome Project will probably be completed by 2006, ahead of
schedule. It may take another hundred years to figure out what each gene does in
regard to the development and function of ‘normal’ individuals. Only then will
the therapeutic payoff start. In the meantime there will be an increasing number
of tantalising bits of diagnostic information, most accompanied by a measure of
uncertainty.
What the project promises to do is to make the unknown known with a
‘scientific certainty’ that is difficult to refute. The potential of this horror
makes people shudder. Not only will they know their own futures, but anyone else
who has the information will have some terrible power over them. The Biblical
adage will have come to pass:
A survey carried out by the author showed that two per cent of those polled
had been refused employment, four per cent refused health insurance and six per
cent refused life insurance on the basis of genetic reports. Another study found
far greater evidence of ‘genetic discrimination’.
Geneticists found it difficult to answer the question: "Should a patient’s
relatives be informed that they may be at genetic risk against the wishes of the
patient?" 4 1% of those polled in the US and 34% outside the US would maintain
the patient’s confidentiality. In many cases, telling unasked relatives is a
practical impossibility because of the difficulty in locating them. The
President’s Commission decided in 1983 that confidentiality could be overruled
if four conditions were met: 1) reasonable efforts to persuade the patient to
disclose voluntarily had failed; 2) there was a high risk of harm to the
relatives if the information was not disclosed, and the information would be
used to avert this harm; 3) the harm suffered would be serious; and 4) only
information directly germane to the relatives’ medical/ genetic status was
conveyed.
Patients took a different view. 75% felt the doctor should inform the
relatives.
66% of geneticists would not tell a man that he is not the father of a child,
even if he asked. 75% or respondent patients, who were mostly women, thought
that the doctor should tell the man who asked, but most thought the doctor
should warn the woman first.
French respondents to the survey often started with the statement: "My rights
end where other people’s rights begin." Chinese respondents and those from most
developing countries said that individuals should act in terms of the welfare of
the population as a whole. Most American geneticists and patients felt that
withholding any service requested by a patient was a denial of patients’ rights.
Addressing the question of whether knowledge is good in itself, the essay
focuses on Sophocles’ statement: "It is not wisdom to be wise, when wisdom
profits not." Referring to the example of Huntington’s disease, Wertz points out
that whilst the test has a 100% certainty, it cannot predict the exact age at
which the disease will appear. Most other genetic tests do not offer such
certainty. Instead, like weather forecasts, they offer ‘percent chances’. Risk
theory suggests that most people tend to overestimate low numeric risks and
underestimate high numeric risks.
Wertz also discusses the stated Chinese goal of human genetics as
‘improvement of the population quality and decrease in population quantity’,
raising the spectre of eugenics. Prenatal diagnosis, ‘prevention of birth
defects’ and reducing ‘the number of deleterious genes in the population’ are
other stated goals in 17 of 37 nations (including India) surveyed.
The final paragraph in this essay is especially interesting. "America will
export its ethical values along with its technology, ultimately leading to world
cultural hegemony in bioethics... We have some ethically dubious practices, such
as patenting of genes and inequality of access to care, that we should probably
not try to export.. . "
Duty to warn (3)
The doctrine that therapists have a duty to warn third parties
of possible harm by their patients was first highlighted in the Tarasof
case. Prosenjit Poddar murdered Tatiana Tarasoff in 1969 just two months
after confiding this intention to a University of California psychologist.
The California Supreme Court held that the therapist has a duty to warn
when ‘in the exercise of his professional skill and knowledge, [the
therapist] determines, or should determine, that a warning is essential
to avert danger arising from the medical or psychological condition of this
patient.’ In an unusual grant of re- hearing, the California Supreme
Court vacated its prior Tarasoff decision, holding instead that ‘[w]hen
a therapist determines, or pursuant to the standards of his profession should
determine, that his patient presents a serious danger of violence to another,
he incurs an obligation to use reasonable care to protect the intended victim
against such danger.’ The court went on to state that the duty could
be discharged in a number of ways, depending on the circumstances, including
‘warn[ing] the intended victim or other likely to appraise the victim
of the danger, to notify the police, or to take whatever other steps are
reasonably necessary under the circumstances. The court had concluded that
‘[t] he protective privilege [to confidentiality] ends where the public
peril begins.'
In Hutchinson v. Patel, the Louisiana Supreme Court confronted the issue of
whether a psychiatrist’s failure to warn or take reasonable precautions to
protect third party interests constitutes malpractice. The Court decided that
the duty to warn requires only reasonable care in applying the standards of the
professional community. In addition, reasonable care must be exercised by the
therapist in discharging the duty to warn to protect the potential victim.
Ethical aspects of the human embryo (4)
De Luca’s essay is warmly commended. It discusses protection
of the human embryo in the light of the proceedings of the Third Symposium
on Bioethics of the Council of Europe in December 1996. It incorporates
the considered views of scholars from the field of ethics, law and religion.
Opinions from the Islamic faith, Jewish religion, the Greek Orthodox Church,
Japanese and Maori cultures are included. An important point raised deserves
special attention:
"Economic forces and the networks formed between the political sphere, public
laboratories, private laboratories and the biomedical and scientific
institutions.. . are for the grey area of the reins of power. Although the
expansionist, secretive approach of the industrial free market may be acceptable
for the production of industrial goods, it is essential that industry’s
appropriation of the human embryo be put to public debate. We can only protect
the human embryo, procreation and child birth if the private sector is
effectively subjected to the laws of ethics being discussed in the public
arena."
Active vs passive euthanasia (5)
The distinction between ‘passive’ and ‘active’
euthanasia has focussed on one allowing nature to take its course and the
other causing death by human intervention. This letting die/ killing dichotomy
has, in turn, led to other difficulties. What constitutes ‘active’
and which actions are really ‘passive’?
Much is made of ‘intervention’ by the therapist and the subsequent withdrawal
of such ‘intervention’, the therapist being held responsible for the
intervention and its consequences. If there be no intervention, the
responsibility for the train of events can be placed on nature. Natural
processes are deemed to be morally neutral, whilst the consequences of human
intervention are open to judgement. Natural deaths are not killing and are thus
neither immoral nor illegal. Implied in the characterisation of intervention of
medical steps as intervention is the thought that in killing a patient one is
the direct cause of death whilst in letting die, one merely allows a
physiological process to follow its natural course. The fallacy of such thinking
is obvious. The physician might opt not to put a patient who is not expected to
survive and cannot breathe on a ventilator as this lack of action will ‘allow
nature to take its course’ and end in certain death.
Naturalness not only permits, it also restricts. In the same patient who is
not expected to survive and cannot breathe, the doctor administering a lethal
injection of morphine will be interpreted as having killed the patient even
though death was a foregone conclusion.
It is important to realise the complex and consequently moral fragility of
the artificial, especially against the pseudo-simplicity of the natural. Might
it not be better to consider whether a step taken is beneficial or right rather
than whether it is natural or induced by man? "Our moral practices already allow
us to kill patients in hopeless and painful conditions, as well they should. It
is a good kind of killing. But now we need to set aside our prejudices against
the artificial and set aside our myths of the natural death and extend the
option of good killing to those trapped by nature."
Elizabeth Kubler- Ross (6)
Incapacitated by a series of strokes, Elizabeth Kubler- Ross
is waiting to die. Decades of work with the terminally ill have done little
to ease her own transition from life to death. As she puts it, "For 15 hours
a day, I sit in the same chair, totally dependent on someone else coming
in here to make me a cup of tea. It’s neither living nor dying. It’s
stuck in the middle. My only regret is that for 40 years I spoke of a good
God who helps people, who knows what you need and how all you have to do
is ask for it. Well, that’s baloney. I want to tell the world that
it’s a bunch of bull. Don’t believe a word of it."
Elizabeth Kubler, psychiatrist and spiritualist, was born in Switzerland in
1926. She married an American doctor, Emmanuel Ross, moved to the United States
and settled in Chicago. In 1969 she publishedOn death and dying- a
book that made her famous and helped launch the hospice movement in the United
States. Today, she thinks suicide may be a legitimate option. When asked which
of the five stages of death (described and popularised by her) she finds herself
in at the moment, she yelled, ‘I’m pissed! ’
The following are from real consent forms received by the institutional
review board at the University of California:
