BIOETHICS DIGEST: Volume 2

Welcome to the second Bioethics Digest, brought to you in association with the editors of the Bioethics Forum. This digest aims to bring you commentary on today’s most topical bioethics issues. The opinions expressed are those of the authors and not The Hastings Center.

After the Supreme Court Decision on Lethal Injection Drug, More Questions

The execution of William Kemmler, August 6, 1890
The execution of William Kemmler, August 6, 1890

Last month, the U.S. Supreme Court ruled that Oklahoma’s substitution of midazolam for sodium thiopental as a sedative in lethal injections does not violate the Eighth Amendment prohibition against cruel and unusual punishment. Now, an important question is whether states will even be able to obtain drugs used in capital punishment. Increasing numbers of professional associations that are essential for providing and compounding lethal injection drugs are urging their members not to do so.

The American Pharmacists Association (APhA) recently issued a statement discouraging pharmacists from participating in capital punishment. The APhA joins the American Medical Association, American Nurses Association, and American Board of Anesthesiology in defining capital punishment as inimical to ethical practice for health care professionals. Following on the heels of the APhA resolution, the International Academy of Compounding Pharmacists (IACP) has also declared that active participation of their members in the administration of the death penalty is unethical.

These changes could not come at a better moment, write Lillian Ringel, the Associate Director of the Columbia University Bioethics program, and Stephanie Holmquist is a course facilitator in the Columbia University Bioethics program, in Bioethics Forum, the blog of the Hastings Center Report. The capital punishment landscape in the U.S. is increasingly baroque. Utah recently reinstated the firing squad for execution when lethal injection compounds are unavailable. Oklahoma has approved capital punishment by nitrogen gas asphyxiation as its second line method of execution, after lethal injection, and before electrocution and the firing squad.

Capital punishment in the U.S. is also mired in concerns about states’ data collection. States that have adopted the Common Rule and collect data on the effects of execution drugs on death row inmates (prisoners are members of a categorically vulnerable population and require additional protections when they are subjects of research) must arguably receive oversight from an IRB and comply with other stipulations of the Common Rule. Otherwise, states’ data collection about lethal injection may constitute illegal human subjects research.

Rats Have Empathy, But What About the Scientists Who Experiment on Them?

Knockout mouse - Wikicommons
Lab rats on a scientists’ gloved hand.

Decades of experiments have shown that rats are smart individuals that feel pain and pleasure, care about one another, can read others’ emotions, and will help unfamiliar rats even at a cost to themselves. It’s time to apply what we’ve learned from these animals and stop conducting experiments on them in laboratories.

Recently, there was substantial media coverage of experiments at Japan’s Kwansei Gakuin University demonstrating that rats will help other rats in need and even prioritize helping others over receiving a tasty reward.

The experimenters placed one rat in a water-filled tank, a situation that terrifies rats and from which they try desperately to escape to avoid drowning. A second rat on a platform had to figure out how to push open a door to help the drowning rat reach a dry area. The experimenters observed that rats quickly learned to open the door to rescue their cagemates. When given the choice between opening one door to save a drowning rat and opening another door to secure a chocolate treat, the platform rats helped the distressed rat first – and then shared the treat with the rescued rat. Rats who had themselves previously been thrown into the water tank were faster at opening the door to help their panicked cohorts.

This study is only the latest in a string of experiments that demonstrate that rats show sympathy for pain and distress experienced by other rats and take action to help them.

Unfortunately, many experimenters miss the forest for the trees, writes Alka Chandna, a senior laboratory oversight specialist for People for the Ethical Treatment of Animals (PETA) in Bioethics Forum. Instead of following this evidence to its logical conclusion that millions of rats shouldn’t be confined, burned, shocked, infected, and crippled in laboratories – or should at least receive some basic protections under the law – many use it as the basis for even more experiments. At least one such experimenter recently acknowledged the inherent conflict: “The more we do experiments like this, the more we wonder if we should do experiments like this.”

When Words Matter: Medical Education and the Care of Transgender Patients

A recruiting poster for Australian nurses from World War I.
A recruiting poster for Australian nurses from World War I.

I was only there to learn how to place IV lines. But as my anesthesia attending and I gathered our needles, tourniquet, and gauze, I noticed that our patient, whom I’ll call Jamie, didn’t appear to fit into a narrowly defined version of gender, writes Colleen Farrell, a fourth year medical student at Harvard, in Bioethics Forum. I wasn’t sure whether to refer to Jamie as she, he, or some other alternative, but imagined it could be quite hurtful if I used the wrong pronoun. I wanted to eliminate that potential for harm.

When it comes to caring for patients like Jamie, in my experience, avenues for improving medical students’ communication skills seem to be lacking. While many communication skills are transferable from one scenario to another, there are also unique issues that arise in caring for transgender patients. My medical school had in fact attempted to teach me how to handle situations like my encounter with Jamie in a lecture on asking patients questions about sexual orientation and gender identity. But real life medical encounters are almost always more complex than the versions presented in a lecture hall.

To address the needs of transgender and gender nonconforming patients, we need physician-mentors experienced in transgender patient care who can help us work through our uncertainty. We need opportunities to gain experience and comfort, through elective rotations in specific LGBT health centers or through simulated encounters with patient-actors. And we need an institutional culture that says loudly and clearly: it’s important to do this well.

Reproduction and the LGBT Parent; a Changing Narrative

"Love Makes A Family"One historically important objection to gay and lesbians relationships is that they are inherently sterile and incapable of producing children. Many gay men, lesbians, and bisexual people have managed to have children anyway, through prior relationships, adoption and by relying on donated gametes and gestational surrogacy.  The prospect of synthetic gametes may lead to further options as well, if researchers can derive female gametes from men and male gametes from women.  With synthetic gametes, a same-sex couple would not need any third-party gamete donor in order to conceive a child. Inventive options are available for transgender people too. Some jurisdictions used to require evidence of sterility before re-categorizing people they treated as male to female, from female to male. Most jurisdictions no longer require sterilization that way, with the interesting result that some transgender men have gestated children.  Transgender women might in the future turn to uterus transplants in order to gestate children, if clinicians can replicate for them the 2014 success they had in securing a live birth for a woman who had a uterus transplant. Artificial gametes might also give transgender men and women the option of being genetic fathers and mothers to their children, respectively.  Nothing about being lesbian, gay, bisexual, or transgender by itself ‘turns off’ the interest in having children. In light of the options now available and of those on the horizon, the future for LGBT people is looking less and less ‘sterile’ all the time.

Timothy F. Murphy is a Professor of Philosophy in the Biomedical Sciences at the University of Illinois College of Medicine at Chicago.  He is also an author with the Hastings Center Report, a prominent journal in biomedical ethics.

Read the collection of articles from the Hastings Center Report and other journals free through July 15th! Read Free

The End of Reparative Therapy

50 Great Myths of Human Sexuality
50 Great Myths of Human Sexuality

With the removal of homosexuality as a mental illness in the 1970’s came a change in how therapists treated gay, lesbian, and bisexual patients. Instead of attempting to change a patient’s sexual orientation, experts were told to help them understand it and learn to cope in what was still a very homophobic society.
When mental health professionals changed, however, religious organizations picked up the mantle and started ministries dedicated to “reparative” therapy. Their members—who were sometimes referred to as ex-gays—went through programs that varied from independent bible study to aversion therapy, which involved administering electric shocks every time a patient became aroused by gay pornography.
These groups were very vocal for a few decades and lent their support to efforts to discriminate against LGBTQ individuals; they argued against teaching about sexual orientation in schools, fought the formation of gay-straight alliances, opposed marriage equality, and worked to prevent LGBTQ individuals from adopting children.
Their arguments were all grounded in the idea that sexual orientation could change, that people didn’t have to be gay. Ex-gays were paraded around as success stories—such as in a 1998 ad that insisted men could “pray away the gay.”
And then the truth began to come out. Some leaders of this movement were caught having homosexual affairs, visiting gay bars, or meeting men online. Others stepped forward to admit they were wrong, that they are still gay, and that sexual orientation does not change. In 2013, Exodus International—one of the largest and at one point most powerful, ex-gay ministries—shut its doors.
Now, in the United States at least, it looks like the time of reparative therapy has passed. The courts have held up laws in two states banning the practice for minors. The White House came out against it. And two Democratic Senators recently introduced a resolution condemning it.
But probably the best sign that its days are numbered come in the apologies from those who once sang its praises. Like these words from Exodus’ last president Alan Chambers: “I am sorry that some of you spent years working through the shame and guilt you felt when your attractions didn’t change….  I am sorry that there were times I didn’t stand up to people publicly “on my side” who called you names like sodomite—or worse.”

Martha Kempner, 2015.
Martha Kempner is co-author with Pepper Schwartz of 50 Great Myths of Human Sexuality published 2015 by Wiley

Contextualizing the LGBT Patient in the Health Care System

clinician and medical recordsThe Institute of Medicine (IOM) in its report, The Health of Lesbian, Gay, Bisexual and Transgendered People: Building a Foundation for Better Understanding, recommends that data on sexual orientation and gender identify be collected and included among other demographic information  routinely stored in patients’ electronic health records. The intent of the IOM recommendation is to improve clinical care and to facilitate research that can address health inequalities among LGBT persons. The reality is that many LGBT persons remain reluctant to disclose their sexual orientation or gender identity, or have that information documented in the electronic health record – even when sexual orientation or gender identity is material to a medical  diagnosis or treatment. This reluctance should be contextualized within the backdrop of a health care system where many lesbian, gay, bisexual, and transgendered persons have had negative, invalidating or discriminatory experiences when attempting to access health care, during their care or treatment, or during the care and treatment of a same-sex partner. As the Institute of Medicine observed, it is necessary to create a care environment in which individuals who have historically been stigmatized and discriminated against feel safe providing this information.  What steps can health care organizations take to demonstrate trustworthiness with respect to the collection and use of information related to sexual orientation or gender identify? Should clinicians’ elicit this information as a routine part of clinical care?

Mary Beth Foglia PhD MA

Department of Bioethics and Humanities, School of Medicine

University of Washington – Seattle

Editor and author for The Hastings Center Report

The Time Is Now: Bioethics and LGBT Issues

LGBT Cover Image“Bioethics has an obligation to work toward the resolution of real and pressing issues.” that’s where Tia Powell and Mary Beth Foglia start with the ideas and driving force behind their special issue, The Time is Now: Bioethics and LGBT Issues for the Hastings Center Review.  With an ultimate goal of encouraging colleagues to incorporate topics related to the LGBT populations into bioethics curricula and scholarship, the two take on several prominent topics of relevance to the LGBT populations but they know there are many more topics of concern to this population and hope that scholarship continues beyond this collection. Read Free through July.

We feel that bioethics has an obligation to discuss [LGBT] history and to help us as a society take responsibility for it. – Tia Powell and Mary Beth Folia

From Tia and Mary Beth:

Andrew Solomon offers an elegant overview of the challenges that bioethics faces in articulating a solid basis for LGBT rights. Timothy F. Murphy asks whether bioethics still faces issues related to lesbian, gay, and bisexual people, given the deletion of homosexuality as a disease and the progress toward same-sex marriage. Jamie Lindemann Nelson’s essay addresses the search for identity for transgender persons and the role of science in that search. Two articles, those by Brendan S. Abel and by Jack Drescher and Jack Pula, take up the complex issue of medical treatment for children who reject their assigned birth gender. Celia B. Fisher and Brian Mustanski address the special challenges of engaging LGBT youth in research, balancing the need for better information about this vulnerable group against the existing restrictions on research involving children. Tia Powell and Edward Stein consider the merits of legal bans on psychotherapies intended to change sexual orientation, particularly in the light of current research on orientation. Mary Beth Foglia and Karen I. Fredricksen-Goldsen highlight health disparities and resilience among LGBT older adults and then discuss the role of nonconscious bias in perpetuating disparities. Stephan Davis and Nancy Berlinger assess the challenges of access to care and health policy for transgender persons. Edward J. Callahan et al. tackle the ways in which diverse aspects of medicine should change to better incorporate the needs of LGBT patients, including through use of the electronic medical record, education of health professionals, and recruitment efforts for LGBT health professionals. Virginia Ashby Sharpe and Uchenna S. Uchendu describe multifaceted efforts within Veterans Administration facilities to create change for LGBT veterans across the largest integrated health care network in the United States. Lance Wahlert and Autumn Fiester find a mixed record in the use of case studies in teaching about LGBT issues

The Physician, the Bioethicist, and the LGBT Community

Lgbt_healthcare_symbolAs a discipline, medical ethics has a long history grappling with questions that grow out of clinical encounters. It asks, for example, “What is expected of a physician in regard to confidentiality and relationships with patients?” By contrast, bioethics emerged in the wake of questions with a distinctly social component to them. It asks, for example, “Who should make decisions about scarce life-saving resources, and how?” In making this kind of shift, bioethics can take account of the contextual features that shape theories of health and disease, professional standards in healthcare, and research agendas. This shift has proved important for the lives and welfare of lesbian, gay, bisexual, and transgender people.  LGBT people are and are not like everyone else. We are not like everyone else in matters of sexuality and gender; we are like everyone else in matters of moral standing. The task ahead for bioethics is to interpret those differences across the breadth of biomedicine, without compromise of moral equality.

Timothy F. Murphy is Professor of Philosophy in the Biomedical Sciences at the University of Illinois College of Medicine at Chicago and Bioethics and Developing World Bioethics contributor

Read Timothy’s expanded research on this topic in Bioethics, available in early view and free for readers throughout LGBT Pride Month.

BIOETHICS DIGEST: Volume 1

1280px-Human_Paneth_cells
Image credit: Jpogi (Wikimedia Commons)

Welcome to the first Bioethics Digest, brought to you in association with the editors of the Bioethics Forum. This digest aims to bring you commentary on today’s most topical bioethics issues. The opinions expressed are those of the authors and not The Hastings Center.

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Sacred versus Synthetic: Nature Preservationism and Biotechnology

Eventbrite-image-400x400One of the long-term contributions of Earth Day, which occurred on April 22, is that it offers a regular, semi-official reminder that a sense of the sacred is a vital part of environmentalism. But in the era of biotechnology, the notion of sacredness can pull in other directions.

A recent public form on synthetic biology hosted by Friends of the Earth and some other civil society groups effectively brought out how the notion of sacredness is woven into objections to genetically modifying microorganisms to produce fuel, cosmetics, medicines, and other chemicals. The event was titled “Sacred versus Synthetic: Competing Visions for Life on Earth,” and what was especially remarkable and helpful about it was that the presentations continually brought concerns about the possible practical harms of GM microorganisms back down to concerns about the very idea of GM microorganisms. To the speakers, the genetic modification of an organism is by definition a harm to nature, and it is perhaps the most fundamental harm to nature.

The goal of protecting life and preserving nature is a good moral starting point, writes Gregory E. Kaebnick, a research scholar at The Hastings Center and editor of the Hastings Center Report and author of Humans in Nature: The World as We find It and the World as We Create It. But a concern to preserve the natural world still requires careful thinking about which ways of altering nature constitute fundamental harms to nature.

“When I first began reading and writing about the genetic modification of organisms, I, too, felt that there was something particularly unattractive about it, that a sense of life’s value should guide us away from all forms of it,” Kaebnick writes. “I now believe that the real friends of earth should look at the big picture–at ecosystems and biodiversity, at the land, at the earth–and that the modification of DNA, per se, is not really the issue. The real issues have to do with the overall human-caused damage to the planet. We should focus on the problems of global climate change, pollution, ecosystem destruction, and human-driven extirpation of species.”

U.S. Bioethics Commission’s Recommendations on Use of Cognitive Enhancers

Image by Wei-Chung et al.
Image by Wei-Chung et al.

The idea that we can get better grades at school and advance our careers by taking drugs that improve concentration and other brain functions is at once controversial and tempting. Is this cheating, or is it in the same realm as drinking coffee to increase alertness? Bioethicists, medical professionals, and the general public are divided on this question.

What’s not contested is that teenagers and adults in the United States are using prescription medications such as Ritalin for nonmedical purposes in an attempt to enhance normal cognitive functioning. People are getting the drugs from doctors, or from patients (such as classmates) with prescriptions for neurological conditions who are willing to sell or share their pills.

Against this Wild West backdrop, the Presidential Commission for the Study of Bioethical Issues (PCSBI) has taken a significant step by issuing recommendations on the ethical use of medications and other means of “neural modification,” which includes drugs and interventions such as deep brain stimulation that  might either treat neurological disorders or augment normal brain function. The recommendations are part of its final report, Grey Matters: Topics at the Intersection of Neuroscience, Ethics and Society.

Those who firmly believe that college students without ADHD who take Ritalin before finals are cheaters or that people in hard-driving careers who use drugs to sustain a seemingly inhuman output of work are frauds (or victims of coercion in a hypercompetitive job market) are likely to be disappointed by the commission’s report, writes Susan Gilbert, editor of Bioethics Forum, the blog of the Hastings Center Report. It is guardedly optimistic about the prospects for neural modification for enhancement purposes, stating that “contemplating novel methods of improving such functions as learning and memory in school or performance in competitive professions is truly exciting.” The commission does not assume that cognitive enhancers will necessarily promote injustice (by benefiting mainly those who are able to afford them) or help level the playing field (by enabling people with below average but still normal memory and other brain functions to perform better). But it concludes that it’s worth finding out.

Sex, Consent, and Dementia

Woman diagnosed as suffering from chronic dementia (Wellcome)
Woman diagnosed as suffering from chronic dementia (Wellcome)

A 78-year‐old man in Iowa, Henry Rayhons, was charged with third‐degree felony sexual abuse for having sex with his wife, who had severe Alzheimer’s, in her nursing home last year. Though Rayhons was acquitted last month, the case raises questions about the capacity to consent in cases of severe dementia, an issue that is not limited to sexual relations, writes Bonnie Steinbock, a Hastings Center Fellow, who is professor emeritus of philosophy at the University at Albany, State University of New York and a professor of bioethics at Union Graduate College’s Center for Bioethics and Clinical Leadership. It also comes up also in cases where patients with dementia initially resist food and water, but can be coaxed to eat. Does opening one’s mouth and ultimately swallowing indicate consent?

The importance of consent in sexual relations is well recognized, but this case is clearly not a case of spousal rape. No one suggests that Mrs. Rayhons resisted sexual contact with her husband, nor were there any signs of abuse. Indeed, by all accounts, theirs was a loving and affectionate relationship, and Mrs. Rayhons was always pleased to see her husband, even in the final stages of her dementia.

In other contexts, the absence of affirmative consent to sexual relations may be the right criterion for rape or other sexual abuse. On many college campuses, the movement is away from “no means no” (absence of consent) to a standard of affirmative consent. That is, both partners must give affirmative consent, whether verbal or otherwise, for sex to be consensual.

However, using affirmative consent as the standard for patients with severe dementia would deprive them of sexual relationships, because few retain the capacity to articulate a desire for sex. That would be a shame, because of the importance for human beings—including those who have dementia — of physical intimacy.

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