Issue 18(3)

Ethical issues are often transacted with passion, righteous anger, and an unhealthy imbalance between heat and light. These strong emotions can be damaging and divisive but also demand our attention and understanding, as we are not, and do not wish to be, thinking robots: we take all of ourselves everywhere.
How then is it possible to look with curiosity rather than pre-conceived positions, academic eyes rather than partisan ones, and remove from the process, at least to start with, the automatic filters of ethnic origin, religious adherence, education, social background, and political views, and the passion that is generated in their defence?

The purpose of this Recent Developments column is to consider the new amendments to Canada’s MAID Act. What is interesting about this development is that the final version of Bill C-7 is significantly different to the initial Bill introduced by the Minister of Justice, the Hon. David Lametti. At the close of my previous discussion, I postulated that “whilst it is clear that this development will result in a wider pool of persons eligible to access MAID, what remains to be seen is just how wide the pool will become.” Now that Bill C-7 has been enacted, it can be added that, for better or worse, the pool is much, much wider than initially thought.

The ongoing pandemic has thrown many challenges to healthcare workers (HCW’s) specially in terms of having safe working conditions and using Personal Protective Equipment (PPE). Inherent to the COVID-19, is its high transmissibility through respiratory droplets, aerosols, and fomites (van Doremalen et al. 2020). As a result, HCW’s must wear PPE all the time while caring for COVID-19 patients. Fogging of the goggles and face shields leads to poor vision which puts them at high risk for various injuries including a needle stick injury while performing medical procedures and phlebotomy. Moreover, many HCW’s from diverse specialities are being mobilized to care for the overwhelming number of these patients, some of them are not accustomed to performing such procedures routinely leaving them vulnerable to a potential health hazard. Coupled with this comes the fear and anxiety of having got infected with COVID-19 by or immediately after a needle stick injury.

We believe that the status of spouses (husband, wife, legal partner) or kin (family member or relation), if co-authors, should be clearly indicated in an academic paper, whether they share the same or have separate family names. For example, a brief statement like “XY and AB are husband and wife,” “XY and AB are father and son,” or “XY and AB are first cousins” should be added in the acknowledgements for clarity and transparency. Spouses (or kin) with collaborative research, or who work in similar or related professional environments, might influence each other ideologically (i.e., bias) and contribute ideas or discussion that might be incorporated into a research project and ultimately into an academic paper.

Stereotypes about exotic peoples and animals of the Orient shaped popular origin stories about COVID-19 in media reports. Outbreak narratives centred on the seafood market in Wuhan began to fall apart as new evidence was published by medical doctors, virologists, and epidemiologists. No viruses in bats or pangolins have been found that are direct ancestors of SARS-CoV2, the virus responsible for COVID-19 symptoms. Viruses are also being transformed as they interact with the human institutions, infrastructures and behaviours that facilitate their spread. Epidemiological growth curves are shaped by national and foreign capital, cosmopolitanism, aspirations for independence and ongoing interdependence, the discourse of power and the discourse of resistance, as well as coexistence and violence. In reckoning with SARS-CoV2, we need to anticipate disruptive surprise of viral emergence rather recursively search for origins. Departing from Foucault’s foundational insights, this article gestures towards genealogies of possible viral futures.

The term “normal” is culturally ubiquitous and conceptually vague. Interestingly, it appears to be a descriptive-normative-hybrid which, unnoticedly, bridges the gap between the descriptive and the normative. People’s beliefs about normality are descriptive and prescriptive and depend on both an average and an ideal. Besides, the term has generally garnered popularity in medicine. However, if medicine heavily relies on the normal, then it should point out how it relates to the concept of health or to statistics, and what, after all, normal means. Most importantly, the normativity of the normal needs to be addressed. Since the apparently neutral label “normal” can exclude, stigmatize, and marginalize people who are defined in contrast to it as abnormal, health professionals should think twice before using the term with patients. The present critical perspective advocates against using the term “normal,” as long as no understanding of a person’s individual normality has been attained. It advocates for the right to autonomously determine one’s own normality. For health professionals I do not see worthwhile benefits of subscribing to the concept of (non-individual and normatively loaded) “normality” and imposing it on their patients. But I do see many risks.

The circumstances of a public health emergency (PHE) shape reasoning and decision-making in ways that deviate from routine circumstances, where adherence to established values, principles, and methodologies is expected. Understanding what drives these deviations is critical to assessing their ethical consequences. In this paper we describe four conditions that influence decision-making during PHEs, in particular regarding the deployment and conduct of research on experimental or novel biomedical interventions. These four conditions are politicization, urgency, uncertainty, and fear. We argue that taken together these four conditions create pressure to address the most visible targets of immediate crisis events, driving emphasis on research and development of biomedical interventions. However, this emphasis raises ethical concerns regarding the extent to which attention to and investment in the underlying causes of PHEs, particularly impoverished global public health infrastructure, is diminished as a result.

This article discusses the ways in which healthcare professionals can use emotion as part of developing an ethical response to the COVID-19 pandemic. Affect theory, a growing approach to inquiry in the social sciences and humanities that appraises the historical and cultural contexts of emotions as expressed through art and politics, offers a frame for clinicians and researchers to consider ethical questions that surround the reopening of the United States economy in the wake of COVID-19. This article uses affect theory to describe how healthcare workers’ emotions are useful for formulating a reopening plan grounded in collective action and a duty to do no harm.

This article poses a response to one argument supporting the force feeding of political prisoners. This argument assumes that prisoners have moral autonomy and thus cannot be force fed in the early stages of their hunger strike. However, as their fasting progresses, their cognitive competence declines, and they are no longer autonomous. Since they are no longer autonomous, force feeding becomes justified. This article questions the recurrent citation of a paper in empirical support of the claim that hunger strike causes mental disorders or cognitive impairments. The paper, written by Daniel Fessler, partially relies on the Minnesota Starvation Experiment conducted in 1944 to 1945 for scientific support. Using widely accepted criteria for assessing the ethical acceptability of clinical research, we argue that the Minnesota Starvation Experiment had significant scientific shortcomings and is a case of unethical research. From this, we question the appropriateness of citing the Minnesota Starvation Experiment and consequently Fessler’s paper. If Citing Fessler’s paper becomes problematic, this particular argument for the force feeding of prisoners loses much of its strength.

Interest in the future, clinical implementation of uterus transplantation for uterine factor infertility was recently boosted by the demonstration of proof-of-concept for deceased uterus donation/transplantation. The ethical dimensions of living and deceased uterus transplantation are explored and addressed in the paper through their comparison to the ethical elements of an existing, legal, assisted reproduction practice in some high-income countries, i.e., gestational surrogacy. A set of six ethics lenses is used in the comparative analysis: reproductive autonomy and rights, informed choice/consent, relevant critical relational theories, health equity, theoretical application of the accepted living donation standard, and comparative benefits and burdens considerations. Gestational surrogacy, as currently practiced in some high-income countries, is the assumed, theoretical base-threshold for determination of ethical acceptability in assisted reproduction practices. The analysis demonstrates that (at the present time): 1) the ethical acceptability of living uterus donation/transplantation is less than that of gestational surrogacy in high-income countries, and 2) the ethical acceptability of deceased uterus donation/transplantation is roughly equivalent to that of gestational surrogacy. This leads to the conclusion that, at the present time, only one version of uterus transplantation practice, i.e., deceased uterus transplantation, should be considered ethically acceptable for possible clinical implementation in high-income countries.

There is a global shortage of nurses that affects healthcare delivery, which will be exacerbated with the increasing demand for healthcare professionals by the aging population. The growing shortage requires an ethical exploration on the issue of nurse migration. In this article, we discuss how migration respects the autonomy of nurses, increases cultural diversity, and leads to improved patient satisfaction and health outcomes. We also discuss the potential for negative impacts on public health infrastructures, lack of respect for cultural diversity, and ethical concerns related to autonomy and justice, including coercion and discrimination. This analysis is written from a rights-based ethics approach by referring to rights held by nurses and patient populations. Nurse migration highlights conflicts between nurses and between nurses and healthcare systems. Increased awareness of ethical challenges surrounding nurse migration must be addressed to enhance the well-being of nurses and patient populations.

Fertility treatments, which are part of “assisted reproductive technologies” (ART), mainly undertaken through in vitro fertilization (IVF), offer the opportunity to infertile couples to conceive. IVF treatments are undertaken in Israel in significantly higher numbers than in the rest of the world. As such, Israel provides an important case-in-point for examining the validity of the actual claims used to justify the more generous public funding of IVF treatments at the policy level. In this article, we utilize an analytical philosophy approach to conduct this examination. First, we highlight two fundamental concepts that were used at the Israeli public policy level in order to justify the generous public funding of IVF treatments. These concepts are “emotional vulnerability” and the “worthlessness of the childless,” where the latter emphasizes the infinite value of children. Then, by applying the perspective of the European model of Bioethical Principlism, and focusing the attention to these two concepts we show that these justifications are invalid. Specifically, it is suggested that these concepts are on the one hand both relying on and expressing the principles of vulnerability, dignity, and integrity; yet on the other hand, these concepts are also undermining the very principles of bioethics they are supposed to express and rely on. Based on this suggested criticism, we offer two “take home” messages informed by our analysis of the Israeli case, but reaching beyond it.

Many higher-income countries are struggling to make decent and affordable care available to their older populations. In response, some Germans are sending their ageing relatives to relatively high-end care homes within Eastern Europe and South-East Asia where the care tends to be more comprehensive and a lot cheaper. At the same time, this practice has caused much controversy within Germany, with some commentators calling it “inhumane” and “shameful.” The aim of this article is to show that such criticisms are exaggerated. Whereas sending people to care homes in lower-income countries can be immoral, I argue that the most promising objections against it do not always apply and, to the extent that they do, do not always provide decisive reasons against sending people abroad. These objections maintain that such expatriations harm three different groups of individuals, namely the emigrants themselves; their friends and relatives; and vulnerable members of the receiving societies.

Obtaining consent for medical treatment in older adults raises a number of complex challenges. Despite being required by ethics and the law, consent for medical treatment is not always validly sought in this population. The dynamic nature of capacity, particularly in individuals who have dementia or other cognitive impairments, adds complexity to obtaining consent. Further challenges arise in ensuring that older people comprehend the medical treatment information provided and that consent is not vitiated by coercion or undue influence. Existing mechanisms to address issues surrounding consent for older adults only address incapacity and raise further challenges. As the ageing population increases, these issues are likely to become more profound, thus action is required to address these challenges. Raising awareness, more education, engaging with people with dementia, and conducting further research would assist in beginning to overcome these challenges.

While pharmaceutical industry involvement in producing, interpreting, and regulating medical knowledge and practice is widely accepted and believed to promote medical innovation, industry-favouring biases may result in prioritizing corporate profit above public health. Using diabetes as our example, we review successive changes over forty years in screening, diagnosis, and treatment guidelines for type 2 diabetes and prediabetes, which have dramatically expanded the population prescribed diabetes drugs, generating a billion-dollar market. We argue that these guideline recommendations have emerged under pervasive industry influence and persisted, despite weak evidence for their health benefits and indications of serious adverse effects associated with many of the drugs they recommend. We consider pharmaceutical industry conflicts of interest in some of the research and publications supporting these revisions, and in related standard-setting committees and oversight panels. We raise concern over the long-term impact of these multifaceted involvements. Rather than accept industry conflicts of interest as normal, needing only to be monitored and managed, we suggest challenging that normalcy, and ask: what are the real costs of tolerating such industry participation? We urge the development of a broader focus to fully understand and curtail the systemic nature of industry’s influence over medical knowledge and practice.

Clinical Ethics Consultations (CEC) are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such support. Physicians in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system.

Animal advocates world-wide have been accused of campaigns immured in racism. Some authors have argued that for animal advocates to avoid this accusation they should simultaneously engage with racial discrimination issues when advocating for animal welfare/rights. This prescription has been mostly explored in the context of the Global North and by looking at Western normative theory. In this article I address this issue but by looking at the context of South Africa and analysing the prescriptions from an Afro-communitarian ethic. I conclude that this ethic prescribes that there is a positive duty to engage in racial discrimination issues and, if one does not do so, a violation of some negative duties occurs.

Committees established for the ethical review of research involving animals have become a widespread legal standard around the world. Despite many differences in their composition, powers, and institutional settings, they share many common problems related to the well-established standards of procedural justice in administrative practice. The paper adapts the general theory of procedural justice to the specific context of ethical review committees. From this perspective, the main concerns over the procedural aspects of the ethical evaluation of research projects are identified and examined. They include in particular the standards of the committees’ composition, impartiality, fair hearing, appeal, transparency, and benevolence. Their proper reflection in the regulatory regimes of animal ethics committees is necessary to secure the standards of fairness of the ethical review itself. This, in turn, is a condition of the moral and social legitimacy of all administrative and quasi-administrative procedures, including the committees’ operations (irrespective of whether they are legally entrusted with the task of authorizing or only evaluating research projects).