“Canada’s Dirty Little Secret” – Ethics In Canada’s Health System

Canada’s Dirty Little Secret

Presenter: Dr. Paul Kamill

http://www.winnipegfreepress.com/arts-and- life/entertainment/books/Albertas-shameful-past-offers-fetid- food- for-thought-112717084.html

1. Abortion

This is a very emotionally loaded topic. For certain religions — actually, for most religions — it is completely unacceptable as a transgression against what it is to be human. It was once estimated that well over two thirds of all pregnancies resulted in a “miscarriage”, which is, in fact, another name for an abortion, but not procured by human agency. These “miscarriages” were largely as a result of non-viability of the fertilised egg. In other words there was some defect.

In the UK there has been a legal right to abortion since 1967 following the introduction of the Abortion Act. The act requires that two medical practitioners, usually the woman’s GP and the gynaecologist to whom the GP has refereed her agree that there are grounds for the termination of pregnancy. See:

http://en.wikipedia.org/wiki/Abortion_in_the_United_Kingdom

In the USA the landmark legal case that is often mentioned is “Roe v. Wade”. The concept of “viability” was introduced with respect to the time limit for an abortion. This is variously considered to be between 24 and 28 weeks of the pregnancy. A 24 week old conceptus would not be viable without modern medical technology.

Peter Singer, a Princeton Philosopher and well known bio- ethicist, makes the point that using ‘viability’ as the point at which abortion becomes disallowed will depend upon where with respect to access to technology the pregnant woman is living. Perhaps she lives in a metropolitan area with easy access to modern facilities. But then perhaps she moves to the remote outback in Australia with virtually no access to support mechanisms for a pre-term birth. While this represents a degree of relativism it makes the point that the acceptance by either the various faith communities or the secular community of this judicial division between what is acceptable and what is not is perhaps on shaky ground.(Singer 1994b)

This is also true if one looks at the suggestion that “conception” is the time at which we accept that the foetus becomes a “human”. Perhaps the fertilized ovum – which we will call Fred, and at this point has been imbued with all the religious aspects of a “human” including a “soul” – divides to become twins. For the sake of completeness let’s call the twins Peter and Paul. What then has happened to the human we named Fred? And what of his soul? Did he die or was he ever ‘living’ and how can we conceptualise his soul?

1. Therapeutic

A woman’s right to control her own body is taken for granted now, and younger people can scarcely believe that abortion used to be a criminal offence, punishable by a prison sentence for the woman and the abortionist. In 1803, abortions in the UK were criminalised. This was the legal position until the Abortion Act 1967 (and still is, in many parts of the world). No doctor who valued his career would perform an abortion and no hospital could do so.

My experience of abortion probably started in 1968 or 1969. This was shortly after the introduction of the “abortion act” in the UK. I was appalled by the attitude of one of the surgeons in the hospital where I was spending an elective period in obstetrics and gynaecology. Termination of pregnancy is actually a relatively simple procedure. However, this particular surgeon opted for reasons of his own to perform “hysteroscopy”, which involves essentially the same procedure as a Caesarian section. This leaves the woman with a permanent scar on her lower abdomen, and in the uterus. Future pregnancies might be problematic.

The hospital was in staunchly Roman Catholic Norfolk. I leave you to draw your own conclusions.

Some of you will have seen the semi-documentary film of Vera Drake. This film outlines the fictionalised life of a “backstreet abortionist”, which was all too common prior to the 1967 act.

For a reasoned view of the film and some of the consequences of believing all you see on film:

http://www.guardian.co.uk/film/2005/jan/06/health.healthandwellbeing

1. “Designer”

Designer babies have become possible through the development of various medical technologies including IVF, Ultrasound, and even pregnancy testing.

If legislation bans a practice does it go away? As a prime example take “Prohibition” in the 1920s and 1930s in the USA.

There is an argument to be made for sex-selective abortion. Banning it will not make it go away. This is argued in a blog on the BMJ Journal’s website.

The argument is very similar to that made by Judith Jarvis Thomson.

http://spot.colorado.edu/~heathwoo/Phil160,Fall02/thomson.htm

2. Euthanasia

This is the “other end of life”. Peter Singer writes in his book “Rethinking Life & Death” recounts the case of Tony Bland, a football (it’s called ‘soccer’ here) fan crushed in a crowd catastrophe at Hillsborough in Sheffield. The accident resulted in brain damage, a situation that is called a Persistent Vegetative State.(Panksepp et al. 2007)

In PVS the brainstem (sometimes known as the lizard-brain) continues to be electrically active. Basic reflex functions of the body may continue such as breathing or circulation. The Tony Bland case in the UK went to the highest court in the UK for consideration. The cortical brain at which level consciousness ‘resides’ ceases to be active. Panksepp has argued that because we are unable to “define consciousness” and the attributes of “being human” it may well be that the only rational form of “euthanasia” for patients in PVS should be active euthanasia, and therefore invokes the doctrine of double effect.(Panksepp, Fuchs, Garcia, & Lesiak 2007)

There is a distinction often made between “direct killing” by, for example, the administration of a lethal drug and “letting die”.ⁱ We can all appreciate that this might be the case, but is it so? James Rachels, an American ethicist, argued that there is no such distinction “letting die” being an act just as administration of the lethal drug was an act, the former being an act of omission.(Dickenson 2001;Rachels 1975)

In the case of Tony Bland the Law Lords finally had to make an attempt at defining what constituted a meaningful life. (Singer 1994a)

As an illustration of some of the difficulties associated with understanding how exactly life is meant to be fulfilling for an individual Robert Kaplan illustrated his analysis of the complicated and scientifically valid ways of estimating quality of life using a syndicated cartoon, Ziggy. (Kaplan 1994) The Quality Adjusted Life Year, or QALY, is used for comparing health states in individuals and improvements or deterioration.(Bakker and van der Linden 1995) There are perhaps other measurements with which I am less familiar such as the EUROQOL. (Elvik 1995) Most adopt a Utilitarian or Consequentialist ethic.(Singer et al. 1995) As Kaplan states, the purpose of healthcare is “to make people live longer and enhance quality of life before death”. The cartoon in question has Ziggy asking a sage what the purpose or “meaning” of life is. The answer is “doin’ stuff” requiring, of course, the individual to be alive.

3. The Übermensch

This section is to remind us that “science” or philosophy may be misused or perverted and applied as pseudo-science. The ideas of Social Darwinism have largely been discredited,(Weikart 2004) although we continue to breed animals or crops for various traits. Indeed we still make attempts to manipulate food crops such as tomatoes using the GM technology now available.

Francis Galton, a cousin of Charles Darwin, coined the term “Eugenics” in 1883 and his essays were published by the Eugenics Education Society in 1909.(Galton 2005) Indiana enacted a “Eugenics Law” in 1907 making sterilization mandatory for certain individuals, notably criminals and mentally defectives, as such deficiencies were believed to be hereditary.

The Nazis in the 1930s based their despicable policy of ethnic cleansing and “racial Hygiene” on pseudo-science and Hitler’s misappropriation of, and total misinterpretation of Nietzsche’s philosophy.(Weikart 2004) It is doubtful that Hitler had ever read Nietzsche.

1. Eugenics

As mentioned in the preamble the term “Eugenics” was first used by Francis Galton, a cousin of Charles Darwin. It was originally motivated more by ‘social science’ than by biological science and still seems to inspire a more politically motivated policy. The problems arise because of the “rising tide of medical technological possibilities

1. Discrimination

Europe and America have had, and continue to have, disputes over ‘race’. The “Jim Crow” laws were revoked or made illegal in the early 1960s in the USA and yet “white supremacists” and other such groups still exist. In Europe the “ethnic cleansing” in the Balkans during the last 20 or so years is evidence of continuing discrimination.

Women and homosexuals continue, in one way or another, to be discriminated against. Often one comes upon ingrained attitudes blaming women for unwanted pregnancies. A student who recently testified to the US Democrats in support of their national healthcare policies and the need for contraception was branded by a ‘right wing’ talk show host as a “slut” and a “prostitute”. While mention was made of “social responsibility” it was clear that this did not apply to the male gender.

His apology was to say the very least less than generous:

“I think it is absolutely absurd that during these very serious political times, we are discussing personal sexual recreational activities before members of Congress. I personally do not agree that American citizens should pay for these social activities. What happened to personal responsibility and accountability? Where do we draw the line? If this is accepted as the norm, what will follow? Will we be debating if taxpayers should pay for new sneakers for all students that are interested in running to keep fit?”

Homosexuals were, in the early 1980s, blamed for “the Gay Plague”, which of course is now known as AIDS.(Adler 1987) In religious circles and less often among secularists homosexuality is abhorred. It has been demonstrated that “Evolutionary theory provides no guide to morality or ethical progress, nor for appropriate social attitudes toward homosexuality”. (Futuyma and Risch 1983)

1. Patriarchy

Most societies and religions are patriarchal. Judaism, Christianity and Islam have all been male dominated. The practice of Suttee among Hindus, although outlawed now, is indicative of male domination in another of the most populous parts of the world. The multiplicity of female deities in Hinduism does not translate into a respect for women. Sikhism alone seems to enable women. The three monotheistic religions all have a male deity. A Jewish prayer holds “I thank the Lord I was not created a woman”!

http://www.guardian.co.uk/commentisfree/2009/may/31/women- religion-equality

4. Technology

We are told that there is a technical fix for just about anything. However, technical fixes can be a problem as well as a boon to mankind. The simplest example I can think of is the introduction of antibiotics after the Second World War. Just as an example here within this relates to a specialty in which I practiced at one time, Venereology.

Up until the end of the Second World War there had been no effective treatment for either gonorrhoea or syphilis. With the introduction of penicillin both became eminently treatable, to such an extent that in the USA venereal disease clinics were closed permanently. It became possible for primary care physicians simply to prescribe medication often without formal diagnosis. This, of course ignored the fact that contact tracing, an integral and highly skilled part of infectious disease control, needed to be undertaken, and that one could not rely upon the ‘say-so’ of the individual that was treated for the infection.

We get to the war in Vietnam. The USA has finally conceded defeat and is shipping its troops back on “flat-tops”. There is an outbreak of what has become known as “Saigon-Rose”. This was a form of penicillin resistant gonorrhoea. (Under the microscope the bacteria are seen as rose pink, hence the name). The GIs being shipped on the flat-tops have an alternate treatment administered by teams flown out to mid- Pacific.

Nevertheless there is a serious outbreak of Saigon-Rose on the West Coast of the USA. The officers, who were just as “human” in their appetites as had been the GIs, had been flown direct from Vietnam to the West Coast! They had been the vectors of transmission. Furthermore, there were no venereal disease clinics with “contact tracers”. The US had to “import” the expertise of the WHO, in the form of consultants in Venereal Diseases from the UK where the Venereal Disease Clinics and the specialists had been maintained!

1. Designer Babies

Most doctors refuse to screen embryos just for sex selection. Dr. Mark Hughes, who helped pioneer the procedure a decade ago, says he developed it for one reason – to help root out disease.
“I went into medicine and to science to diagnose and treat and hopefully cure disease,” says Hughes. “Your gender is not a disease, last time I checked. There’s no pathology. There’s no suffering. There’s no illness. And I don’t think doctors have any business being there.”
The original purpose of embryo screening was groundbreaking: to diagnose serious genetic disease in embryos like Tay-Sachs, sickle cell anemia, and cystic fibrosis before pregnancy.
“It used to be the doctor would put his or her hand on the woman’s abdomen and say, ‘Yeah everything’s fine.’ And then we had ultrasounds, and then we had amniocentesis,” says Hughes. “This concept was let’s make the diagnosis before the couple ever gets pregnant in the first place. Before they ever start their pregnancy, let’s avoid this disease and prune this serious disorder from their family tree forever.”

Now here is a statement from a doctor and a scientist who has developed a medical technology he intended for one purpose who now finds it being used for a wholly different purpose. That ‘purpose’ is perilously close to Eugenics, whichever way one views it, either as a benefit to mankind or as an ‘abuse’ of science.

1. ToP

Termination of Pregnancy on demand?

You will notice that I call this pregnancy. The religious view is that conception confers rights that are those granted to all human life. The idea of “sanctity of life” has to some extent been mentioned above.

5. Question?

What are Humanists to think? There is no life other than this one and how do we view what we have? We are alive. We each feel that our lives are worthwhile and worth living. What are our responsibilities both to ourselves (egoism) and to others (altruism) or coming generations and the planet?

Is there a point at which we can say that our life is no longer salvageable and we become a burden not only to ourselves but to others?

At the other end of life is there a point at which one becomes a human with all the potential for good – and evil – that this term implies?

There is the massive question of what exactly is meant by the ideas of Mind or Consciousness. When exactly do we acquire such attributes?

References

Adler, M.W. 1987. Development of the epidemic. British Medical Journal, 294, 1083-1085

Bakker, C. & van der Linden, S. 1995. Health related utility measurement: an introduction. J.Rheumatol., 22, (6) 1197-1199

Dickenson, D.L. 2001. Practitioner attitudes in the United States and United Kingdom toward decisions at the end of life: Are medical ethicists out of touch? Western Journal of Medicine, 174, (2) 103

Elvik, R. 1995. The validity of using health state indexes in measuring the consequences of traffic injury for public health. Social Science & Medicine, 40, (10) 1385-1398

Futuyma, D.J. & Risch, S.J. 1983. Sexual orientation, sociobiology, and evolution. Journal of Homosexuality, 9, (2-3) 157-168

Galton, D.J. 2005. Eugenics: some lessons from the past. Reproductive Biomedicine Online, 10, Suppl-6

Jennett, B. 2002, “Ethical issues.,” In The vegetative state. Medical facts, ethical and legal dilemmas., Cambridge: Cambridge University Press, pp. 97-125.

Kaplan, R.M. 1994. The Ziggy theorem: toward an outcomes-focused health psychology. Health Psychol., 13, (6) 451-460

Panksepp, J., Fuchs, T., Garcia, V.A., & Lesiak, A. 2007. Does any aspect of mind survive brain damage that typically leads to a persistent vegetative state? Ethical considerations. Philosophy, Ethics, & Humanities In Medicine, 2, 32

Rachels, J. 1975. Active and passive euthanasia. New England Journal of Medicine, 292, (2) 78-80

Renwick, C. 2011. From political economy to sociology: Francis Galton and the social-scientific origins of eugenics. British Journal for the History of Science, 44, (162:Pt 3) t-69

Singer, P. 1994a, “Tony Bland and the sanctity of human life.,” In Rethinking Life & Death. The Collapse of Our Traditional Ethics., 1 ed. Oxford: Oxford University Press, pp. 57-84.

Singer, P. 1994b, “Uncertain Beginnings.,” In Rethinking Life & Death. The Collapse of Our Traditional Ethics., 1 ed. Oxford: Oxford University Press, pp. 81-105.

Singer, P., McKie, J., Kuhse, H., & Richardson, J. 1995. Double jeopardy and the use of QALYs in health care allocation. Journal of Medical Ethics, 21, (3) 144-150

Weikart, R. 2004, “The Origin of Ethics and the Rise of Moral Relativism.,” In From Darwin to Hitler. Evolutionary Ethics, Eugenics, and Racism in Germany., New York: Palgrave Macmillan, pp. 21-42.

i “The law makes much of intention, as do Catholic theologians. Defenders of treatment withdrawal maintain that death is a foreseen but not intended consequence of the decision to withdraw nonbeneficial or unwanted treatment. It might even be argued as an example of the doctrine of double effect, more often applied to drugs given to relieve symptoms but which may hasten death. Others maintain that as the rationale for stopping ANH [Artificial Nutrition and Hydration] is that life in PVS is not a benefit, and that as death is such an inevitable consequence, it is naive to pretend that the patient’s death was not intended. Indeed the phrase to ‘let die” leaves no doubt about the intention. Motive is not the same as intention — the good motives of those accused of active ‘mercy’ killings do not prevent them facing criminal charges and being convicted, although their motives often result in mitigating the sentence passed”.(Jennett 2002) Page 113.