the author replies tRobert Wells expressed several concerns about my article. I want to clarify a few of his misconceptions in hopes that readers will better grasp the point I was trying to make in my essay. Wells has accused me of sophistry, the practice of tricking someone by making a clever argument. If I had wanted to trick readers, I would not have used the word “rationing.” I would have made an argument in favor of rationing while avoiding the word “rationing.” I would have used words like “value” and “comparative effectiveness research” in hopes that readers would not see what I was up to. Instead, I specifically used charged terms like “rationing” and “cost effectiveness” in an attempt to make my argument as clear and nondeceptive as possible. But based on Wells’s response, I wasn’t as clear as I hoped. So let me address a few of his other points. Wells implies that I am in favor of assigning people to “classes.” But I never wrote about class assignment in the essay. I think, though, that the fact that Wells brings up this concern about class assignment reveals one of the problems with using loaded words like “rationing.” The word has such strong negative connotations that mere mention of it causes some people to see unethical practices, like denying individuals care on the basis of class assignment, even when no such argument is being made. Wells also seems to misunderstand why I brought up antibiotic use. Imagine a woman with an uncomplicated urinary tract infection. We know that old-fashioned antibiotics will cure the vast majority of such infections. We also know that broader-spectrum antibiotics will have a slightly greater chance of eliminating the infection. Most of us physicians would prescribe the older antibiotic, recognizing that we can turn to the newer, broad-spectrum antibiotic if the patient’s infection persists. We turn first to the slightly less effective antibiotic in part because we want to promote public health. Look at it this way: If the only thing we physicians cared about were the patients in front of us, we would be even more likely to start them 4 HASTIN G S C E N T E R R E P ORT
on powerful antibiotics. Instead, we restrain ourselves for the greater good. I could describe this use of antibiotics as a justifiable rationing decision—physicians forgo very small chances of benefit for their patients in order to promote the best interests of patients at large. But physicians who feel in their gut that rationing is always wrong would recoil at that idea. So the profession has turned to calling this “antibiotic stewardship,” and most physicians consequently embrace the idea. The more relevant issue is not what we call this practice, but instead, whether this practice is ever acceptable. Is it okay for physicians to trade off small benefits to their patients for the greater good of the population? I would answer that it is. But it is also important to understand that if I claim that antibiotic steward-
Mere mention of “rationing” causes some to see unethical practices. ship can be a morally acceptable practice, that’s not the same as claiming that antibiotic stewardship is always morally acceptable. For example, it would be immoral to allow a patient to suffer from a life-threatening and reversible infection just in order to reduce antibiotic resistance in the population at large. One problem with the word “rationing” is that it so depresses people, to use Wells’s language, that they leap to understandable but unjustifiable conclusions. If someone argues that rationing is sometimes morally acceptable in health care settings, then some people assume that they are arguing that all rationing is acceptable. That might be why Wells leapt to the conclusion that there is nothing to stop physicians working to assign patients to “classes.” To reiterate a main point of my earlier essay, sometimes it is difficult to engage in careful reasoning when we use emotionally charged words. • Peter A. Ubel Duke University DOI: 10.1002/hast.463
u Can Voice
Be Given If No One Is Listening?
How do the politics of abortion decisions reinforce notions of the self not only in relation to the fetus but also in relation to the man and woman who had sex? I ask this question after reflecting on the provocative and thoughtful essay “Men and Abortion Decisions,” by John Hardwig (March-April 2015). For Hardwig, the decision to have a child results in obligations and consequences that extend beyond the woman and her experience of childbirth, and, for that reason, the decision to go forward with a pregnancy should not rest exclusively with the woman. Childbirth represents only one piece of the many constituting the experience of parenthood, and, given this, he argues that both partners should have the opportunity to consent to parenthood and all that it entails. However, for Hardwig, this logic about shared decision-making applies only to women planning to go forward with a pregnancy, not women planning to have an abortion. In the latter case, hashing out the interests and values of both parties becomes moot: if one partner does not wish to become a parent, then that is a morally sufficient reason to terminate the pregnancy. “It is worth pausing to note,” Hardwig writes, “that my view does not mean that a woman who is planning to have an abortion needs to discuss this decision with her sexual partner. Not at all.” I would like to consider how this claim—one adopted by some mainstream pro-choice advocates as well as Hardwig—privileges notions of an individualized self over notions of an interdependent one. Hardwig aims to prioritize informed consent, not necessarily bodily autonomy for women, as a moral requisite in becoming a parent. However, by unquestioningly dismissing the intangible and tangible benefits that might result from a reasonable discussion between the man and the woman faced with a pregnancy, he misses an opportunity to argue for a male voice in July-August 2015
abortion decisions—which is his central aim—in a way that highlights a nontrivial contradiction between mainstream feminist theory and practice. Many contemporary feminist thinkers have critiqued presumptions of an autonomous self, one that makes decisions in a vacuum where relationships and mutual obligations do not exist. Humans are interrelated, and, in my view, respect for persons requires recognizing the particular relationships that constitute the self. One form of recognition and respect for persons is listening to the voices of those in relation to you, if you have reason to believe that you are not endangering yourself by engaging in a discussion—this latter contingency is considerable and is addressed more below. The tangible benefits of choosing to have a discussion include affording moments of ethical reflection and creating opportunities for shared decision-making. How often do we go into a conversation with our minds made up only then to have them changed? How often are we later grateful for that change? The intangible benefits of choosing to have a discussion include affording moments for mutual personal reflection, which might affect understandings of identity, ethnicity, community, or faith. It seems inconsistent for relational feminists to advocate for an interdependent self and simultaneously fail to question whether there are benefits to engaging in a conversation about a woman’s plan to have an abortion before she goes forward with that plan. The kind of recognition that I am envisioning does not impede the woman from having the final say over what happens to her body. Without imposing any obligations, I merely want to ask, in cases where a woman feels it safe to do so— and, certainly, there will be particular cases where it might not be safe to do so—should she share her plan to seek an abortion with her sexual partner? Even if the answer to the “should” is no, there might be tangible and intangible benefits that such sharing can result in. It is also possible that the costs of attempting this kind of shared decisionmaking could outweigh the benefits July-August 2015
that I’ve described. What if you have a one-night stand? Are you obligated to have such a conversation with someone you barely know? What about a woman who consents to sex in the context of an unhealthy or abusive relationship? Should a woman feel obligated to disclose a pregnancy to a man who might manipulate her into parenting a child that she might not have had otherwise? These are questions that raise weighty exceptions accounting for possible harms that some women might face in pursuing such a conversation. However, there is a marked difference between protecting yourself from a threatening situation and avoiding an extremely difficult conversation with possible moral significance. Making such a determination might not be as clear-cut in real time, but I want to con-
Respect for persons requires recognizing the particular relationships that constitute the self. clude by focusing on those cases where women can safely discuss their plan to abort a pregnancy with their sexual partner. Like Hardwig, I am interested in questioning how the politics of abortion decisions have “reinvented patriarchy.” Pro-choice feminists have sought to have their voices heard in a world where bodily autonomy did not—and in many places still does not—exist for women. This is admirable and brave. However, seeking to have your own voice heard does not necessarily require silencing others. Can a woman understand herself as equal if sharing and defending her deeply held interests threatens that sense of equality? Can voice be given if listening is precluded? • Chelsea A. Jack The Hastings Center DOI: 10.1002/hast.464
the author replies tI acknowledge, even insist on, the epistemic, the personal development, and the moral growth potentials of a
ON THE WEB n Bioethics Forum http://www.bioethicsforum.org Sex, Consent, and Dementia By Bonnie Steinbock Using affirmative consent as the standard would deprive patients with severe dementia 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—even older ones, even ones who have dementia—of physical intimacy. Why New Zealand Should Permit Aid in Dying By Sue Dessayer Porter [T]he New Zealand case pivots around the interpretation of “aiding or abetting suicide.” . . . If the Crimes Act, Section 179, would be interpreted to separate the concepts of suicide and aid-in-dying, [Lecretia Seales’s] doctor could be protected from prosecution should she assist Seales by prescribing a medication to enable her to end her life peacefully. Suing for Justice? More on the U.S. STD Studies in Guatemala By Susan M. Reverby This new lawsuit raises the serious and still unresolved question of how to obtain justice for those harmed by the study. The difficulties are enormous. The names in the records are vague. The study took place nearly 70 years ago. The U.S. Public Health Service ran it with funds from the National Institutes of Health and the Health Ministry in Guatemala. So who should pay for the harm to the victims and their families? Why College Students Use Cognitive Enhancers: It’s Not Only about Grades By Susan Gilbert [I]t’s safe to assume that many college students used stimulants such as Ritalin and Adderall to get through finals. While the students may have been motivated to improve their odds of getting good grades, a new study suggests that students’ reasons for taking simulants aren’t so blatantly opportunistic. H AS TI N GS C E N TE R RE P O RT
5
on powerful antibiotics. Instead, we restrain ourselves for the greater good. I could describe this use of antibiotics as a justifiable rationing decision—physicians forgo very small chances of benefit for their patients in order to promote the best interests of patients at large. But physicians who feel in their gut that rationing is always wrong would recoil at that idea. So the profession has turned to calling this “antibiotic stewardship,” and most physicians consequently embrace the idea. The more relevant issue is not what we call this practice, but instead, whether this practice is ever acceptable. Is it okay for physicians to trade off small benefits to their patients for the greater good of the population? I would answer that it is. But it is also important to understand that if I claim that antibiotic steward-
Mere mention of “rationing” causes some to see unethical practices. ship can be a morally acceptable practice, that’s not the same as claiming that antibiotic stewardship is always morally acceptable. For example, it would be immoral to allow a patient to suffer from a life-threatening and reversible infection just in order to reduce antibiotic resistance in the population at large. One problem with the word “rationing” is that it so depresses people, to use Wells’s language, that they leap to understandable but unjustifiable conclusions. If someone argues that rationing is sometimes morally acceptable in health care settings, then some people assume that they are arguing that all rationing is acceptable. That might be why Wells leapt to the conclusion that there is nothing to stop physicians working to assign patients to “classes.” To reiterate a main point of my earlier essay, sometimes it is difficult to engage in careful reasoning when we use emotionally charged words. • Peter A. Ubel Duke University DOI: 10.1002/hast.463
u Can Voice
Be Given If No One Is Listening?
How do the politics of abortion decisions reinforce notions of the self not only in relation to the fetus but also in relation to the man and woman who had sex? I ask this question after reflecting on the provocative and thoughtful essay “Men and Abortion Decisions,” by John Hardwig (March-April 2015). For Hardwig, the decision to have a child results in obligations and consequences that extend beyond the woman and her experience of childbirth, and, for that reason, the decision to go forward with a pregnancy should not rest exclusively with the woman. Childbirth represents only one piece of the many constituting the experience of parenthood, and, given this, he argues that both partners should have the opportunity to consent to parenthood and all that it entails. However, for Hardwig, this logic about shared decision-making applies only to women planning to go forward with a pregnancy, not women planning to have an abortion. In the latter case, hashing out the interests and values of both parties becomes moot: if one partner does not wish to become a parent, then that is a morally sufficient reason to terminate the pregnancy. “It is worth pausing to note,” Hardwig writes, “that my view does not mean that a woman who is planning to have an abortion needs to discuss this decision with her sexual partner. Not at all.” I would like to consider how this claim—one adopted by some mainstream pro-choice advocates as well as Hardwig—privileges notions of an individualized self over notions of an interdependent one. Hardwig aims to prioritize informed consent, not necessarily bodily autonomy for women, as a moral requisite in becoming a parent. However, by unquestioningly dismissing the intangible and tangible benefits that might result from a reasonable discussion between the man and the woman faced with a pregnancy, he misses an opportunity to argue for a male voice in July-August 2015
abortion decisions—which is his central aim—in a way that highlights a nontrivial contradiction between mainstream feminist theory and practice. Many contemporary feminist thinkers have critiqued presumptions of an autonomous self, one that makes decisions in a vacuum where relationships and mutual obligations do not exist. Humans are interrelated, and, in my view, respect for persons requires recognizing the particular relationships that constitute the self. One form of recognition and respect for persons is listening to the voices of those in relation to you, if you have reason to believe that you are not endangering yourself by engaging in a discussion—this latter contingency is considerable and is addressed more below. The tangible benefits of choosing to have a discussion include affording moments of ethical reflection and creating opportunities for shared decision-making. How often do we go into a conversation with our minds made up only then to have them changed? How often are we later grateful for that change? The intangible benefits of choosing to have a discussion include affording moments for mutual personal reflection, which might affect understandings of identity, ethnicity, community, or faith. It seems inconsistent for relational feminists to advocate for an interdependent self and simultaneously fail to question whether there are benefits to engaging in a conversation about a woman’s plan to have an abortion before she goes forward with that plan. The kind of recognition that I am envisioning does not impede the woman from having the final say over what happens to her body. Without imposing any obligations, I merely want to ask, in cases where a woman feels it safe to do so— and, certainly, there will be particular cases where it might not be safe to do so—should she share her plan to seek an abortion with her sexual partner? Even if the answer to the “should” is no, there might be tangible and intangible benefits that such sharing can result in. It is also possible that the costs of attempting this kind of shared decisionmaking could outweigh the benefits July-August 2015
that I’ve described. What if you have a one-night stand? Are you obligated to have such a conversation with someone you barely know? What about a woman who consents to sex in the context of an unhealthy or abusive relationship? Should a woman feel obligated to disclose a pregnancy to a man who might manipulate her into parenting a child that she might not have had otherwise? These are questions that raise weighty exceptions accounting for possible harms that some women might face in pursuing such a conversation. However, there is a marked difference between protecting yourself from a threatening situation and avoiding an extremely difficult conversation with possible moral significance. Making such a determination might not be as clear-cut in real time, but I want to con-
Respect for persons requires recognizing the particular relationships that constitute the self. clude by focusing on those cases where women can safely discuss their plan to abort a pregnancy with their sexual partner. Like Hardwig, I am interested in questioning how the politics of abortion decisions have “reinvented patriarchy.” Pro-choice feminists have sought to have their voices heard in a world where bodily autonomy did not—and in many places still does not—exist for women. This is admirable and brave. However, seeking to have your own voice heard does not necessarily require silencing others. Can a woman understand herself as equal if sharing and defending her deeply held interests threatens that sense of equality? Can voice be given if listening is precluded? • Chelsea A. Jack The Hastings Center DOI: 10.1002/hast.464
the author replies tI acknowledge, even insist on, the epistemic, the personal development, and the moral growth potentials of a
ON THE WEB n Bioethics Forum http://www.bioethicsforum.org Sex, Consent, and Dementia By Bonnie Steinbock Using affirmative consent as the standard would deprive patients with severe dementia 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—even older ones, even ones who have dementia—of physical intimacy. Why New Zealand Should Permit Aid in Dying By Sue Dessayer Porter [T]he New Zealand case pivots around the interpretation of “aiding or abetting suicide.” . . . If the Crimes Act, Section 179, would be interpreted to separate the concepts of suicide and aid-in-dying, [Lecretia Seales’s] doctor could be protected from prosecution should she assist Seales by prescribing a medication to enable her to end her life peacefully. Suing for Justice? More on the U.S. STD Studies in Guatemala By Susan M. Reverby This new lawsuit raises the serious and still unresolved question of how to obtain justice for those harmed by the study. The difficulties are enormous. The names in the records are vague. The study took place nearly 70 years ago. The U.S. Public Health Service ran it with funds from the National Institutes of Health and the Health Ministry in Guatemala. So who should pay for the harm to the victims and their families? Why College Students Use Cognitive Enhancers: It’s Not Only about Grades By Susan Gilbert [I]t’s safe to assume that many college students used stimulants such as Ritalin and Adderall to get through finals. While the students may have been motivated to improve their odds of getting good grades, a new study suggests that students’ reasons for taking simulants aren’t so blatantly opportunistic. H AS TI N GS C E N TE R RE P O RT
5
