Artificial Orguns 16(1):102-104, Blackwell Scientific Publications, Inc., Boston 0 1992 International Society for Artificial Organs
If We Can Do It, Should We? Michael Kaye Division of Nephrology, Montreal General Hospital, Montreal, Canada
Fourth, we might deliberately adopt no formal policy on any individual issue (allowing for a few exceptions), but attempt to educate the public and professions at large regarding the values underlying the ethics of choice in the medical context. You may have guessed that this is the approach that I favor, and I would like to explain why. First, because of the cultural and moral diversity within any country and between countries, it may be wrong t o impose one ethical position on all citizens. This approach was acceptable (although not necessarily right), in previous eras when one creed or viewpoint was obligatory for all the people. For example, because of Jewish, Christian, or Islamic views, in much of the world one day a week, either Saturday, Sunday, or Friday, is set aside for all commercial enterprises to close. A religious custom is imposed on all whether they subscribe to those beliefs or not. We are seeing a slow but perceptible movement away from that so that those who wish to observe the Sabbath can, leaving the others with the freedom to do their own thing. As an example of what I am referring to, consider the current Canadian law on abortion. There is none! The previous law was deemed incompatible with our charter of human rights and freedoms in January 1988. The government introduced new (and very unpopular) legislation, and it was defeated in Parliament and never became law. Thus, for three years there have been no laws restricting, mandating, or guiding abortion in Canada, and we have managed very well in their absence. Far better, in my view, than the United States where the controversy over Roe versus Wade threatens to divide the country in senseless hostility. The Catholic Health Association of Canada in their 1991 booklet states: “Direct abortion . . . is immoral” (1). At the same time, in Dr. Morgenthaler’s clinics across the country and in many hospitals (including my own) abortion is available on demand. Now I would like to clarify my viewpoint here. I
We are all aware of the express rate of development of new knowledge, techniques and devices in all branches of medicine. What was undreamt of when I was in medical school has become commonplace today. These changes will not peak, plateau, or slow down but rather will continue to increase in an exponential manner as each new area of knowledge leads to not one or two, but multiple areas of development and application. What I would like to consider in this talk is the appropriate role of bioethics in the face of this explosion in technique. There would seem to be several options. First, each country could legislate what should and should not be done. Detailed laws would be passed to guide and determine human action whether this is surrogate motherhood, abortion, commerce in transplantable organs, and so on. Given the power and importance of the judiciary and the apparent desirability of regulating this vital area, at first glance this seems an appropriate solution. Second, in a manner that this society represents, one could attempt an international set of regulations or guidelines that would be acceptable to several countries, the European community, the whole of North America, and so on. Third, a country could appoint a learned group of individuals to spend time (and money) and consider how and what should be permitted. Such a Royal Commission on reproductive technology is currently deliberating in Canada. They were supposed to finalize their recommendations by year’s end but instead have asked for, and received, an extension. Received October 1991. Address correspondence and reprint requests to Dr. M. Kaye at Division of Nephrology, Montreal General Hospital, Montreal, Canada. This work was presented in part at the VIIIth World Congress of the International Society for Artificial Organs, held August 19-23, 1991, Montreal, Canada.
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IF WE CAN DO IT, SHOULD WE? TABLE 1. Termination of life-sawing treatment 1. Advance directives by a person when competent have moral weight and should generally be followed. 2. Immediate family usually help make treatment decisions for their incompetent relative. 3. Termination of life-saving treatment for an incompetent oatient who has not Drovided anv advanced directive regarding their wishes ’is usually decided upon jointly by the attending physician and immediate family.
am not saying that Sunday closing or abortion is either good or bad. There are valid arguments both for and against. What I am saying is that these ethical choices depend on individual circumstances, background, education, and many other factors. There are no universal rights and wrongs here and legislation may well be inappropriate. The second reason that I advocate a laissez-faire policy relates to the issue of individuality, or distinctiveness. One of the amazing things about being a physician is the recognition of the separateness of each patient and the unique set of circumstances, desires, and expectations that characterize the individual patient. The caricature of “the breast lump in 7C” is so far from reality that it does not bear consideration. Now, if we are dealing with a hundred, a million, or five billion unique individuals, how can we possibly tell them what they should and should not do when we are dealing with new advances in medicine? Civil and criminal laws have taken thousands of years to evolve to their present status. All would agree that theft, murder, rape, arson, and so on are interdicted. How should we become so wise as to know what is right for everyone for problems that did not exist 5, 10, or 30 years ago? Let me illustrate this dilemma with two examples. Table 1 shows a series of statements most of us would probably agree with. It certainly corresponds to current clinical practice in many hospitals. The Hastings Center report on the termination of life sustaining treatment states that “all invasive procedures for supplying nutrition and hydrationall enteral and parenteral techniques-should be considered procedures that require the patient’s or surrogate’s consent, and procedures that the patient or surrogate may choose to forego” (2). Mrs. X is currently aged 80. In 1978, she had a stroke, which left her with a paralyzed left arm. In 1985, she had a femoral neck fracture. At this time dysphagia developed found to be due to an esophageal stricture (Schatzki’s ring), and subsequently she was maintained on pureed food only. In 1987, at the age of 76, she suffered another stroke which
103
resulted in pseudobulbar palsy. She could not communicate, had minimal spontaneous movement, was incontinent, and unable to take food. Nevertheless, she cooperated with all treatment including attempts at physiotherapy. Nasal tube feeding (Dobhoff) was impossible and four weeks after admission, without further improvement, the family unanimously agreed that she would not have wanted to continue living in her present state, and they decided they did not want any further active treatment, in particular a feeding gastrostomy. However, because of the patient’s compliance with treatment, as well as the possibility of further neurological improvement, it was recommended that a gastrostomy for feeding purposes be done. Now, four and one-half years later she remains confined to hospital, requiring nursing care. She is up in a chair daily, understands what is taking place, and plays a good game of checkers. Her husband, who has faithfully visited her daily, believes the correct decision was made almost five years ago. The second example is taken from recent reports in the media. The background is surrogate motherhood, which many believe is wrong. In the U.S., both Michigan and Florida make it a crime to arrange surrogacy contracts, to be a surrogate mother, or to father a child with a surrogate. West Germany was supposed to prohibit surrogate motherhood starting this year. In Quebec, the Bar Association and the Quebec Council of the Status of Women condemn surrogacy and want it banned. The Catholic Health Association of Canada booklet that I quoted earlier states: “Embryo or male gamete transfers to surrogate mothers are not permitted because such procedures violate the unity and dignity of marriage and the natural bonding involved in pregnancy” (3). The case in point is Mrs. Schweitzer from South Dakota who is 42 and is carrying twins for her daughter who was born without a uterus. Both daughter and son-in-law are the biological parents
(4). Dr. Jay Katz, an authority on a variety of ethical issues, is quoted by the New York Times as saying that ”Schweitzer’s surrogacy was a very bad idea” (5). Arthur Caplan, an ethicist from Minnesota, says “I think it is ethically admirable” (6). I happen to wholeheartedly agree. My point in citing these cases is the undesirability and impossibility in my view of passing just laws and regulations regarding technology that is new and that, in some cases, could be good and worthArtif Organs, Vol. 16, No. 1 , 1992
104
M . KAYE
while but on occasions could have unfortunate end results and should not be used. In each of the two cases presented, the right course of action, the ethically desirable choice, was debatable with valid opinions on both sides. Again I would suggest that there may be no universal solution to these ethical dilemmas, but what might be the right course of action for some may be the wrong one for others. This is not like homicide or burglary or libel where the action is invariably wrong. Many, but not all, ethical dilemmas frequently do not lend themselves to unequivocal answers. There are innumerable new things that we can do. Whether we should will take time and much thought. In some instances we should follow a certain path but not in others. In the meantime, may we be spared the Royal Commis-
Artif Orguns, Vol. 16, N o , 1 , 1992
sions and the many lawyers who would decide for us. REFERENCES 1. Human reproduction: abortions. In: Heulrh cure ethics guide. Ottawa, Ontario: Catholic Health Association of Canada, 1991, p. 39. 2. Guidelines on the termination of life-sustaining treatment and the care of the dying. New York: The Hastings Center, 1987. 3. Human reproduction: surrogate mothers. In: Heulth cure ethics guide. Ottawa, Ontario: Catholic Health Association of Canada, 1991, p. 39. 4. When grandmother is the mother until birth. New York Times 1991 Aug 5 , pp. AI-2. 5 . When grandmother is the mother until birth. New York Times 1991 Aug 5 . pp. AI-2. 6. When grandmother is the mother until birth. New York Times 1991 Aug 5 , pp. AI-2.
If We Can Do It, Should We? Michael Kaye Division of Nephrology, Montreal General Hospital, Montreal, Canada
Fourth, we might deliberately adopt no formal policy on any individual issue (allowing for a few exceptions), but attempt to educate the public and professions at large regarding the values underlying the ethics of choice in the medical context. You may have guessed that this is the approach that I favor, and I would like to explain why. First, because of the cultural and moral diversity within any country and between countries, it may be wrong t o impose one ethical position on all citizens. This approach was acceptable (although not necessarily right), in previous eras when one creed or viewpoint was obligatory for all the people. For example, because of Jewish, Christian, or Islamic views, in much of the world one day a week, either Saturday, Sunday, or Friday, is set aside for all commercial enterprises to close. A religious custom is imposed on all whether they subscribe to those beliefs or not. We are seeing a slow but perceptible movement away from that so that those who wish to observe the Sabbath can, leaving the others with the freedom to do their own thing. As an example of what I am referring to, consider the current Canadian law on abortion. There is none! The previous law was deemed incompatible with our charter of human rights and freedoms in January 1988. The government introduced new (and very unpopular) legislation, and it was defeated in Parliament and never became law. Thus, for three years there have been no laws restricting, mandating, or guiding abortion in Canada, and we have managed very well in their absence. Far better, in my view, than the United States where the controversy over Roe versus Wade threatens to divide the country in senseless hostility. The Catholic Health Association of Canada in their 1991 booklet states: “Direct abortion . . . is immoral” (1). At the same time, in Dr. Morgenthaler’s clinics across the country and in many hospitals (including my own) abortion is available on demand. Now I would like to clarify my viewpoint here. I
We are all aware of the express rate of development of new knowledge, techniques and devices in all branches of medicine. What was undreamt of when I was in medical school has become commonplace today. These changes will not peak, plateau, or slow down but rather will continue to increase in an exponential manner as each new area of knowledge leads to not one or two, but multiple areas of development and application. What I would like to consider in this talk is the appropriate role of bioethics in the face of this explosion in technique. There would seem to be several options. First, each country could legislate what should and should not be done. Detailed laws would be passed to guide and determine human action whether this is surrogate motherhood, abortion, commerce in transplantable organs, and so on. Given the power and importance of the judiciary and the apparent desirability of regulating this vital area, at first glance this seems an appropriate solution. Second, in a manner that this society represents, one could attempt an international set of regulations or guidelines that would be acceptable to several countries, the European community, the whole of North America, and so on. Third, a country could appoint a learned group of individuals to spend time (and money) and consider how and what should be permitted. Such a Royal Commission on reproductive technology is currently deliberating in Canada. They were supposed to finalize their recommendations by year’s end but instead have asked for, and received, an extension. Received October 1991. Address correspondence and reprint requests to Dr. M. Kaye at Division of Nephrology, Montreal General Hospital, Montreal, Canada. This work was presented in part at the VIIIth World Congress of the International Society for Artificial Organs, held August 19-23, 1991, Montreal, Canada.
102
IF WE CAN DO IT, SHOULD WE? TABLE 1. Termination of life-sawing treatment 1. Advance directives by a person when competent have moral weight and should generally be followed. 2. Immediate family usually help make treatment decisions for their incompetent relative. 3. Termination of life-saving treatment for an incompetent oatient who has not Drovided anv advanced directive regarding their wishes ’is usually decided upon jointly by the attending physician and immediate family.
am not saying that Sunday closing or abortion is either good or bad. There are valid arguments both for and against. What I am saying is that these ethical choices depend on individual circumstances, background, education, and many other factors. There are no universal rights and wrongs here and legislation may well be inappropriate. The second reason that I advocate a laissez-faire policy relates to the issue of individuality, or distinctiveness. One of the amazing things about being a physician is the recognition of the separateness of each patient and the unique set of circumstances, desires, and expectations that characterize the individual patient. The caricature of “the breast lump in 7C” is so far from reality that it does not bear consideration. Now, if we are dealing with a hundred, a million, or five billion unique individuals, how can we possibly tell them what they should and should not do when we are dealing with new advances in medicine? Civil and criminal laws have taken thousands of years to evolve to their present status. All would agree that theft, murder, rape, arson, and so on are interdicted. How should we become so wise as to know what is right for everyone for problems that did not exist 5, 10, or 30 years ago? Let me illustrate this dilemma with two examples. Table 1 shows a series of statements most of us would probably agree with. It certainly corresponds to current clinical practice in many hospitals. The Hastings Center report on the termination of life sustaining treatment states that “all invasive procedures for supplying nutrition and hydrationall enteral and parenteral techniques-should be considered procedures that require the patient’s or surrogate’s consent, and procedures that the patient or surrogate may choose to forego” (2). Mrs. X is currently aged 80. In 1978, she had a stroke, which left her with a paralyzed left arm. In 1985, she had a femoral neck fracture. At this time dysphagia developed found to be due to an esophageal stricture (Schatzki’s ring), and subsequently she was maintained on pureed food only. In 1987, at the age of 76, she suffered another stroke which
103
resulted in pseudobulbar palsy. She could not communicate, had minimal spontaneous movement, was incontinent, and unable to take food. Nevertheless, she cooperated with all treatment including attempts at physiotherapy. Nasal tube feeding (Dobhoff) was impossible and four weeks after admission, without further improvement, the family unanimously agreed that she would not have wanted to continue living in her present state, and they decided they did not want any further active treatment, in particular a feeding gastrostomy. However, because of the patient’s compliance with treatment, as well as the possibility of further neurological improvement, it was recommended that a gastrostomy for feeding purposes be done. Now, four and one-half years later she remains confined to hospital, requiring nursing care. She is up in a chair daily, understands what is taking place, and plays a good game of checkers. Her husband, who has faithfully visited her daily, believes the correct decision was made almost five years ago. The second example is taken from recent reports in the media. The background is surrogate motherhood, which many believe is wrong. In the U.S., both Michigan and Florida make it a crime to arrange surrogacy contracts, to be a surrogate mother, or to father a child with a surrogate. West Germany was supposed to prohibit surrogate motherhood starting this year. In Quebec, the Bar Association and the Quebec Council of the Status of Women condemn surrogacy and want it banned. The Catholic Health Association of Canada booklet that I quoted earlier states: “Embryo or male gamete transfers to surrogate mothers are not permitted because such procedures violate the unity and dignity of marriage and the natural bonding involved in pregnancy” (3). The case in point is Mrs. Schweitzer from South Dakota who is 42 and is carrying twins for her daughter who was born without a uterus. Both daughter and son-in-law are the biological parents
(4). Dr. Jay Katz, an authority on a variety of ethical issues, is quoted by the New York Times as saying that ”Schweitzer’s surrogacy was a very bad idea” (5). Arthur Caplan, an ethicist from Minnesota, says “I think it is ethically admirable” (6). I happen to wholeheartedly agree. My point in citing these cases is the undesirability and impossibility in my view of passing just laws and regulations regarding technology that is new and that, in some cases, could be good and worthArtif Organs, Vol. 16, No. 1 , 1992
104
M . KAYE
while but on occasions could have unfortunate end results and should not be used. In each of the two cases presented, the right course of action, the ethically desirable choice, was debatable with valid opinions on both sides. Again I would suggest that there may be no universal solution to these ethical dilemmas, but what might be the right course of action for some may be the wrong one for others. This is not like homicide or burglary or libel where the action is invariably wrong. Many, but not all, ethical dilemmas frequently do not lend themselves to unequivocal answers. There are innumerable new things that we can do. Whether we should will take time and much thought. In some instances we should follow a certain path but not in others. In the meantime, may we be spared the Royal Commis-
Artif Orguns, Vol. 16, N o , 1 , 1992
sions and the many lawyers who would decide for us. REFERENCES 1. Human reproduction: abortions. In: Heulrh cure ethics guide. Ottawa, Ontario: Catholic Health Association of Canada, 1991, p. 39. 2. Guidelines on the termination of life-sustaining treatment and the care of the dying. New York: The Hastings Center, 1987. 3. Human reproduction: surrogate mothers. In: Heulth cure ethics guide. Ottawa, Ontario: Catholic Health Association of Canada, 1991, p. 39. 4. When grandmother is the mother until birth. New York Times 1991 Aug 5 , pp. AI-2. 5 . When grandmother is the mother until birth. New York Times 1991 Aug 5 . pp. AI-2. 6. When grandmother is the mother until birth. New York Times 1991 Aug 5 , pp. AI-2.
