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There was a debate recently about organ donation, and one group of people

There was a debate recently about organ donation, and one group of people adamantly opposed the notion of making organ donation mandatory or even opt-out, because, and I quote, "They're my organs and nobody else gets to decide what to do with them." Considering organ donation only ever occurs when a person is deceased and no longer has any use for the organs, how is ownership of organs even relevant to the discussion? Why shouldn't it be acceptable to make organ donation opt-out, or even mandatory?

The claim that a deceased person has no use for her organs, that the integrity of her body after her death is of no importance to her, is a claim that many dispute, typically in the context of some religious beliefs or others. It seems best for the state to avoid policies that some citizens find offensive on the basis of religious beliefs which the state is in no position to refute. Fortunately, we can avoid such policies in this case: by making organ donations opt-out, as you suggest, we'd have all the organs we might need.

The reason against this which you cite ("They're my organs and nobody else gets to decide what to do with them") is not a good reason against the opt-out solution. Yes, they are her organs and she alone gets to decide what to do with them -- but we still need to have a fall-back default for those cases in which a person dies without leaving clear instructions. Here any default society might settle upon is in the same boat, e.g. subject to the objection that it may not be what the deceased would have wanted when she was still alive. Still, society needs to set up some default and may then democratically select and implement any default so long as it is widely publicized and can easily be overruled by the person while she is still alive. In this democratic process, I for one would argue for the opt-out solution because it would bring huge benefits to people in need of organs.

Is it ethical for a pharmaceutical company to keep the results of a negative

Is it ethical for a pharmaceutical company to keep the results of a negative clinical trial secret? Patients participate in clinical trials of an investigational drug for many reasons. One of these reasons may be the desire to benefit society. If a pharmaceutical company keeps clinical trial results secret, society will not benefit. (Companies keep negative results secret because they want to avoid benefiting a competitor or simply because there is a cost to releasing the information.) There are many adverse consequences of the failure to make negative data public. For example, other companies may unwittingly conduct clinical trials on drugs that work by the same biological mechanism subjecting many people to risks without the possibility of benefit. In addition, the negative results represent important scientific information that may guide researchers to the development of drug strategies that do provide a positive benefit for patients. When pharmaceutical companies enroll patients in a clinical trial,...

I can see some justification for wishing to nuance negative results, by claiming that they might be contradicted by future more positive results and so on, but on the whole it is important that negative results are made available generally. This has nothing to do with the wishes of the participants in the experiments, it seems to me, but their general public duty to help people avoid harm. There are two pragmatic aspects to this which are significant. The public ought to realize that results go in a variety of directions and should try to be sophisticated in working out what those results mean. Secondly, companies that are frank about negative results will gain more respect than if they do not, and so might themselves benefit anyway.

I am now taking a medication once a month to manage a symptom of a slow-growing

I am now taking a medication once a month to manage a symptom of a slow-growing cancer that I have. I just started Medicare last year and see by my statements that the cancer center charges my Medicare an enormous sum of money for this treatment and my oncologist says that there is not a generic equivalent that can be administered this way. Is it ethical for them to charge this sum (over $10,000) for an injection and is it morally "acceptable" for me to take this, at great cost to my fellow taxpayers?

It is very good of you to pay attention to these costs borne by others -- most people don't. Given the amount involved ($120,000 per annum), I think you should make an effort to find out more. Your oncologist says that no generic drug "can be administered this way" -- well, is there a compelling reason why it should be so administered, or would you be equally well off with the generic product administered in some other way? It is quite possible that your oncologist makes a lot more money from giving you the expensive medication rather than the cheaper one, so explore the question on the internet and perhaps also ring Medicare to get their opinion. If we all pay attention in this way, then it will be much harder for pharmaceutical companies and medical providers to overcharge the system we all pay for.

If the expensive drug you are taking really is the only way to manage the symptom in question, then I would expect this symptom to be serious enough to justify this lavish reimbursement. But perhaps the symptom isn't very bad and the treatment is reimbursed only because of some corporate lobbying? If so, you might well forego the treatment and even question more generally its use in cases such as yours. On the other hand, if the treatment makes you feel and function much better, then you are surely entitled to it. You should then not feel bad about the cost you are imposing on the rest of us, for the roles might easily have been reversed with you contributing to the cost of relieving my severe cancer symptoms. If the treatment helps you substantially, I for one am willing to help pay for it (and so are, I daresay, most others).

Is it unethical to charge $10,000 for an injection? I cannot answer this from the facts you provide. I am sure that the marginal cost of producing the fluid injected is a tiny fraction of $10,000. But then it may have been very expensive to develop and test this treatment, in which case the price tag might be justifiable. Or the price tag may be the result of lobbying and corruption, in which case it would not be justifiable. Again, you might spend a little time on finding out more.

Is it paradoxical for the US government to render embryonic stem cell research

Is it paradoxical for the US government to render embryonic stem cell research illegal, in a country where abortion is legal??

The current debates about embryonic stem cell research concern whether federal funding should be spent upon it, not on whether such research is banned in the USA. Similarly, federal funding for abortion is more controversial than its legality.

Definitions of health tend to focus on the absence of non-health, as in "health

Definitions of health tend to focus on the absence of non-health, as in "health is the absence of disease," or in terms of what health affords us, as in "health allows one to lead a vital life." These approaches seem to avoid consideration of what health is. Why do we do this? Is it possible that something can only be defined in terms of what it is not, or what it leads to? How would we go about considering a definition of health?

Actually, the WHO defined health in 1946 as "a state of complete physical, mental and social well-being." So health can be defined positively; the question is how useful such a definition is. Some think that this definition sets the bar too high (who among is is healthy according to that definition?) others that it gives us no help with prioritizing health care interventions (is it more important to improve the health of those who are already fairly healthy or those who are not health at all?), still others that it confuses general well-being with health. It may be that we do not need a general definition of health, just particular definitions appropriate to particular contexts.

I'd like some help for a panel discussion next week on "What makes a good doctor

I'd like some help for a panel discussion next week on "What makes a good doctor". My weekly reading of the BMJ online (which I access through a university library) yields a spate of articles, and over 70 criteria and still counting. An epidemiologist proposed "a doctor who is interested not only in the individual patient but also in the likely health of other relevant people. This of course recalls the poem of the 6 blind Hindoo scholars describing an elephant (qg, which is shorthand for "google this for more", similar to qv). A coffee-time discussion today foussed on whether a doctor should be "touchy-feely" or not. The answer is, of course, it all depends. No for an intensivist at the bedside of a gravely ill patient, yes when s/he is talking to the relatives about possible outcomes of proposed treatments or withholding them. There is of course William Osler's Aequanimitas, which advises emotional detachment. Are there other useful talking points like "touchy-feely" to convince or suggest to other...

I can only speak to the issue of what seems to be to be one of the necessery conditions for being a good doctor, namely, the capacity to listen. No more than that -to draw people's feelings out.Many people are terrified of doctors for the sentences that they seem to pass down. It is imperative that docs grasp the vulnerability that people feel with them. I understand that a certain level of detachment is required for cutting into someone but that same kind of dteachment need not exist at the bedside or in the exam room. Our inner lives inscribe themselves on our body and for good treatment a doc has to make an effort to connect and understand what is going on behind the eyes. Perhaps I am misreading but the references in the question to "touchy-feely points" seems to me to suggest a somewhat dismissive atttitude towards the emotional life. But again, essential to being a god doc is the generosity of heart and psychological literacy to take the time to get to know the people you are treating. Thanks for the important question.

As someone who is clinically depressed, I have often wondered: philosophically

As someone who is clinically depressed, I have often wondered: philosophically speaking, is trying to treat depression wrong? People are depressed for a reason, possibly because life's pretty damned depressing once you get down to it. It seems to me that in plenty of cases, depression is a logical reaction to this planet, a rather depressing thought in and of itself. Despite the wars and the plagues and the genocides and the poverty and the seemingly countless other reasons for one to be depressed, people treat depression like a disease when it seems more like a perfectly acceptable reaction to the human condition. Treating depression like this appears to me as a rather unsubtle way of trying to trick people into believing everything is going to be okay when reality seems to contradict this. Any thoughts?

Depression used to be classified in two forms: endogenous ("originating from within") and reactive. There was an obvious point to this way of classifying things, but a different way has been suggested recently. The newer way is to distinguish between cases in which depression, the medical condition, is present, with its bodily neurophysiological causes, and cases in which only symptoms of depression are present, and which lack the underlying neurophysiological cause. The symptoms might however be produced by some environmental cause, a depressing incident, a personal loss or a major setback in life, without the marked and persisting change in the biochemistry of the brain which is believed to underly the medical condition. The significant difference between the two kinds of condition seems to be that changes in the environment typically don’t touch the medical condition. That may even be a defining characteristic of the condition, as well the usual things doctors look for, such as failure of concentration, changes in eating habits, sleep disturbances, and so on. (Grief, perhaps, can be severe enough to be a borderline case, or develop into real depression.)

Whether to treat with medication should be based on this distinction, or one like it. When the condition is serious enough to block the happy and satisfying life that we could otherwise reasonably expect, then we should perhaps be thinking about treating it with medication. If we see a friend or family member going through the darkness and dangers of severe depression, we will want to do what we can, and we all have an obligation to help, especially if we are medical professionals.

There is by the way also some interesting empirical evidence that people suffering from depression are actually more accurate in their judgments of situations with possible negative outcomes than people without the condition. From this point of view it might look as though the depression is the result of the more accurate perception! On the other hand, depression causes inaccurate and falsely negative mis-readings of facial expressions.

The world situation is disturbing. But if someone has real depression, can’t work, can’t sleep properly, can’t form ideas or concentrate, then this may have to do with an organic problem. What is being removed by medication is this very clear and noticeable condition, with all its miseries. It would be a trick and a tricky philosophical proposition if treatment just removed the perceptions and judgments of the world situation. But they may not actually be the cause of the distress, though it can seem as though they are. The situation is rather that proper medication may be able to prevent irrelevant and unnecessary distress, and even to make it possible to act on the view one has of the world situation.

Should people who engage in health damaging choices like smoking, drinking, drug

Should people who engage in health damaging choices like smoking, drinking, drug abuse, overeating be denied organ transplants if their organs where to fail as a result of their actions?

I don't see why. If there is reason to think that these bad choices would continue in such a way as to make the transplant likely to fail, then I can see having them be a factor. But if a patient needs a transplant, then it does not seem to me to be up to the medical profession to deny that transplant on some moralistic ground.

Consider two cases, where both need a kidney transplant. In one case (A), we have good reason to believe that the patient needs the transplant because of drug abuse earlier in their lives. (Let's not complicate the issue further by going into how likely we think it is that the person might return to drug abuse if the transplant is done successfully.) In the other case (B), we see no such evidence, but we also do know that B has been guilty several times in his life of physically or sexually abusing members of his family in numerous ways. Imagine finally that only A and B could be plausible candidates for this transplant--the kidney will spoil and be useless to anyone if the transplant is not made in the next day. Should it be a medical decision to withhold the transplant from A or B because of what we know about them?

The reason I give this case is because I think that there may be any number of factors that might incline us to favor one over another candidate for a transplant. Maybe A is also a really funny person who is charming to be with and B is a total grouch liked by very few people. Should that matter? I can sympathize with those who feel the pull of such considerations, but I really think it would be a very bad idea to have doctors or medical staff making medical decisions based on such factors.

Medical teams do have criteria they apply to these decisions, and perhaps the sself-inflicted nature of some medical conditions should count as a kind of "tie-breaker" in otherwise similar cases. But bringing in more such considerations seems to me to be an extremely risky business, and judgments about these are not appropriately made by medical professionals.

A friend of mine has an adult daughter who is mentally disabled. Roughly

A friend of mine has an adult daughter who is mentally disabled. Roughly speaking, her daughter thinks and talks like a seven-year old child, and cannot take care of herself. The disabled daughter is sexually interested in men, but as far as I know she never had sex with anyone. When she was 20-something, the mother had the daughter medically sterilized. This brought her no suffering, and she behaves as she did before. The mother's fear was that she would get pregnant. For a few weeks every year, the daughter is away from her mother in a clinic for mentally disabled people. I wonder if it was morally acceptable for the mother to have her daughter sterilized.

This is the kind of case that makes reasonable people feel very squeamish, and over which reasonable people can disagree. But though I won't be surprised if others respond and reject what I am about to say, I'm inclined to side with the mother.

Ethical theorists generally approach questions like these from one of three basic approaches. One of these is called the deontological approach, which tends to focus on our moral notions of basic obligations and responsibilities. If we think that everyone, no matter what their mental defects, has a fundamental right to autonomy, then the mother's actions obviously interfered with the daughter's autonomy with respect to having (her own biological) children. On the other hand, we may doubt that such a fundamental extends in an absolute or complete way to someone who is incapable of exercising that autonomy, which appears to be the fact about this case. The daughter could biologically have a child, but could not actually be responsible for the child she might have. So my own reaction is to think that this particular "right" (the right to have biological children) is not a basic right at all. If so, there seems to be no reason to think the mother violated her daughter's rights.

Another way to approach such questions is "consequentialism," which estimates the value of actions in terms of foreseeable and morally relevant consequences. A rough and ready way of thinking of this case in such a way is to ask, "What if the daughted did get pregnant?" The obvious answers are: (a) She could have an abortion, or (b) she could give birth and then give the child up for adoption, or (c) some family member(s) could raise the child for/with her. It is not clear to me that forcing the daughted into situation (a) isn't pretty much comparable to what the mother did: one way or the other this is to force the daughter into an invasive medical procedure for which the daughter has not the competence to give genuine assent. But in this case, it might actually be much worse than what the mother did, because not only could there be other medical risks here, but also possibly emotional risks--even seven-years-olds can feel emotions and have these be significant in their lives. Moreover, situation (a) is one that might have to be repeated, maybe even many times! I think you can see how this works, by just thinking about how (b) and (c) could play out. There looks to be lots of realistic and likely outcomes that are very negative in each case. The mother's action prevented any and all of these bad consequences.

Finaally, there is a virtue theoretic approach, according to which we assess actions as indications of, and motivated by, morally significant character traits. The mother had her daughter sterilized for what are likely to be many different reasons (including, as I have suggested, concerns about likely bad consequences). Are we prepared to say that in doing this, the mother's motives were (mainly) selfish ones? If so, we would condemn the selfishness--but this seems quite wrong to me, since the mother seems to continue to take care of the daughter in what sounds like a very unselfish way. Instead, I am inclined to think the mother did it out of concern for the daughter, and for those the daughter's actions might impact. That concern, and the mother's sense of responsibility in this matter, seem to me to indicate something more like virtue than vice.

By each measure, accordingly, I am inclined to think the mother did the right thing.

Should circumcising your child be illegal? I certainly think that female

Should circumcising your child be illegal? I certainly think that female circumcision like that practiced in Islam should be, but what about a male child? The operation doesn’t seem too invasive but shouldn’t a young boy be given the right to choose? I mean, it –is- hygienic but it also mitigates sexual pleasure. Maybe I’d prefer to be delighted than clean? It's my body! Do I have to get pregnant before I actually have rights over it? I mean, if a girl who’s under age can’t be forced to have an abortion, why can people slice off the foreskin of my reproductive organs without consulting me? It seems to me that this tradition is only allowed because it's religious-which is absurd. It's also religious for a Muslim to strike his wife with an open palm to the head when she leaves the house without his permission. Some cults practice human sacrifice-we don’t allow these just because they’re religious culture/tradition, why circumcision? Just because a baby can’t speak out?

You have some rather inaccurate views on Islam. Islam has nothing to say about female circumcision, although it is true that the practice is not uncommon in some Muslim societies. It is also not an Islamic practice to assault wives for leaving the house without permission, although again it does go on. Just because such practices exist in Muslim societies does not mean that they are Islamic.

But you raise an interesting issue, how far can the mutilation of an infant or child be justified if carried out for religious reasons? It is accepted now I think largely because it is held to be good for the child, not as you suggest for religious reasons. This is the difference between male and female circumcision, the former is generally supposed to be a benign and helpful procedure, the latter the reverse. I suppose the question is how confident we are that the procedure is helpful, and how important is it that it be carried out at such an early age, as against interfering in the rights of the individual to hold onto his various bits and pieces. I do not know what science suggests on this issue, but it had better be a pretty strong argument. Otherwise assault on the individual in this radical sort of way would be very difficult to justify.

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