Medical Ethics

What makes the approach of Thomas Aquinas to natural law, Summa Theogiae, I-II, q. 94, the most comprehensive presentation? Outline four main advantages of his approach in moral norms and bio-ethics.

by Matthew Charlesworth SJ

Unpublished. Written for BTh 1st Year T13B – Fundamental Moral Theology II, Hekima College, 2 February 2012. (1235 words)

The work of St Thomas Aquinas has for centuries been the major content in all theological education, and indeed... more The work of St Thomas Aquinas has for centuries been the major content in all theological education, and indeed continues to be recommended reading by the Second Vatican Council. Gula defines nature as “the total complexity of human reality take in all its relationships and with all its potential … providing the potential which would make it possible for each person to come to wholeness in community with others seeking wholeness”. But this holistic understanding was not always the case. Classically nature, or more specifically, human nature, has been understood to have two parts, viz. the biological and the rational. This position is as a result of Aquinas’ major contribution to NL Theory as contained in his Summa Theologiæ (ST, I-II, q. 94) where he combined the two prevailing positions in NL Theory viz. the Aristotelian and Stoic Greek philosophers’ emphasis on biological physicality, and the Roman jurisprudence that championed reason and rationality. This was not just a bringing together of Greek and Roman thought, but as Pope Benedict noted, Aquinas “succeeded in establishing a fruitful confrontation with the Arab and Hebrew thought of his time” Additionally, there was an extant Hebrew understanding of NL that held it to be inextricably intertwined with creation, as John Paul II and Gula observes.

Do Embryos Have Interests? Why Embryos Are Identical to Future Persons But Not Harmed by Death

by Aaron Simmons

Published in Journal of Bioethical Inquiry, March 2012

One possible reason to oppose stem cell research on human embryos lies in the thought that death harms embryos by... more One possible reason to oppose stem cell research on human embryos lies in the thought that death harms embryos by depriving them of their valuable future lives as adult humans. Some have challenged this argument on the grounds that embryos aren’t identical to adults: either due to the potential for embryos to twin or because we do not exist until the fetus develops consciousness. I show that these arguments fail and that embryos have future adult lives. However, I contend that their future lives don't have value for them since they are incapable of having desires. I illuminate the connection between having interests and having desires in a way that other authors have not.

Engineering love

by Brian Earp

Savulescu, J. and Sandberg, A. (2012). Love machine: Engineering lifelong romance. New Scientist, 2864, 28-29.

Essay partially adapted from Earp, B. D., Sandberg, A., and Savulescu, J. (2012). Natural selection, childrearing, and the ethics of marriage (and divorce): Building a case for the neuroenhancement of human relationships. Philosophy & Technology, forthcoming [see "profile" box in article].

Available at the New Scientist website: http://www.newscientist.com/article/mg21428646.200-love-machine-engineering-lifelong-romance.html

New Scientist BIG IDEA section, May 2012.

With break-up and divorce a major part of modern life, it looks... more New Scientist BIG IDEA section, May 2012.

With break-up and divorce a major part of modern life, it looks like we may be outliving our inborn capacity to love. But there could be a way to outwit evolution and make love last.

Also available at New Scientist: http://www.newscientist.com/article/mg21428646.200-love-machine-engineering-lifelong-romance.html.

The Argument from Transfer

by Christian Munthe

Final version published in Bioethics 1996, 10 (1): 27-42.

Utilitarian arguments on bioethical issues regarding human reproduction typically start with the view that it is... more Utilitarian arguments on bioethical issues regarding human reproduction typically start with the view that it is wrong, other things being equal, not to procreate when this would have resulted in an additional being with a life worth living. The paper takes this view for granted and examines the common utilitarian claim that overpopulation and destitution in the world mean that, in practice, this obligation to procreate, other things being equal, often turns into a (categorical) obligation not to procreate. A version of this argument is defended - a version called the argument from transfer - according to which, rather than having additional children and care for them in order to make them happy, many people in the West ought to abstain from procreation and take care of destitute children already existing. The reasoning leading up to this conclusion raises some philosophical questions, seldom discussed in connection with bioethics, which indicate that the argument from transfer, although supporting the claim above, cannot neutralise the obligation to create more happy people as easily as assumed by utilitarians. It is argued that the argument from transfer may place many people facing the choice of procreation in a peculiar moral dilemma.

Narrative Medicine and Japan – Canonizing Curricula, Creating Applications, and Reacting to Rapid Professionalization

by Russell Kabir

Written in December 2010, submitted as honors thesis in May 2011.

Exploring the practice of medicine with narrative competence within the Japanese canon of literature, a process and... more Exploring the practice of medicine with narrative competence within the Japanese canon of literature, a process and paradigm known as narrative medicine, could suggest novel solutions to the concerns of the Japanese medical system, pedagogy, and societal infrastructure.

How the Practice and its Patients Make Therapeutic Poetry–From Normative to Narrative and Palliative to Posthumous

by Russell Kabir

Cryopreservation of Ovarian Tissue in Pediatrics: What is the Child's Best Interest?

by Fermín Jesus González-Melado

Overview of psychiatric ethics III: principles-based ethics

by Christopher Ryan

Robertson, M., C. J. Ryan, and G. Walter. 2007. Overview of psychiatric ethics III: principles-based ethics. Australasian Psychiatry 15  (4): 281-286.

Objective: The aim of this paper is to consider the application of principlebased medical ethics to psychiatry. more Objective: The aim of this paper is to consider the application of principlebased medical ethics to psychiatry.

Conclusions: Principles-based medical ethics is a useful tool for resolving ethical dilemmas in psychiatry in that clinical aspects of ethical dilemmas can be better articulated than in other methods. The ethical dilemmas unique to psychiatry, such as those related to impairment of autonomy, present a challenge to the method. After considering a case example, we conclude that psychiatrists can best utilise a principles based approach to ethical dilemmas when they combine this with a level of critical reflection in the light of other ethical theories, such as virtue ethics, as well as close consideration of the clinical and social context of the ethical dilemma.

Mental health acts that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia

by Christopher Ryan

Large, M., O. Neilssen, C. J. Ryan, and R. Hayes. 2008. Mental health acts that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia. Social Psychiatry and Psychiatric Epidemiology 43: 251-256.

Introduction: A long duration of untreated psychosis (DUP) is associated with a worse prognosis, an increased risk of... more Introduction: A long duration of untreated psychosis (DUP) is associated with a worse prognosis, an increased risk of suicide and may be linked to serious violence. Mental health laws that require patients to be dangerous to themselves or to others before they can receive involuntary psychiatric treatment may make it more difficult to treat patients in their first episode of psychosis.

Methods: The mean and median DUP reported in studies of schizophrenia related psychoses were examined. A comparison was made between the DUP reported from jurisdictions that had an obligatory dangerousness criterion (ODC) and those with other criteria for involuntary treatment.

Results: The average mean DUP in samples from jurisdictions with an ODC was 79.5 weeks, but was only 55.6 weeks in those jurisdictions that did not have an ODC (P < 0.007).

Conclusions:  Mental health laws that require the patient to be assessed as dangerous before they can receive involuntary treatment are associated with significantly longer DUP. As reducing DUP is an intervention that can improve the prognosis of schizophrenia, this finding suggests that mental health laws should be amended to allow
treatment on grounds other than dangerousness, at least in the crucial first episode of psychosis.

The danger of dangerousness. An argument against the dangerousness criterion in mental health acts

by Christopher Ryan

Large, M., C. J. Ryan, O. Nielssen, and R. Hayes. 2008. The danger of dangerousness. An argument against the dangerousness criterion in mental health acts. Journal of Medical Ethics 34: 877-881.

Objectives: The mental health legislation of most developed countries includes either a dangerousness criterion or an... more Objectives: The mental health legislation of most developed countries includes either a dangerousness criterion or an obligatory dangerousness criterion (ODC). A dangerousness criterion holds that mentally ill people may be given treatment without consent if they are deemed to be a risk to themselves or others. An ODC holds that mentally ill people may be given treatment without consent only if they are deemed to be a risk to themselves or others. This paper argues that the dangerousness criterion is unnecessary, unethical and, in the case of the ODC, potentially harmful to mentally ill people and to the rest of the community.

Methods: We examine the history of the dangerousness criterion, and provide reasoned argument and empirical evidence in support of our position.

Results: Dangerousness criteria are not required to balance the perceived loss of autonomy arising from mental health legislation. Dangerousness criteria unfairly discriminate against the mentally ill, as they represent an unreasonable barrier to treatment without consent, and they spread the burden of risk that any mentally ill person might become violent across large numbers of mentally ill people who will never become violent. Mental health legislation that includes an ODC is associated with a longer duration of untreated psychosis, and probably contributes to a poorer prognosis and an increase risk of suicide and violence in patients in their first episode of psychosis.

Conclusions: Dangerousness criteria should be removed from mental health legislation and be replaced by criteria that focus on a patient's capacity to refuse treatment.

Rationality and the wish to die - a response to Clarke [Letter]

by Christopher Ryan

Ryan, Christopher James. 2006. Rationality and the wish to die - a response to Clarke [Letter]. Journal of Medical Ethics 26: 217.

The ethical management of body integrity identity disorder: reply to Pies [Comment]

by Christopher Ryan

Ryan, Christopher James. 2009. The ethical management of body integrity identity disorder: reply to Pies [Comment]. Neuroethics 2 (3): 181.

I have suggested that deciding between competing treatments should involve a complicated but familiar algorithm that... more I have suggested that deciding between competing treatments should involve a complicated but familiar algorithm that weighs four factors: chance of relief of suffering, risk of adverse event, cost and patient preference. [1] In suggesting that ethical decisions about management “also be informed by our models of disease processes” and “‘make sense’ in the light of [those] models”, Dr Pies appears to imply that interventions should be preferentially aimed at the organ with the pathology, and that pathological organ-prioritisation bears some additional ethical weight in the decision. This cannot be true.

Minority report

by Christopher Ryan

Ryan, Christopher James. 2009. Minority report. Openmind Magazine 157: 16-17.

In the 2002 film Minority Report we are introduced to a world where all future violence is prevented. A special police... more In the 2002 film Minority Report we are introduced to a world where all future violence is prevented. A special police department called Precrime apprehends people days before they commit a crime, based on the report of three psychic young people – precogs – who are permanently wired into a computer. The story follows the plight of John Anderton, played by Tom Cruise, who discovers he is about to be arrested for a murder he is sure he will never commit.

Amputating healthy limbs

by Christopher Ryan

Ryan, C. J. 2009. Amputating healthy limbs. Issues 86 (March): 31-33.

Jill has two normal legs, but she wants one of them chopped off.

Otherwise, Jill (not her real name) is... more Jill has two normal legs, but she wants one of them chopped off.

Otherwise, Jill (not her real name) is perfectly normal. She is 48 and a married mother of two. She is a business woman and successfully manages three city gift shops. In her spare time, she is manager of her 10-year-old’s soccer team.

Jill’s only complaint is her left leg. Specifically, it is her foot and shin up to exactly 4 cm below her left knee. She can draw a line around her leg at the exact point. Above that line, her leg is perfectly normal.

Out on a limb: the ethical management of body integrity identity disorder

by Christopher Ryan

Ryan, Christopher James. 2009. Out on a limb: the ethical management of body integrity identity disorder. Neuroethics 2 (1): 21-33.

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where... more Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the diagnosis and consideration of other treatment options.

The validity and utility of risk assessment for inpatient suicide

by Christopher Ryan

Large, Matthew, Christopher Ryan, and Olav Nielssen. 2011. The validity and utility of risk assessment for inpatient suicide. Australasian Psychiatry 19 (6): 507-512.

Objective: It is widely assumed that identifying clinical risk factors can allow us to determine which patients are at... more Objective: It is widely assumed that identifying clinical risk factors can allow us to determine which patients are at high risk of suicide while in hospital, and that identifying those patients can help prevent inpatient suicide. We aimed to examine the validity and utility of categorizing psychiatric patients to be at either high or low risk of committing suicide while in hospital.

Method: The assumption that high-risk categorizations are valid was examined by comparing factors included in high-risk models derived from individual studies of inpatient suicide with the results of a meta-analysis of factors associated with inpatient suicide. A valid high-risk model was then applied to a hypothetical clinical setting in order to test the assumption that high-risk categorizations are useful.

Results: The existing models for assessing whether inpatients are at high risk of suicide all include one or more factors that were not found to be associated with inpatient suicide by meta-analysis and were probably chance associations. Depressed mood and a prior history of self-harm are the only well-established independent risk factors for inpatient suicide. Using these risk factors to classify patients as being at high or low risk would prevent few, if any, suicides, and would come at a considerable cost in terms of more restrictive care of many patients and the reduced level of care available to the remaining patients.

Conclusions: Risk categorization of individual patients has no role to play in preventing the suicide of psychiatric inpatients.

Clinical decisions in psychiatry should not be based on risk assessment

by Christopher Ryan

Ryan, Christopher, Olav Nielssen, Michael Paton, and Matthew Large. 2010. Clinical decisions in psychiatry should not be based on risk assessment. Australasian Psychiatry 18 (5): 398-403.

Objective: Risk assessments that place patients in high or low risk categories have been widely adopted by mental... more Objective: Risk assessments that place patients in high or low risk categories have been widely adopted by mental health services in an attempt to reduce the harms associated with psychiatric disorders. This paper examines the effects of categorization based on the results of a risk assessment.

Methods: The violence prediction instrument derived from the MacArthur Study of Mental Disorder and Violence was used to illustrate the nature and effects of risk assessment and the consequent categorization of patients.

Results: The majority of patients categorized as being at high risk will not commit any harmful acts.

Conclusions: Patients who are classified as high risk share the cost of efforts to reduce harm in the form of additional treatment and restrictions, although the majority will not go on to commit a harmful act. Clinical decisions made on the basis of risk assessment also divert resources away from patients classified as low risk, even though a significant proportion do go on to a commit harmful act. We argue that psychiatric professionals should discuss the risks of treatment and of non-treatment with patients (or with their substitute decision-makers) and should maintain a duty to warn about the consequences of not having treatment. However, assessment of risk of harm should not form the basis for clinical decision making. We should aim to provide optimal care according to the treatment needs of each patient, regardless of the perceived risk of adverse events.

Ethics, psychiatry and end-of-life issues

by Christopher Ryan

Ryan, Christopher J. 2010. Ethics, psychiatry and end-of-life issues. Psychiatric Times 27 (6): 26-27.

At the end of life, psychiatrists are often asked to assess a patient’s capacity to refuse treatment, but the role of... more At the end of life, psychiatrists are often asked to assess a patient’s capacity to refuse treatment, but the role of the psychiatrist in this situation is much broader. Even when a person’s mental capacity is not at issue, subtle and not-so-subtle psychological forces can weigh heavily on life-and-death decisions that may be elucidated with a psychiatric assessment. In an ideal world envisaged by supporters of physician-assisted death, patients ask for assistance to die because they have weighed the pros and cons of continued existence; finding the option of prolonging life unsatisfactory, they opt for death at a time of their own choosing—an exit with dignity and grace. Although this scenario may happen, it is far from universal. Often, a request for physician-assisted dying or for withdrawal of life-sustaining treatment results more from a fear of the unknown, a need to maintain control, or a misunderstanding of what the future may bring.

College activities and the ethics of advertising

by Christopher Ryan

Ryan, Christopher, Garry Walter, and Michael Robertson. 2010. College activities and the ethics of advertising. Australasian Psychiatry 18 (2): 101-105.

Objectives: The aim of this paper is to examine whether advertising in the College journals and at RANZCP Congress, in... more Objectives: The aim of this paper is to examine whether advertising in the College journals and at RANZCP Congress, in particular from pharmaceutical companies, gives rise to a conflict of interests, and to discuss how this should be managed.

Conclusions: While advertising will often represent a conflict of interests, banning advertising from the College journals or Congress is unlikely to the best way to manage this. Conflicts of interest may be better managed by development of clear policies on advertisements, broadening the advertising base (i.e. beyond pharmaceutical companies), checking the accuracy of advertisements, and, in the case of Congress, ceasing sponsored symposia.

One flu over the cuckoo's nest: comparing legislated coervice treatment for mental illness and other illness

by Christopher Ryan

Ryan, Christopher James. 2011. One flu over the cuckoo's nest: comparing legislated coervice treatment for mental illness and other illness. Journal of Bioethical Inquiry 8 (1): 87-93.

Many of the world’s mental health acts, including all Australian legislation, allow for the coercive detention and... more Many of the world’s mental health acts, including all Australian legislation, allow for the coercive detention and treatment of people with mental illnesses if they are deemed likely to harm themselves or others. Numerous authors have argued that legislated powers to impose coercive treatment in psychiatric illness should pivot on the presence or absence of capacity not likely harm, but no Australian act uses this criterion. In this paper, I add a novel element to these arguments by comparing the use of the harm to others justification for coercive treatment
in mental illness with its use in illness due to infectious disease, and suggest a double standard applies. People with mental illness are subjected to coercive treatments at levels of risk to others far, far lower than would precipitate coercive treatment in people with influenza. In effect, this element of mental health legislation represents an example of sanism—state-sanctioned discrimination against people with mental illnesses.