Thursday, March 26, 2015

Conscientious objection in medicine: Private ideological convictions must not supersede public service obligations

Canada’s Supreme Court decided that Canadians’ constitutional rights are violated by the criminalisation of assisted dying. Canada’s politicians are currently scrambling to come up with an assisted dying regime within the 12 month period that the Supreme Court gave them to fix the problem.

Since then the Canadian Medical Association, the country’s doctors’ lobby organisation, has insisted not only that doctors must not be forced to provide assisted dying, but also that doctors must not be required to transfer patients asking for assisted dying on to a colleague who they know will oblige these patients.(1) 

In many countries, including Canada, conscientious objection clauses protect – mostly - health care professionals from being forced to act against their individual ideological convictions. I suspect it isn’t unfair to note that these protections in the real world are nothing other than protections for Christian doctors who are unwilling to deliver services they would be obliged to deliver to patients who are legally entitled to receive these services, were it not for their religiously motivated objections.(2) Secular health care professionals could arguably avail themselves of conscience clauses, but in a liberal democracy, what reasonable conscience based cause could they have to refuse the provision of health care services to patients? Conscience clauses today are by and large a concession of special rights to Christian health care professionals, at least in secular Western democracies.

An uneasy compromise is often struck that stipulates that conscientious objectors must not be forced to deliver the health care services that they object to, but that they must ensure that patients will be transferred to a health care professional willing to provide the requested service. Typically they are prohibited from engaging in activities aimed at persuading the patient to see the errors of their ways. Typically they must also transfer the patient in an expeditious manner to their more obliging colleague.

Looked at from a conscientious objector’s perspective, this compromise is anything but a compromise. If I object to abortion because I believe that abortion is akin to murder, as Christian objectors happen to believe, surely my moral responsibility is barely smaller if I knowingly pass a pregnant woman looking for an abortion on to a colleague who will commit the act rather than if I do it myself. Christians are not typically known to see these issues through a consequentialist analytical lense, but even from their perspective, moral responsibility is barely reduced by the compromise. I sympathise with their objections to the compromise, because it is not a compromise. A compromise under the circumstances arguably is not feasible to begin with.  

Patients are entitled to receive uniform service delivery from health care professionals. They ought not to be subjected to today’s conscientious objection lottery. The Canadian Medical Association proposes that Canada ought to establish a website where patients can ascertain where the nearest non-objecting doctor is located.(3) One difficulty with this proposition is that in many rural areas there might be only one doctor and the next – more obliging - health care professional might actually be a flight away. Nothing would stop us from taking this proposal to its absurd logical conclusion: why not establish comprehensive websites where patients can find out whether their doctor objects on grounds of conscience to treating sexually active gay patients, or perhaps whether their conscience prohibits them from treating patients of a particular objectionable ethnicity. Consequentialists might well decide not to treat Ebola Virus Disease patients because of the risk involved, call it their consequentialist conscience. Health care service delivery would soon become a random event, entirely based on the vagaries of conscientious objections. Incidentally, Canadian doctors’ legal conscience protections do not actually cover these kinds of objections, because really these protections are designed to protect Christian doctors’ convictions, despite feeble attempts at giving them a lick of neutrality paint. The odd thing about conscientious objections is that there is no way to find out whether they are genuine or just a matter of convenience. Even if they were genuinely held beliefs, why should that constitute a sound reason for refusing service delivery?

The very idea that we ought to countenance conscientious objection in any profession is objectionable.(4) Nobody forces anyone to become a professional. It is a voluntary choice. A conscientious objector in medicine is not dissimilar to a taxi driver who joins a taxi company that runs a fleet of mostly combustion engine cars and who objects on grounds of conscience to drive those cars due to environmental concerns. Why did she become a taxi driver in the first place? Perhaps she should have opened a bicycle taxi company instead. I recall well, during an extended teaching stint in a dental school, that in every intake there were a fair number of dental students mentioning that they settled on going to dental school rather than medical school because of their objections to abortion. That seems a much more reasonable decision than to join a medical school and cause throughout one’s working life problems for patients seeking medical care for health issues that they are legally entitled to receive medical care for and that one objects to for one reason or another. Societies ought not to prioritise individual ideological commitments of some health care professionals over patients’ rights to receive professional care in a timely and hassle free fashion. Dying patients living in rural areas should not be subjected to an access-to-assisted-dying-lottery caused by conscientious objectors. Doctors are first and foremost providers of health care services. Society has every right to determine what kinds of services they ought to deliver.

That a doctors’ lobby organisation such as the Canadian Medical Association should aim to prioritise its members’ interests over patient access to care is not terribly surprising, albeit disappointing. Canadian legislators would do well to ignore its plea on this occasion.








[1] Sharon K. 2015. Unacceptable to force doctors to participate in assisted dying against their conscience: CMA. National Post March 05. [Accessed March 26, 2015.]
[2] Leiter B. 2013. Why Tolerate Religion? Princeton, NJ: Princeton University Press.
[3] Kirkey S. Op.cit.
[4] Savulescu J. 2006. Conscientious objection in medicine. bmj 332: 294

Saturday, February 07, 2015

Assisted Dying coming to Canada

What a week this past week has been. While I was away on a business trip to Europe the Supreme Court of Canada (SCC) let it be known that it would release on Friday this week its decision on the so-called Carter case, that is, it would pronounce on the constitutionality of the bits and pieces in our Criminal Code that criminalise assisted dying.

Unless you have lived under a rock during these last few years you will know that I spent a significant amount of my time arguing in favour of the decriminalisation of assisted dying in the country, no least in a report of an expert panel the Royal Society of Canada asked me to chair, on end-of-life decision-making in Canada. In addition I wrote a large number of newspaper columns on the issue and gave oodles of TV interviews and what-not to advance that cause.

So, there I was holed up in hotel rooms in Brussels and Geneva trying to respond to media inquiries. Fearlessly I predicted that the court would come to a unanimous decision and that it would decriminalise assisted dying. I couldn't see, given what we know from jurisdictions that have decriminalised, that the Justices would fall for the slippery-slope clap-trap rolled out by religious opponents of assisted dying, and, of course, their biggest ally, the current Attorney General of this country. I also couldn't see that the Justices would wilfully ignore consistent opinion polls suggesting that overwhelming (I mean: more than 80%) majorities of Canadians are in favour of a change toward making assisted dying available.

It turns out, I was right. The SCC came down with this unanimous decision, defining thus who would be able to receive assistance in dying: a 'competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.'

This is pretty much what we recommended in our report. What I find particularly important about these criteria is that the Justices rejected a threshold requiring that patients must be in a terminal condition, or near the end of life. The current legislation, on this count, in Quebec, will have to be re-written. At the last minute opponents of Quebec's legislation added this threshold, and, thanks to the SCC decision, it will have to be taken out of Quebec's legislation again as it would unjustly deprive people of access to assisted dying who are not close to the end of their lives.

I think, among the important lessons to be learned from all this, is this one: Opponents of assisted dying should reconsider their campaign strategies. They decided that telling anecdotes from jurisdictions that have decriminalised, making up a lot of stuff about things that allegedly happened in such jurisdictions and telling half-truths about what allegedly happened in jurisdictions that have decriminalized worked in their religious echo chamber of pro-life websites, as well as with allied newspaper columnists like the National Post's Barbara Kay and the Toronto Star's Rosie DiManno, and so it would probably work with Supreme Court Justices, too. Turns out, Supreme Court Justices are a bit smarter than DiManno and Kay, who have shown themselves clueless about the issue at hand throughout their years of campaigning in their newspaper columns against assisted dying. The judges looked at the actual evidence and 'rejected the argument that adoption of a regulatory regime would initiate a descent down a slippery slope into homicide.'

The other vacuous agitprop campaign tool deployed by this camp was their ever-growing concern for 'the vulnerable'. Given that they didn't want assisted dying available to anyone, they were careful never to define 'vulnerable'. Turns out, they and their government ally, the Attorney General, really meant everyone. Vulnerability ceases then to be a useful threshold criterion for anything. The Attorney General eventually said, on the Court record, that 'every person is potentially vulnerable.' The Supreme Court called curtains on this rhetoric, too. It states point blank, 'We do not agree.' - 

Aggressive lying and fudging of the issues apparently takes you only that far when it comes to Canada's Supreme Court Justices.

I wonder whether one analysis in the judgment (paragraphs 64-66) could be interpreted as rejecting the Catholic acts and omissions doctrine. Check that one out yourself. Worth a read.

Sunday, January 04, 2015

Restorative justice Dalhousie University style

5 Jan 2015 Update on the post below. Dalhousie University announced today that the dental students in question have been suspended from participation in clinics. Apparently they would still be able to attend classes with the fellow female classmates that were the subject of their rape fantasies. Mind boggling. -----

Quite remarkable events are occurring currently at Dalhousie University's Dental School. They take place against the backdrop of an ongoing international outcry about alleged or real rape cultures on university campuses across North America.
What happened at Dalhousie is that a bunch of male dentistry students made on a private Facebook page statements celebrating the rape of female fellow students, they reportedly ranked these women for 'hate sex', fantasized about chloroforming them, then raping them, the list goes on.
Invariably there has been talk about boys will be boys, immaturity and whatnot. The truth, however, is that these men are adults. They have just about completed a graduate program in dentistry. Here are a bunch of screenshots from their little FB horror show. Misogyny is apparently not a phenomenon limited to student conduct at Dalhousie's School of Dentistry.
If the reported facts are correct, I cannot see how any of these students could possibly be permitted to complete their studies and graduate. I also cannot see how anyone could provide them in good conscience with a license to practice dentistry. These students are clearly unfit to become health care professionals. It is that simple. Vulnerable patients should be wary of any regulatory body that saw fit to provide such people with a license to practice dentistry.
Given that these students are at the end of the 4th year, one also has to wonder how effective the Dental School's professional ethics education has been.
Well, you'd expect that a professional school would simply eject students that demonstrably committed such offences. Not so at Dalhousie. Its President decided to embark on a restorative justice course of action. He is supported by an unsigned letter purportedly from a Dalhousie Feminist Legal Association. The anonymous authors of the letter clearly love restorative justice. Thing is, Dalhousie, prior to engaging in its restorative justice activity, didn't even bother checking with all of the women named in the Facebook group posts whether they thought that that would be an appropriate course of action. At least one of the women named in the Facebook group's messages is explicitly opposed to the informal restorative justice process. She calls the whole idea 'shocking'. It is clear today that there was no consensus among these women about this approach. That alone calls into question its appropriateness.
I am not sure where I stand with regard to restorative justice activities. I find the whole idea to subject the victims of violence or abuse to the need to talk to their abusers, make the latter understand and whatnot pretty silly stuff. I can see that it might work in terms of rehabilitating someone, but really, why should that be a victim's job to begin with? In South Africa the Truth and Reconciliation Commission seems to have been a bit of a failure. Many of those whose loved-ones were murdered by the apartheid regime weren't quite happy that everyone was forgiven by the TRC, provided they showed enough contrition - fake or otherwise. You talk to Black South Africans in the streets of, say, Johannesburg today and you'll hear that very many of them think that they were robbed of justice by the activities of the TRC.
For the men involved in the Facebook group this restoration exercise provides a shot at walking away scotch-free provided they show enough contrition and reach some consensus with their victims. The fact of the matter is that there will never be a realistic chance of telling whether they have shown genuine insight or whether they were focused on becoming dentists, no matter what. They have been told that they might still be expelled from University, so they have every incentive to grovel as sincerely as they can, no matter what their actual views on the subject. Here is some indication regarding their capacity to show insight and remorse.
Meanwhile, come Monday morning, the women subjected to rape fantasies by their male classmates will be lucky enough to face them again in class and dental clinics while the restoration show gets on the road. Is this mind boggling? Not just a little bit. One wonders what's going on in the minds of senior management at Dalhousie.
In any case, the university remains responsible for disciplining students that violate its codes of conduct. Several faculty members of the university have lodged a formal complaint that should have triggered a formal investigation (quite distinct from the informal and ultimately toothless restoration exercise). They wrote this letter on December 21, 2014 to Dalhousie's Acting Vice Provost for Student Affairs. The faculty members have not heard back since then. Keep in mind, on Monday these students will be back in class.
These faculty members called it right. They asked for a formal disciplinary investigation and a suspension of the students while the investigation is under way. They realised that permitting these men to continue attending classes will not be a cost neutral activity to many of their female classmates. Apparently even this insight is lost on the Dalhousie administration. 
While there is nothing per se wrong with following the informal process of restorative justice, it clearly is insufficient to address the problem at hand. A formal disciplinary investigation is called for, independent of the restorative justice exercise. The men involved and identified in the Facebook postings should be suspended until that formal investigation has run its course.

Monday, December 29, 2014

Academics running OA journals - a new variety of academic self-exploitation?

An interesting phenomenon can currently be observed in the humanities - academics engaging in new forms of self-exploitation. It's linked to the OA hype gripping the academy. How does it work?

Well, in the old days for-profit publishers essentially took over the production and distribution of our peer reviewed content for us. We managed the academic side of the process (peer review etc), they managed the rest. They made (well, still make) a killing on our labour by virtue of being able to force university libraries to pay often exorbitant subscription fees so that we can access research that we produced in the first place.

Came OA, the idea that research paid for mostly by taxpayers should be made available free of charge to anyone anywhere. I call this the having-your-cake-and-eating-it model. Academics typically loves these sorts of models. Thing is, you can't actually have your cake and eat it. OA turned out to be - by and large - a model whereby costs were switched to the producers of the research. Academics suddenly had to pay huge amounts (typically these days about 3000  $ per pop) to be able to play (hence I coined these publishing models 'pay-to-play'). So, while in the not so great old days our libraries were bled dry by greedy publishers, under the new model the only academics capable of publishing their research outputs would be those with research funds able to cover those fees.

That can probably work for folks in the STEM subjects, but this can't work for humanities scholars. Most of us typically produce our research during term breaks, most of us don't sit on large quantities of research funding. In fact, most of us don't have research funding at all.

Here kicks the self-exploitation model in that I started of with. Some well-intentioned humanities scholars have since decided to set up their own OA journals, where neither readers pay, nor those who submit their content for review. Given that barriers to entry are fairly low these days (you need a webserver and publishing software), that is prima facie not a terrible idea. And yet, it does sound like yet another having-your-cake-and-eating-it model, doesn't it? It kind of is. Essentially, those who run those journals have embarked on a never-ending journey of self-exploitation. Nobody pays for anything, you volunteer your time (in return for your name on a journal website masthead), you rely probably to some extent on grad students and postdocs to keep your enterprise afloat, you divert research funding to keep the administrative side of your publishing operation ticking, universities provide the web-server, etc.

The reality here is that academics so volunteer to undertake the tasks publishers (be they OA or subscription based) typically undertake. Will these academics see a benefit from the institutions whose libraries would save large amounts of money if this model took hold (there would be no costs involved in subscribing to journals or in submitting content to them)? The long and short of it is that that is not the case. That funding will disappear elsewhere (a new soccer stadium anyone? new Principal's residence? ) So, really we see a case of academics exploiting themselves, no more, no less. They volunteer their time to undertake administrative (ie journal publishing) tasks that other professionals should undertake, and that these professionals should be paid to undertake, and that these professionals have been undertaken for a very long time.

Now, I'm the last to think that an argument from tradition is a good argument, but it is worth noting that the model whereby those who produce journals are paid for their labour has worked pretty well for us in the academy. You can have a legitimate argument about the cost side of things, about publishers' ever diminishing support services to academic journals, all of that, but fundamentally things work.  We get our content out in reputable academic journals, and the content is available ever more easily and at ever greater speed to other academics. On the other hand, the publishing landscape is littered with the corpses of journals that relied on volunteers to keep all aspects of their operations alive because they insisted on being 'free'. The truth is though, well-paid academics spend their time undertaking administrative tasks involved in producing these journals when they could be doing actual research, teach, or provide other services to their employers, ie the universities where they work.

There was a time when I was worried about what would happen to the published peer reviewed content after the failure of these kinds of publications. Would they also disappear into the rubbish bins of the internet? Thankfully that doesn't have to be the case. We have today numerous repositories where such outlets can store their articles after their demise. So, as long as that occurs, at least the content can survive the demise of the journals themselves.

Still, if I was a budding academic thinking about where to place my first or second peer reviewed journal article, would these kinds of journals be my first choice? Probably not.

Monday, December 08, 2014

National Post commentator makes up stuff about assisted dying

Andrew Coyne, well-known conservative part of Canada's commentariat, makes up stuff about assisted dying today. He deploys in his commentary pretty much every variety of slippery slope arguments that is known to humankind (they're usually all false, folks learn that in Logic101 classes). Bioethics students to the front. Whoever finds the most errors in Coyne's piece wins my last book :).  Inbox me with your findings.

This is in part what he writes:

"Udo Schuklenk, professor of bioethics at Queen’s University and chair of the Royal Society of Canada’s panel on “End of Life Decision Making,” recently published a paper advocating the euthanizing, with parents’ consent, of infants with severe deformities, a practice he likened to “post-natal abortion.” Eike-Henner Kluge, former director of ethics for the Canadian Medical Association, has made similar arguments for including the mentally incompetent among those eligible for euthanization. This is hardly a theoretical concern. In countries where assisted suicide/euthanasia has been legalized, it is increasingly the practice. Belgium, where euthanasia on the Quebec model has been legal since 2002, this year extended it to children, joining the Netherlands, where it has been lawful since the 1990s. In Switzerland it is permitted to euthanize the mentally ill. And the list continues to grow: prisoners serving life sentences are the latest addition. What begins in compassion, it seems, ends in eugenics."

Let me just note here that my contribution didn't once mention 'severe deformities', but hey.  I didn't even mention deformity by some other name as a relevant decision-making criterion. Making up stuff - steady as they write.

Coyne then claims that infanticide is increasingly the practice in countries where assisted suicide and/or euthanasia have been legalized. It turns that the published data cited in my paper show that the opposite is actually the case. Cases whereby the lives of newborns have been terminated whose continuing life-preserving treatment would have been futile have halved in the Netherlands (one of Coyne's straw men) since the mid 1990. Worth noting, virtually all of these life endings were not caused by acts of euthanasia, the act that excites Coyne so much. So, assisted dying does demonstrably not lead to a situation where infanticide is increasingly the practice, the opposite is the case actually.

Slippery slopes typically claim (as Coyne does) that as a result of the slippery slope more (rather than less) cases of something wrong occur. Coyne doesn't even engage the question of whether there might be good reason for why these newborns' lives were terminated by active means or by means of withholding life-preserving care. To him it's all bad. Nothing wrong with living life in a simple world unencumbered by facts. In this case, it's a world of make-belief, because these kinds of cases actually halved in number since the mid 1990.  Then Coyne moves seamlessly from infanticide to the mentally ill. Well, mental illness doesn't necessarily render you incompetent, legally or ethically.

Coyne's apocalyptic journey ends where it must end, in good ol eugenics. Case closed. Has he provided any evidence for this claim at least. Oops, no, that's where this rambling anti-euthanasia commentary abruptly ends.

Let me leave you with a bit more of Coyne's musings. He writes in the same piece, 'Advocates, impatient with such arbitrary distinctions as that between suicide and assisted suicide — of what use is the right to kill oneself, they ask, if you are physically incapable of carrying it out? — are nevertheless at pains to preserve the distinction between terminal illness and mere depression...' . I'm not a professional commentator, so let me just note with some bewilderment that I do indeed think that there's a different between what's commonly understood to be a terminal illness (say, late-stage cancer) and depression. They are simply different kinds of illnesses, one kills ya, the other one doesn't. Apparently, to a commentator on a roll it's all the same, kinda.

I'm always puzzled under what rocks major news organizations find these people. In the good old days they'd have had fact checkers at least that would have fixed (and re-written) Coyne's piece, today, they write and upload at manic speed. Oh well.

Tuesday, December 02, 2014

Conservative and Liberal Canadian Senators bring assisted dying bill on the way

Conservative Ontario Senator Nancy Ruth and Liberal British Columbia Senator Larry Campbell have introduced today an assisted dying bill in the Canadian Senate. They hope to have it voted on during the spring session of the House. From there it would proceed to the House of Commons for further deliberation and eventual vote.

You might recall that Conservative MP Stephen Fletcher introduced such a bill in the House of Commons, but it was killed there by procedural means by a government determined not to be associated with legislation that's broadly in sync with what more than 80% of Canadians want to see happen in the country.

We will see how this pans out. With a bit of luck it adds further momentum to the currently ongoing Supreme Court of Canada case. Certainly anything helping the momentum toward the decriminalization of assisted dying in the country is to be applauded.

Given that we are going into a federal election in 2015, I can't wait to see how the parties' head honchos and election strategists will try to wriggle their way out of this one. It's a topic that political parties and their parliamentary voting drones try to avoid as much as the plague, despite overwhelming societal support for such a change. - It goes without saying, the honourable exception was Bill 52 in Quebec, there introduced with cross-party support.

The Senate bill reportedly differs from MP Fletcher's bill in three respects:

  • It clarifies the roles of the assisting physician, the consulting physician, and who can be official witnesses.
  • It requires doctors to report to their provincial ministry that they have assisted with a death and provide a certificate with all relevant details
  • It requires a 14-day waiting period after a patient's first request to a physician for help with dying, followed by a second conversation to confirm the patient's wishes

Monday, December 01, 2014

Globe and Mail misleads about HIV/AIDS legal basics and vaccine research

Hmm, the Globe and Mail newspaper, Canada's only paper that comes reasonably close to being a national quality outlet, decided to contribute to today's World AIDS Day by offering a list of nine things we should know about HIV.  Good idea, questionable execution.

Under point five the paper informs us in the subheading going with point five (out of nine)

'5. In Canada, it’s is illegal for HIV-positive people to have sex without disclosing their status.'

Except... it isn't actually illegal for HIV-positive people to have sex without disclosing their status. As the journalist responsible for the list notes in the paragraph right under the subheading,
'A more recent Supreme Court ruling stated that a person living with HIV does not have to disclose their status before having vaginal sex if a condom is used and the person has a low viral load.'

That's actually the case. Canadians who happen to be HIV-positive, have an undetectable viral load and use condom during sexual intercourse are not under a legal obligation to disclose their HIV-status to their sex partners.

Important lesson. Make sure to scan more than just the subheadings of the Globe and Mail.

The journalist writing up the nine point list of random 'facts' made up another 'fact' altogether:

'8. The first and only preventative HIV vaccine is being developed in Ontario, but it still has a way to go.'

Reality check:  lots of preventative vaccine candidates are being tested in clinical trials. They pretty much all flamed out to date without doing much. The Globe and Mail journalist responsible for the nine point list links this particular 'fact' to a 2013 article in a business paper alerting readers to the fact that a team at Western University succeeded in testing their vaccine candidate in a phase 1 clinical trial. Phase 1 clinical trials only test for toxicity, no more. So, the long and short of it is that nothing much is being 'developed' on the preventative vaccine front in Ontario. Here's the Globe and Mail take on this: 'Preliminary clinical trial results appear positive but there are still many hurdles to overcome, including manufacturing and regulatory approval.' That's a funny way of looking at a vaccine candidate that has - according to the report the Globe and Mail article uses as reference - barely emanated from phase 1. If you think that manufacturing and regulatory approval are the relevant hurdles to take when it hasn't been established that the agent actually works as a preventative agent, you might want to reconsider your investment strategies as far as pharmaceutical companies are concerned.

This hyping of clinical research in the absence of firm evidence seems to become standard journalistic operating procedure in this country, ever since experimental agents were randomly promoted to Ebola vaccines by eager journalists across the country.

Check out the Globe and Mail piece, some of the other 'facts' seems suspicious, too, but I don't have the time to fact-check this particular list of 'facts' in detail.

In Saskatchewan, where the prevalence rate is three times the national average, a person is infected even more frequently.. A person is infected with HIV in Canada every three hours.

In Saskatchewan, where the prevalence rate is three times the national average, a person is infected even more frequently.