Fault and the allocation of spare organs

This paper argues that rectificatory justice should supplement distributive justice in allocating priority of access to scarce medical resources. Where a patient is at fault for the scarcity of healthy organs a principle of restitution requires that she should give priority to the faultless. Such restitution is non-punitive, and is akin to reparation in civil law, not criminal law. However, it is doubtful whether such a principle can be fairly applied within the present culture of governmental complicity in cigarette advertising.

Between enthusiasm, compliance and protest: the churches, eugenics and the Nazi "euthanasia" programme

This account of how the two major Churches responded to the Nazi ‘euthanasia’ programme, namely the mass murder of the mentally ill and mentally or physically deficient between 1939 and 1945, deals with the responses of their hierarchies and the stratagems adopted by the asylums which were part of their respective charitable networks. It is based upon both original archival sources and a large variety of secondary literature dealing with the two Churches and the individual asylums. Before considering how the Churches conducted themselves during the Nazi period, it is necessary to establish the broader context of their response to eugenics in general.

Scientific and ethical concerns in neural fetal tissue transplantation

This report presents a brief overview of the medical and ethical issues involved with the procurement, preparation, safety, efficacy, and subject protection of human fetal central nervous system tissue in the context of neural transplantation. The ethical perspectives from which to view the clinical use of fetal tissue include the following: 1) that fetal tissue from elective abortions is a surgical specimen; 2) that the use of such tissue involves fetal experimentation in which the fetus is a subject; and 3) that fetal tissue is considered as a cadaveric organ specimen, similar to other organs, but with special considerations compared with adult cadaveric tissue. The latter approach appears to be the most applicable and is parallel to the use of cadaveric organs and tissues after a declaration of brain death. Additional issues include the following: 1) the safety and quality of fetal tissue for implantation; 2) the hypothesis that "legitimization" and "redemption" (potentially positive effects of tissue donation in general) may lead to an increase in elective abortion rates; 3) the ethical issues of the validity and value of human experimentation involving neural grafting; and 4) the type of consent to be obtained and the appropriate timing. Elective abortions, however, probably will continue to be the primary source of fetal tissue for grafting for some time, until other tissue sources become available.

The ethics of medical involvement in torture

The difficulties of establishing a definition of torture are discussed, and a definition is suggested. It is then argued that, irrespective of general ethical questions, doctors in particular should never be involved because of their social role.

The ethics of medical involvement in torture: commentary

Torture does need to be defined if we are to know exactly what we are seeking to ban; but no single definition will do, because there are many possible ones, and we may want to treat different practices that might be called torture differently. Compare the case of homicide; we do not want to punish manslaughter as severely as murder, and may not want to punish killing in self-defence at all. There are degrees of torture as of murder. Unclarities simply play into the hands of would-be torturers. Downie is unsuccessful in deriving the duty of doctors not to be involved in torture from an analysis of the word `doctor'. It may be contrary to the role-duty of doctors to participate in torture; but there might be other duties which overrode this role-duty. The right approach is to ask what principles for the conduct of doctors have the highest acceptance-utility, or, as Kant might have equivalently put it, what the impartial furtherance of everyone's ends demands. This approach yields the result that torture (suitably defined) should be banned absolutely. It also yields prescriptions for the conduct of doctors where, in spite of them, torture is taking place.

Ethics of fetal tissue transplantation

Now that the Clinton Administration has overturned the ban on federal funding for fetal tissue transplantation, old ethical issues renew their relevance and new ethical issues arise. Is fetal tissue transplantation necessary and beneficial? Are fetal rights violated by the use of fetal tissue in research? Is there a moral danger that the potential of fetal tissue donation will encourage elective abortions? Should pregnant women be allowed to designate specific fetal transplant recipients? What criteria should be used to select fetal tissue transplants? Whose consent should be required for the use of fetal tissue for transplantation? We review the current state of clinical research with fetal tissue transplantation, the legal history of fetal tissue research, the major arguments against the use of fetal tissue for transplantation, and the new postmoratorium ethical dilemmas. We include recommendations for guidelines to govern the medical treatment of fetal tissue in transplantation.

The role of physicians in conflicts and humanitarian crises. Case studies from the field missions of Physicians for Human Rights, 1988 to 1993

Violations of human rights in wars, civil conflicts, and brutal repression mounted by governments against their own citizens often have profound consequences to individual and public health and may, in turn, produce humanitarian crises. The skills of physicians, medical and forensic scientists, and other health workers are uniquely valuable in human rights investigations and documentation, producing evidence of abuse more credible and less vulnerable to challenge than traditional methods of case reporting. Only in recent decades, however, have physicians organized specifically to meet this responsibility. This article presents case studies from the field missions of Physicians for Human Rights to illustrate the investigation and documentation of violations of medical neutrality, refugee health crises, the use of indiscriminate weapons, torture, deliberate injury and rape, and mass executions. Participation of health workers in the defense of human rights now includes investigation and documentation of health effects in threatened populations as well as individual victims.

The ethical use of fetal tissue for transplantation and research

The exercise of organ and tissue transplantation is a common occurrence in our society. Expectations of future advances in this arena are raising many ethical, moral and public-policy questions. The scientific data base supporting the usefulness of fetal tissue to repair or reverse disease is modest, and uses are speculative. Should fetal tissue transplantation research proceed and, if so, under what conditions? This paper examines the issues related to the use and procurement of fetal tissue for research and transplantation.

Conscience, referral, and physician assisted suicide

Practices such as physician assisted suicide, even if legal, engender a range of moral conflicts to which many are oblivious. A recent proposal for physician assisted suicide provides an example by calling upon physicians opposed to suicide to refer patients to other, more sympathetic, physicians. However, the proposal does not address the moral concerns of those physicians for whom such referral would be morally objectionable.

The use of fetal tissue for therapeutic applications

In recent years, dramatic progress has been made through research using dead human fetal tissue. Cellular transplantation is an attractive alternative to organ grafting when only a discrete function of the organ is impaired. Early fetal donor cells have an advantage because they engraft readily and do not cause graft-versus-host disease. Similarly, the fetus is an ideal recipient of allogenic fetal cells as it is incapable of rejecting them early in gestation. Recent research advances have led to its use in endocrine, neurologic and immune system disorders as well as in hematologic and hepatic deficiencies. Concurrently, this research has led to controversy over the ethics of using human fetal tissue, particularly tissue from induced abortions. Although legalized abortion remains a hotly debated controversial issue in the USA and some other countries, a consensus has been forming, in the scientific community, on the ethical use of fetal tissue in research and clinical transplantation. This review presents the theoretical background and recent research and clinical advances in fetal tissue transplantation, in the light of the current debate on its ethical and moral implications.

The Polkinghorne Report on Fetal Research: nice recommendations, shame about the reasoning

In 1989, in the wake of the first operations to transplant fetal tissue into the brains of sufferers from Parkinson's Disease, the UK Code of Practice governing the use of the fetus for research was overhauled by an eminent committee under the chairmanship of the Reverend Dr John Polkinghorne. The Polkinghorne Report has, however, attracted remarkably little comment or analysis. This paper is believed to be the first to subject it to sustained ethical and legal scrutiny. The author concludes that, although the committee's recommendations meet the major objections to the Code of Practice, the report is nevertheless vulnerable to criticism in its treatment of at least three issues: the moral status of the fetus; paternal consent to fetal use, and the ethical inter-relation of fetal use and abortion.

The snake on the caduceus: dimensions of medical and psychiatric responsibility in the Third Reich

The literature on the activities of medical professionals during the tumultuous years of the Third Reich has, over the last decade, increased substantially. However, many questions remain unanswered and the subject is likely to receive further attention following recent access to previously restricted archival material in Eastern Europe. In this paper, based on the English language literature, the author explores the role of medicine, and in particular psychiatry, in defining the bio-medical vision that was central to Nazi ideology.

Bioethics and anti-bioethics in light of Nazi medicine: what must we remember?

Only recently have historians explored in depth the role of the medical profession in Nazi Germany. Several recent works reveal that physicians joined the Nazi party in disproportionate numbers and lent both their efforts and their authority to Nazi eugenic and racist programs. While the crimes of the physician Mengele and a few others are well known, recent research points to a much broader involvement by the profession, even in its everyday clinical work. Analogous activities existed in the German legal and industrial communities; disruption of the medical ethic thus sprang from the broader social contexts of Nazi Germany. The new United States Holocaust Memorial Museum, now opening on the Mall in Washington, D.C., will have an opportunity to educate the public about both the great crimes at Auschwitz and other camps, and the gradual but thorough degradation of ethics in the German medical profession. From this presentation, contemporary bioethics can ponder the proper use of the Nazi analogy in bioethical debate.

Nursing in Nazi Germany

German nursing did indeed change during the Nazi period. There were external changes, in terms of the improved social status of nursing, the tightening and unification of professional nursing organizations, the laws affecting nursing, and the politicization of the profession. Articles written by nurses at the time and more recent interviews suggest that there were internal changes as well. It appears that at least a portion of German nurses accepted the National Socialism reinterpretation of professional nursing ethics and humanitarian principles in the assumption that through their obedience they were doing good. This historical research points to clear lessons for contemporary nurses. Nurses in Nazi Germany were under the illusion that they were remaining true to their professional ethics, unaffected by the social change around them. This apolitical professional consciousness made it possible for the profession to be subsumed as a part of the larger political system. I believe that we must be clear that nursing never takes place in a value-free, neutral context; it is always a socially significant force. This means that we cannot simply observe what is taking place around us but must take a stand and get involved, helping to shape sociopolitical developments. I also believe that we must deal with the history of our profession, especially its darkest hours, so that we may remain sensitive to any signs of inhumanity. We must call into question traditional principles, such as obedience, and replace them with professional competence, professionalism, and creative self-consciousness. And not least, we have a moral obligation to the millions of victims of National Socialism, even if it only means that, through historical research, we assure that they are not forgotten. By taking responsibility for this part of our history, we can become more sensitive for the future, with eyes and ears open for all social injustices.

Constraints and heroes

A story, perhaps apocryphal, is told about the United States surgical team which pioneered the first artificial heart procedure. It is said that the team received a number of telephone calls from people around the country who, worried about the ailing heart recipient, offered to donate to him their own hearts. When the surgical team, justifiably curious, sent psychiatrists to examine these donors, they found to their surprise that many of the donors were rational, competent, sincere, and fully aware that as a consequence of donating their hearts they would die.... My concerns here will be threefold. First, I want to add some substance to the widely-held intuition that there is something morally objectionable about a physician participating in procedures which put even a willing subject at risk. In so doing, I want to explore the larger question of why such a puzzle arises -- why physicians, and many others, find it morally objectionable to help someone do something which all agree to be heroic. Finally, I will start by examining some ways of framing the issue, widely employed in medical ethics, which I believe are simply wrong. This sort of puzzle is much more interesting than proponents of these standard arguments would have us believe, and it illustrates some larger points about morality which are often overlooked.

Do pharmacists have a right to refuse to fill prescriptions for abortifacient drugs?

Some pharmacists who believe that abortion is immoral are troubled by the thought that they might be required to fill prescriptions for abortifacient drugs like mifepristone. Do pharmacists have the right to refuse to fill such prescriptions?

Questions about the rights of professionals have both moral and legal dimensions. I will assume—although this assumption is by no means axiomatic or uncontested—that the rights and responsibilities of persons in general and professionals in particular ought to be grounded in morality and not the law. For example, a person who breaks the speed limit to bring a critically ill friend to a hospital's emergency room violates the law, but may be morally justified in doing so. There is no legal duty to rescue a person in danger, but many moral communities hold that our moral duty of beneficence requires us to prevent harm to others, at least if in so doing we are not placing ourselves and others at great risk of harm.

It never dies: assessing the Nazi analogy in bioethics

... As should be evident from the foregoing analysis, I have significant reservations about the moral utility of the Nazi analogy in debates over bioethics issues. Nevertheless, I am unable to dismiss its force entirely. I want to suggest that the real threat to the moral and human values expressed by the analogy will come not from responsibly formulated and clearly articulated proposals that undergo debate and scrutiny in the public forum, and whose practical impact in a democratic society is limited by institutional review and procedural safeguards. My concern instead is with the psychology of moral distancing, in which moral conscience is compartmentalized from vocational interests, such as the pursuit of scientific knowledge through biomedical research. It is the kind of psychology that Robert Jay Lifton has referrred to as "doubling: the division of the self into two functioning wholes, so that a part-self acts as an entire self," and which Lifton believes enabled the transformation of physicians from healers to killers in Nazi Germany....

Ethical issues in brain-cell transplantation

The ethical ramifications of intracranial transplantation are many. While the majority of ethical concerns have focused on the relationship of transplantation of fetal brain tissue to elective abortion, there are other significant issues relating to graft recipients (patients and their families) and to the allocation of public resources for clinical transplantation research. In this article, some of these latter problems will be considered first, followed by a discussion of the constraints derived from the abortion question that are placed on transplantation.

Medical selection: Auschwitz antecedents and effluent

Medical selection in Auschwitz represents the penultimate application of the traditional paradigm of medicine: the physician as gatekeeper and decision maker. The historical evolution of that role is considered in the context of public health, medical police, quarantine, and immigration. In Nazi Germany the physician was assigned responsibility for selection on behalf of the state. The ethical implications of medical selection are considered in the context of medicine today in an age of sophisticated biotechnology, constrained resources, and an aging population; an age in which the medical profession has yet to establish a fundamental system of values.

Fetal tissue transplantation: can it be morally insulated from abortion?

Ethical controversy over transplantation of human fetal tissue has arisen because the source of tissue is induced abortions. Opposition to such transplants has been based on various arguments, including the following: rightful informed consent cannot be obtained for use of fetal tissue from induced abortions, and fetal tissue transplantation might result in an increase in the number of abortions. These arguments were not accepted by the National Institutes of Health (NIH) Human Fetal Tissue Transplantation Research Panel. The majority opinion of the panel stated that abortion and fetal tissue use are entirely separate issues, and that tissue use is ethically acceptable because it can be morally insulated from the issue of abortion. In support of this view, panel members and others have replied to the arguments put forward by opponents of fetal tissue use. However, replies to the two arguments mentioned above have been unsatisfactory, and the shortcomings of those replies are identified herein. Examination of the arguments pro and con suggests that fetal tissue use cannot be completely insulated from the issue of abortion. Thus, in seeking an ethical justification for fetal tissue transplantation we must consider reasons other than those put forward by the NIH panel. In this paper it is argued that whatever wrong is involved in using fetal tissue from induced abortions must be balanced against the benefits for patients, and it is on this basis that fetal tissue transplantation can be ethically justified.

Ethics, public policy, and human fetal tissue transplantation research

This article focuses on the deliberations of the National Institutes of Health Human Fetal Tissue Transplantation Research Panel in 1988. It explores various arguments for and against the use of fetal tissue for transplantation research, following elective abortion, and for and against the use of federal funds for such research. After examining the relevance of various positions on the moral status of the fetus and the morality of abortion, the article critically examines charges that such research, especially with federal funds, would involve complicity in the moral evil of abortion, would legitimate abortion practices, and would provide incentives for abortions. Finally, it considers whether the donation model is appropriate for the transfer of human fetal tissue and whether the woman who chooses to have an abortion is the apppropriate donor of the tissue.