Taking Sides: Clashing Views on Controversial Bioethical Issues

This debate-style reader is designed to introduce students to controversies in bioethical issues through readings that reflect a variety of viewpoints. Each issue is framed with an issue summary, an issue introduction, and a postscript. The Taking Sides readers feature annotated listings of selected World Wide Web sites. Taking Sides is supported by our student website at www.dushkin.com/online/.

PART 1. Medical Decision Making

ISSUE 1. Is Informed Consent Still Central to Medical Ethics?

YES: Robert M. Arnold and Charles W. Lidz, from “Informed Consent: Clinical Aspects of Consent in Health Care,” in Stephen G. Post, ed., Encyclopedia of Bioethics, vol. 3, 3rd ed. (Macmillan, 2003)

NO: Onora O’Neill, from Autonomy and Trust in Bioethics (Cambridge University Press, 2002)

Physician Robert M. Arnold and professor of psychiatry and sociology Charles W. Lidz assert that informed consent in clinical care is an essential process that promotes good communication and patient autonomy despite the obstacles of implementation. Philosopher Onora O’Neill argues that the most evident change in medical practice in recent decades may be a loss of trust in physicians rather than any growth of patient autonomy. Informed consent in practice, she says, often amounts simply to a right to choose or refuse treatments, not a deeper and more meaningful expression of self-mastery.

ISSUE 2. Can Family Interests Ethically Outweigh Patient Autonomy?

YES: John Hardwig, from “What About the Family?” Hastings Center Report (March–April 1990)

NO: Jeffrey Blustein, from “The Family in Medical Decisionmaking,” Hastings Center Report (May–June 1993)

John Hardwig, an associate professor of medical ethics, argues that the prevalent ethic of patient autonomy ignores family interests in medical treatment decisions. He maintains that physicians should recognize these interests as legitimate. Bioethicist Jeffrey Blustein contends that although families can be an important resource in helping patients make better decisions about their care, the ultimate decision-making authority should remain with the patient.

ISSUE 3. Does Direct-to-Consumer Advertising of Medication Enhance Patient Autonomy?

YES: Alan F. Holmer, from “Direct-to-Consumer Prescription Drug Advertising Builds Bridges Between Patients and Physicians,” Journal of the American Medical Association (January 27, 1999)

NO: Matthew F. Hollon, from “Direct-to-Consumer Marketing of Prescription Drugs,” Journal of the American Medical Association (January 27, 1999)

Alan F. Holmer, an attorney and head of the Pharmaceutical Research and Manufacturers of America, argues that advertising of medication empowers consumers by educating them about health conditions and possible treatments. Matthew F. Hollon, a physician, believes that advertising of medication is designed to increase consumer demand, rather than for educational purposes, and has little public health value.

PART 2. Death and Dying

ISSUE 4. Are Some Advance Directives Too Risky for Patients?

YES: Christopher James Ryan, from “Betting Your Life: An Argument Against Certain Advance Directives,” Journal of Medical Ethics (vol. 22, 1996)

NO: Steven Luttrell and Ann Sommerville, from “Limiting Risks by Curtailing Rights: A Response to Dr. Ryan,” Journal of Medical Ethics (vol. 22, 1996)

Psychiatrist Christopher James Ryan argues that advance directives that refuse active treatment in situations when a patient’s incompetence is potentially reversible should be abolished because healthy people are likely to underestimate their desire for treatment should they become ill. Geriatricians Steven Luttrell and Ann Sommerville assert that respect for the principle of autonomy requires that individuals be permitted to make risky choices about their own lives and that ignoring autonomous choices made by competent adults reinstates the outmoded notion of medical paternalism.

ISSUE 5. Should Physicians Be Allowed to Assist in Patient Suicide?

YES: Marcia Angell, from “The Supreme Court and Physician-Assisted Suicide—The Ultimate Right,” The New England Journal of Medicine (January 2, 1997)

NO: Kathleen M. Foley, from “Competent Care for the Dying Instead of Physician-Assisted Suicide,” The New England Journal of Medicine (January 2, 1997)

Physician Marcia Angell asserts that a physician’s main duties are to respect patient autonomy and to relieve suffering, even if that sometimes means assisting in a patient’s death. Physician Kathleen M. Foley counters that if physician-assisted suicide becomes legal, it will begin to substitute for interventions that otherwise might enhance the quality of life for dying patients.

ISSUE 6. Should Truth-Telling Depend on the Patient’s Culture?

YES: Leslie J. Blackhall, Gelya Frank, Sheila Murphy, and Vicki Michel, from “Bioethics in a Different Tongue: The Case of Truth-Telling,” Journal of Urban Health (March 2001)

NO: Mark Kuczewski and Patrick J. McCruden, from “Informed Consent: Does It Take a Village? The Problem of Culture and Truth Telling,” Cambridge Quarterly of Healthcare Ethics (2001)

Leslie J. Blackhall, Gelya Frank, and Sheila Murphy, from the University of Southern California, and Vicki Michel from the Loyola Law School, advise clinical and bioethics professionals facing truth-telling dilemmas to make room for the diverse ethical views of the populations they serve. Philosopher Mark Kuczewski and bioethicist Patrick J. McCruden argue that by insisting on informed consent or an appropriate waiver process, the health care system respects cultural differences rather than stereotyping them.

ISSUE 7. Should Doctors Be Able to Refuse Demands for “Futile” Treatment?

YES: Steven H. Miles, from “Informed Demand for ‘Non-Beneficial’ Medical Treatment,” The New England Journal of Medicine (August 15, 1991)

NO: Felicia Ackerman, from “The Significance of a Wish,” Hastings Center Report (July–August 1991)

Physician Steven H. Miles maintains that physicians’ duty to follow patients’ wishes ends when the requests are inconsistent with what medical care can reasonably be expected to achieve, when they violate community standards of care, and when they consume an unfair share of collective resources. Philosopher Felicia Ackerman contends that it is ethically inappropriate for physicians to decide what kind of life is worth prolonging and that decisions involving personal values should be made by the patient or family.

PART 3. Choices in Reproduction

ISSUE 8. Is Abortion Immoral?

YES: Patrick Lee and Robert P. George, from “The Wrong of Abortion,” in Andrew Cohen and Christopher Heath Wellman, eds., Contemporary Debates in Applied Ethics (Blackwell, 2005)

NO: Margaret Olivia Little, from “The Morality of Abortion,” in Bonnie Steinbock, John D. Arras, and Alex John London, eds., Ethical Issues in Modern Medicine (McGraw-Hill, 2003)

Philosopher Patrick Lee and professor of jurisprudence Robert P. George assert that human embryos and fetuses are complete (though immature) human beings and that intentional abortion is unjust and objectively immoral. Philosopher Margaret Olivia Little believes that the moral status of the fetus is only one aspect of the morality of abortion. She points to gestation as an intimacy, motherhood as a relationship, and creation as a process to advance a more nuanced approach.

ISSUE 9. Should Pregnant Women Be Punished for Exposing Fetuses to Risk?

YES: Jean Toal, from Majority Opinion, Cornelia Whitner, Respondent, v. State of South Carolina, Petitioner (July 15, 1997)

NO: Lynn M. Paltrow, from “Punishment and Prejudice: Judging Drug-Using Pregnant Women,” in Julia E. Hanigsberg and Sara Ruddick, eds., Mother Troubles: Rethinking Contemporary Maternal Dilemmas (Beacon Press, 1999)

In a case involving a pregnant woman’s use of crack cocaine, a majority of the supreme court of South Carolina ruled that a state legislature may impose additional criminal penalties on pregnant drug-using women without violating their constitutional right of privacy. Attorney Lynn M. Paltrow argues that treating drug-using pregnant women as criminals targets poor, African American women while ignoring other drug usage and fails to provide the resources to assist them in recovery.

PART 4. Children and Bioethics

ISSUE 10. Should Adolescents Make Their Own Life-and-Death Decisions?

YES: Robert F. Weir and Charles Peters, from “Affirming the Decisions Adolescents Make About Life and Death,” Hastings Center Report (November–December 1997)

NO: Lainie Friedman Ross, from “Health Care Decisionmaking by Children: Is It in Their Best Interest?” Hastings Center Report (November–December 1997)

Ethicist Robert F. Weir and pediatrician Charles Peters assert that adolescents with normal cognitive and developmental skills have the capacity to make decisions about their own health care. Advance directives, if used appropriately, can give older pediatric patients a voice in their care. Pediatrician Lainie Friedman Ross counters that parents should be responsible for making their child’s health care decisions. Children need to develop virtues, such as self-control, that will enhance their long-term, not just immediate, autonomy.

ISSUE 11. Do Parents Harm Their Children When They Refuse Medical Treatment on Religious Grounds?

YES: Massachusetts Citizens for Children, from “Death by Religious Exemption,” http://www.masskids.org/dbre/dbre_1.html (January 1992)

NO: Mark Sheldon, from “Ethical Issues in the Forced Transfusion of Jehovah’s Witness Children,” The Journal of E...