Anna Smajdor

Towards an understanding of resilience and its relevance to medical training

Medical Education 2012: 46: 349–356

The limits of empathy: problems in medical education and practice

Empathy is commonly regarded as an essential attribute for doctors and there is a conviction that empathy must be taught to medical students. Yet it is not clear exactly what empathy is, from a philosophical or sociological point of view, or whether it can be taught. The meaning, role and relevance of empathy in medical education have tended to be unquestioningly assumed; there is a need to examine and contextualise these assumptions. This paper opens up that debate, arguing that ‘empathy’, as it is commonly understood, is neither necessary nor sufficient to guarantee good medical or ethical practice.

The Moral Imperative for Ectogenesis

“Dissecting Bioethics,” edited by Tuija Takala and Matti Hayry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison peoples actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.

Ethical challenges in fetal surgery

Fetal surgery has been practised for some decades now. However, it remains a highly complex area, both medically and ethically. This paper shows how the routine use of ultrasound has been a catalyst for fetal surgery, in creating new needs and new incentives for intervention. Some of the needs met by fetal surgery are those of parents and clinicians who experience stress while waiting for the birth of a fetus with known anomalies. The paper suggests that the role of technology and visualisation techniques in creating and meeting such new needs is ethically problematic. It then addresses the idea that fetal surgery should be restricted to interventions that are life-saving for the fetus, arguing that this restriction is unduly paternalistic. Fetal surgery poses challenges for an autonomy-based system of ethics. However, it is risky to circumvent these challenges by restricting the choices open to pregnant women, even when these choices appear excessively altruistic.

The ethics of egg donation in the over fifties.

It has been conclusively demonstrated that postmenopausal women can gestate and give birth to children. However, to do so, they require donated oocytes, which are in short supply. In this paper, I explore a number of arguments for limiting access to donated oocytes to women of normal reproductive age. I consider the idea that older women have already had their chance to reproduce, and have chosen to forego it. I also consider the question of whether younger women have a more compelling clinical need, and ask whether the risks involved in postmenopausal motherhood are excessive. I argue that many of the concerns about postmenopausal motherhood are based on unjustified assumptions. Postmenopausal women are treated very differently to men of similar ages in the context of reproduction. I question whether this constitutes unjust discrimination or whether it reflects intrinsic differences between womens and mens reproductive capacities, and parental roles. In either case, women are often at a disadvantage and are subject to heavy social pressure in their reproductive choices. I conclude that there are no compelling reasons for a systematic ban on the use of donated oocytes in postmenopausal women. However, the procurement of oocytes for use in any woman raises some series ethical issues, and as new technologies and research avenues proliferate, pressure on this resource is likely to increase.

Between Fecklessness and Selfishness: Is There a Biologically Optimal Time for Motherhood?

In Britain, two spectres of ‘inappropriate’ reproductive choice have become increasingly prevalent in the media over recent years. On one hand, we are presented with the young mother, feckless, ignorant and dependent on state handouts for survival. On the other, the selfish older woman attempting to manipulate her biological functions to fit her career schedule. Seemingly, the timespan during which a woman may reproduce without public censure is rather narrow. But on what basis are these judgements being made, and what is the solution? Daniel Callahan argues that women should reproduce at an earlier age in order to avoid the medical risks to themselves and their offspring associated with advanced maternal age. The implication of this is that biologically optimal reproductive outcomes should take precedence over social aspirations, which can – according to Callahan – be pursued later in life. In this chapter I suggest that a phenomenon as complex as reproduction cannot necessarily be split neatly into social and biological components. What constitutes a ‘biologically optimal’ time for reproduction is in itself largely socially determined.

Reification and compassion in medicine: A tale of two systems

In this paper, I will explore ideas advanced by Bradshaw, Pence and others who have written on compassion in healthcare. I will attempt to see how and whether their assumptions about compassion can be justified, and explore the role compassion should play in a modern healthcare system. I will justify scepticism at the idea of attempting to incentivise compassion through metrics. The Francis Report raises important questions concerning the nature of a healthcare system that harms rather than helps patients. If something is failing in modern healthcare, those in charge should naturally seek to remedy it. I will investigate whether this is due to the disappearance of compassion, and if so, what is it that is emerging to fill its place. I will consider whether we need to rehabilitate or enforce compassion in the system, or to acknowledge that our modern healthcare systems are incompatible with compassion and how we can make the best of what remains.

How useful is the concept of the 'harm threshold' in reproductive ethics and law?

In his book Reasons and Persons, Derek Parfit suggests that people are not harmed by being conceived with a disease or disability if they could not have existed without suffering that particular condition. He nevertheless contends that entities can be harmed if the suffering they experience is sufficiently severe. By implication, there is a threshold which divides harmful from non-harmful conceptions. The assumption that such a threshold exists has come to play a part in UK policy making. I argue that Parfit’s distinction between harmful and non-harmful conceptions is untenable. Drawing on Kant’s refutation of the ontological argument for God’s existence, I suggest that the act of creation cannot be identical with the act of harming—nor indeed of benefiting—however great the offspring’s suffering may be. I suggest that Parfit is right that bringing children into existence does not usually harm them, but I argue that this must be applied to all conceptions, since Parfit cannot show how the harm threshold can be operationalised. If we think certain conceptions are unethical or should be illegal, this must be on other grounds than that the child is harmed by them. I show that a Millian approach in this context fails to exemplify the empirical and epistemological advantages which are commonly associated with it, and that harm-based legislation would need to be based on broader harm considerations than those relating to the child who is conceived.

Postmenopausal Motherhood Reloaded: Advanced Age and In Vitro Derived Gametes

In this paper we look at the implications of an emerging technology for the case in favor of, or against, postmenopausal motherhood. Technologies such as in vitro derived gametes (sperm and eggs derived from nonreproductive cells) have the potential to influence the ways in which reproductive medicine is practiced, and are already bringing new dimensions to debates in this area. We explain what in vitro derived gametes are and how their development may impact on the case of postmenopausal motherhood. We briefly review some of the concerns that postmenopausal motherhood has raised—and the implications that the successful development, and use in reproduction, of artificial gametes might have for such concerns. The concerns addressed include arguments from nature, risks and efficacy, reduced energy of the mother, and maternal life expectancy. We also consider whether the use of in vitro derived gametes to facilitate postmenopausal motherhood would contribute to reinforcing a narrow, geneticized account of reproduction and a pro-reproductive culture that encourages women to produce genetically related offspring at all costs.

In Defense of Ectogenesis

In his article ‘‘Research Priorities and the Future of Pregnancy’’ in this issue of CQ, Timothy Murphy evaluates some of the arguments I advanced in an earlier publication, ‘‘The Moral Imperative for Ectogenesis.’’ In this reply to Murphy’s article, I acknowledge some of his points and seek to show why some of his objections are not as powerful as he thinks. I start here by summarizing the argument put forward in my original article. Pregnancy is a condition that causes pain and suffering, and that affects only women. The fact that men do not have to go through pregnancy to have a genetically related child, whereas women do, is a natural inequality. Ronald Dworkin argues that natural inequalities are candidates for redistributive justice. Dworkin recommends a veil-of-ignorance technique for describing which inequalities might be ‘‘insured’’ against, that is, which medical treatments should be funded. I suggest that there is a strong case for prioritizing research into ectogenesis as an alternative to pregnancy. I conclude by asking the reader the following: if you did not know whether you would be a man or a woman, would you prefer to be born into Society A, in which women bear all the burdens and risks of pregnancy, or Society B, in which ectogenesis 1 has been perfected.