Jocelyn Downie

End‐Of‐Life Decision‐Making in Canada: The Report by the Royal Society of Canada Expert Panel on End‐Of‐Life Decision‐Making

This report on end-of-life decision-making in Canada was produced by an international expert panel and commissioned by the Royal Society of Canada. It consists of five chapters. Chapter 1 reviews what is known about end-of-life care and opinions about assisted dying in Canada. Chapter 2 reviews the legal status quo in Canada with regard to various forms of assisted death. Chapter 3 reviews ethical issues pertaining to assisted death. The analysis is grounded in core values central to Canadas constitutional order. Chapter 4 reviews the experiences had in a number of jurisdictions that have decriminalized or recently reviewed assisted dying in some shape or form. Chapter 5 provides recommendations with regard to the provision of palliative care in Canada, as well as recommendations for reform with respect to the various forms of assisted death covered in this document.

The OHRP and SUPPORT - Another view

A group of physicians, bioethicists, and scholars in allied fields agrees with the Office for Human Research Protections about the informed-consent documents in SUPPORT.

A Comprehensive Analysis of MRI Research Risks: In Support of Full Disclosure

Magnetic resonance imaging (MRI) procedures have been used for over 20 years. This modality is considered relatively safe and holds great promise. Yet, MRI has a number of risks. In order for MRI research to meet the Canadian standard of disclosure, the investigator must communicate and make note of all risks in their research protocols and consent forms. Those creating and reviewing research protocols and consent forms must take notice of the different circumstances under which MRI poses a risk. First, this paper will describe the current standard of disclosure in Canada for research participants. Second, the paper will provide a comprehensive synthesis of the known physical and psychological risks associated with MRI. Third, the paper will provide recommendations concerning areas for further investigation and risk reduction strategies. This information will thus equip researchers and research ethics boards (REBs) with the criteria needed for the composition of research protocols that meet the Canadian disclosure standard.

Children and decisionmaking in health research.

In March 1998 the Office of Bioethics Education and Research at Dalhousie University hosted a multidisciplinary workshop, “Assent and Dissent in Research Involving Children.” The overall objectives for the meeting were: first, to promote and protect the health and well-being of children by ensuring that potentially beneficial biomedical and health research involving children was not inappropriately precluded; and second, that when such research did proceed, it was appropriately respectful of children. For the purposes of the discussion, appropriate respect included both protection from harm and promotion of the capacity for independent decision-making. Particular attention was focused on the roles and responsibilities of children and their parent(s) or legal guardian(s) in decisionmaking about research participation.

Pediatric Neuroimaging Ethics

Neuroimaging has provided insight into numerous neurological disorders in children, such as epilepsy and cerebral palsy. Many clinicians and investigators believe that neuroimaging holds great promise, especially in the areas of behavioral and cognitive disorders. However, concerns about the risks of various neuroimaging modalities and the potential for misinterpretation of imaging results are mounting. Imaging evaluations also raise questions about stigmatization, allocation of resources, and confidentiality. Children are particularly vulnerable in this milieu and require special attention with regards to safety guidelines and modality adaptations. This article examines pediatric neuroimaging practice through an ethics lens. Most authors in the field of neuroethics focus on the future concerns of neuroimaging. In contrast, our paper examines ethical matters surrounding current clinical applications in the pediatric population. We first provide a brief overview of the neuroimaging technologies most commonly used in a pediatric clinical context and then discuss a variety of ethical issues arising from the use of these technologies.

Transnational Trade in Human Eggs: Law, Policy, and (In)Action in Canada

In this paper, we provide as accurate a picture as possible of transnational trade in human eggs involving Canadians. We explain the legal status in Canada, and call for reform in the regulation, of such trade.

Professional recommendations: disclosing facts and values

It is not unusual for patients and their families, when confronted with difficult medical choices, to ask their physicians for advice. This paper outlines the shades of meaning of two questions frequently put to physicians: “What should I do?” and “What would you do?” It is argued that these are not questions about objective matters of fact. Hence, any response to such questions requires an understanding, appreciation, and disclosure of the personal context and values that inform the recommendation. A framework for considering and articulating a response to these questions is suggested, using as a heuristic the phrasing “If I were you…/If it were me…” Journal of Medical Ethics

Ethics Education for Canadian Medical Students

This study was designed to determine the nature, extent, and quality of medical ethics education for students in Canadian medical schools. In 1989, a questionnaire that used primarily open-ended questions was sent to all 16 Canadian medical schools; they all responded. Significant findings include the following: 15 of the 16 schools provided some ethics education (with wide-ranging objectives); the amounts of time alloted for such instruction ranged from ten and a half hours to 45 hours (per degree, not per year), with no discernible pattern in the distribution of hours across the years; most teaching was case-based and issue-oriented; most instructors were physicians; and almost all the schools conducted assessments of students using a pass-fail standard.

Eligibility for organ donation: a medico-legal perspective on defining and determining death

PurposeIn the context of post-mortem organ donation, there is an obvious need for certainty regarding the legal definition and determination of death, as individuals must be legally pronounced dead before organs may be procured for donation. Surprisingly then, the legal situation in Canada with regard to the definition and determination of death is uncertain. The purpose of this review is to provide anesthesiologists and critical care specialists with a medico-legal perspective regarding the definition and determination of death (particularly as it relates to non-heart-beating donor protocols) and to contribute to ongoing improvement in policies, protocols, and practices in this area.Principal findingsThe status quo with regard to the current legal definition of death is presented as well as the criteria for determining if and when death has occurred. A number of important problems with the status quo are described, followed by a series of recommendations to address these problems.ConclusionsThe legal deficiencies regarding the definition and determination of death in Canada may place health care providers at risk of civil or criminal liability, discourage potential organ donation, and frustrate the wishes of some individuals to donate their organs. The definition and criteria for the determination of death should be clearly set out in legislation. In addition, the current use of non-heart-beating donor protocols in Canada will remain inconsistent with Canadian law until more persuasive evidence on the potential return of cardiac function after cardiac arrest is gathered and made publicly available or until a concrete proposal to abandon the dead donor rule and amend Canadian law is adopted following a process of public debate and intense multidisciplinary review.RésuméObjectifDans le contexte d’un don d’organe post-mortem, il est évident qu’il est nécessaire de ne laisser la place à aucun doute quant à la définition et à la détermination du décès; en effet, un individu doit être déclaré légalement mort avant que ses organes ne puissent être utilisés pour un don. Dès lors, il est surprenant de noter que la situation légale au Canada concernant la définition et la détermination du décès est floue. L’objectif de ce compte-rendu est de proposer aux anesthésiologistes et intensivistes une perspective médico-légale quant à la définition et la détermination du décès (en particulier en ce qui touche aux protocoles de donneurs à cœur non-battant) et d’apporter notre contribution aux progrès continus en matière de politiques, de protocoles et de pratiques dans ce domaine.Constatations principalesNous présentons le statu quo concernant la définition légale actuelle du décès ainsi que les critères utilisés pour déterminer si et quand le décès est survenu. Plusieurs problèmes importants concernant le statu quo sont décrits; nous proposons ensuite une série de recommandations pour résoudre ces problèmes.ConclusionLes lacunes légales quant à la définition et la détermination du décès au Canada pourraient mettre les professionnels de la santé à risque de poursuites en responsabilité civile ou criminelle, décourager les dons d’organe potentiels, et frustrer le souhait de certaines personnes de faire don de leurs organes. La définition et les critères employés pour déterminer le décès devraient être clairement énoncés dans la loi. En outre, l’utilisation actuelle de protocoles de donneurs à cœur non-battant au Canada demeurera en contradiction avec la loi canadienne jusqu’à ce que davantage de données probantes convaincantes concernant le retour potentiel de la fonction cardiaque après un arrêt cardiaque soient récoltées ou rendues publiques, ou jusqu’à ce qu’une proposition concrète d’abandonner la règle du donneur décédé et d’amender la loi canadienne soit adoptée après un processus incluant un débat public et une révision pluridisciplinaire approfondie.

The Limits of Altruism and Arbitrary Age Limits

Michael Benatar and David Benatar (2003) conclude that amputating normal, natural, protective, and sexually important tissue from a nonconsenting infant does not constitute abuse but is rather a matter for parental discretion. But to arrive at this conclusion, they ignore several important points. First, the prepuce is a unique, complex structure necessary for normal sexual function and is composed of thousands of specialized nerves, Meissner’s corpuscles, vascular systems, and stimuli receptors that have evolved over millions of years to maximize human sexual experience (Winkelmann 1956; 1959; Lakshmanan and Prakash 1980; Taylor et al. 1996; Halata and Spaethe 1997; Fleiss et al. 1998; Cold and McGrath 1999; Cold and Taylor 1999; O’Hara and O’Hara 1999). The inherent pain aside,1 such an amputation deprives an individual of a normal penis and of the full range and depth of sexual pleasure it provides. It should be self-evident that cutting off primary sexual tissue unalterably changes the way sexual acts are perceived and performed. To assert otherwise places the burden of proof upon those who would alter the normal anatomy and natural sexual experience. The Benatars fail to provide such proof. Second, not one national medical society in the world recommends infant circumcision. This includes the American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, American Cancer Society, and the American College of Obstetricians and Gynecologists. In fact, most world medical societies recommend against it and agree with the conclusions of the Canadian Paediatric Society that in the absence of unequivocal medical indication, “Circumcision of newborns should not be routinely performed” (CIRP 2002). Third, worldwide, circumcision of male or female genitals is relatively rare. Other than as religious rite, nontherapeutic circumcision is almost never performed in Europe, Australia, New Zealand, non-Muslim Asia (with the exception of South Korea), or Latin America. Approximately 85% of the world’s male population and 98% of the world’s female population are not circumcised (Wallerstein 1985). The United States is the only country in the world to circumcise a majority of infant males for nonreligious reasons. Fourth, the authors hint, but choose not to demonstrate, that the individual’s right to bodily integrity can be abridged for cultural, religious, or other perceived “beneats” imposed by force. This suggestion goes in the face of centuries of social evolution and law that has come to recognize the individual’s right to bodily integrity against coercive pressures that do not have compelling, demonstrable, medical beneat (Brigman 1984; Dwyer 1994; Denniston 1996; Chessler 1997; Smith J. 1998; Povenmire 1999; Price 1999; Van Howe 1999; Boyle et al. 2000; Somerville 2000; Svoboda et al. 2000; Dritsas 2001). This sovereignty asserts that children are not the chattel of parents, physicians, the group, or nation. Their genitals are not communal property. Others have no right to impose, by force, their cultural, religious, or aesthetic preferences upon an individual’s body without substantial medical beneat. Numerous human-rights documents declare the selfevident but hard-won right to bodily integrity. Forced male circumcision has been recognized as a human-rights violation in at least one legal case and in two United Nations reports. It can be deemed a violation in accordance with such documents as the United Nations Universal Declaration of Human Rights (Article 5) and the United Nations Convention on the Rights of the Child (Article 13). On 26 January 2001 the U.N. Committee on the Rights of the Child received conclusions and recommendations on reports submitted to it by nine countries. Among the conclusions received was that all children “should be allowed to decide at 21 years of age whether or not they want to be circumcised” (United Nations 1998). For these reasons and many others, the Swedish parliament has recently voted unanimously to consider whether infant male circumcision is a human-rights violation equal to female circumcision. Failure to consider these and other important issues in the case of forced genital cutting leaves the arguments put Open Peer Commentaries