Mark Sheldon

Ethical issues in the forced transfusion of Jehovah's Witness children

This paper examines the views of Jehovahs Witnesses in regards to their refusal of blood transfusions for themselves and their children. After setting out the legal framework society presently has in place for dealing with such refusals, the paper reviews the ethics literature that justifies the intervention by the State to force the transfusion of Jehovahs Witness children. It is claimed that the arguments such literature develops are seriously problematic. A different approach is suggested.

The clinical response to brain death : A policy proposal

ABSTRACT The ethical and scientific literature reflects a certain amount of controversy and confusion surrounding the concept of death by neurological criteria, or brain death. The issues surrounding brain death occur with limited frequency for those working in acute critical care settings. Even so, the literature and our own experiences evidence the discomfort of caregivers and policymakers when dealing with brain-dead patients and their family and loved ones. One particular area in which there seems to be significant diversity of opinion is what should occur when death by neurological criteria is pronounced. At some hospitals, when the patient is pronounced dead by neurological criteria, the support equipment is removed from the body immediately and the body is prepared for visitation by family or is transported to the morgue. In other hospitals, support equipment is maintained for a certain limited period to allow the family to be present when the equipment is ultimately removed. In general, however, it appears that institutional guidelines and policy are vague, at best, or often silent about the issue of when, how, and, to some extent, who decides what is done with the body. This policy paper discusses the confusion of care providers as well as lay persons related to the general concepts of death by neurological criteria. In addition, alternative approaches to the withdrawal of support equipment are examined. This article may also allow nursing administrators to better understand the importance of establishing specific clinical guidelines for their staff related to patients declared dead by neurological criteria. Our conclusion is that a universal policy should be adopted whereby all institutions develop the same guidelines concerning when and how treatment modalities should be withdrawn on their brain-dead patients. Such policy guidelines may not extinguish the misconceptions, misunderstandings, and discomforts that are present with a diagnosis of brain death, but it would certainly allow for more consistent actions on the part of the caregivers. Consistency would substantially benefit caregivers, families, and society alike.

Male circumcision, religious preferences, and the question of harm

In “Between Prophylaxis and Child Abuse: The Ethics of Neonatal Male Circumcision,” Michael and David Benatar (2003) stake out a moderate position, proposing that, arst, the choice of whether to circumcise a male child is an acceptable choice and a choice appropriately left to parental prerogatives, and, second, that the participation of the physician is permissible as well. The basis upon which such a conclusion is viewed as acceptable is the empirical evidence that tips in favor of perceiving circumcision as providing a beneat and not a signiacant risk, and also that not all medical service has to be in response only to what is medically indicated. An important part of the paper is the dispassionate, thoughtful, and apparently fair manner in which the empirical evidence on either side of the question is carefully analyzed. Of course, much turns on the question of whether what seems to be the case regarding the analysis of the empirical studies is in fact the case. That is, if the studies in question did and serious harms associated with male circumcision and no beneats, a very different conclusion regarding parental choice and physician involvement might be in order, or, at least, a different set of arguments would have to be developed in order to support the same conclusion. With the latter point in mind, I want to address two issues that were touched on in the paper but need to be developed more fully. The arst has to do with the religious dimension that is associated with the practice and what complications follow if one permits a consideration of this association. The second has to do with medical interventions that occur, at parental discretion, that are not actually medically indicated. My purpose is not to put forward conclusions that I want to defend (at least not at this time) but to point out issues that would seem to require further discussion. What if it were the case that male circumcision posed a real risk and was a religious requirement? Would it still be a matter for parental choice or discretion? Probably most would argue that it should not be. The Benatars would likely argue to this conclusion, as well. But, as I pointed out elsewhere (Sheldon 1996; 2000), when religion is involved, matters become complicated. Different perspectives come into play that are simply incompatible, that pass each other as a result of operating within a different set of priorities. Most perceive the refusal of a blood transfusion by a Jehovah’s Witness parent as the gold standard for unacceptable parental choice. The reason for this is that there is no perceived ambiguity regarding harm to the child. If the child does not receive the blood transfusion, he or she will die and death is a harm. There might be signiacant acceptance of this parental discretion if death were only vaguely possible. But since it is just about certain that death will occur, almost all people will push for intervention that would oppose parental discretion. The problem, however, is that as soon as one brings religion into the mix one ands that what constitutes harm becomes complicated, becomes a matter of perspective. For instance, in the case of the Jehovah’s Witnesses, harm occurs when one receives a blood transfusion, not when one dies. While this might, to many, sound preposterous, the fact is that we actually do not know who is correct on this question. We might actually suffer a harm when we receive a blood transfusion—the harm of being cut off from eternal life—but not when we die physically. Furthermore, we currently have no way to settle the differing claims on this question, to determine, actually, which is right. We would have to die in order to determine an answer to the question, and, even then, our personal fate might be such that we will never be availed of a position that would enable us to answer the question. What does this mean for the question of male circumcision? What it means is that if we intervene in parental decision making in this case, where the reason for male circumcision is religious in nature, we might have to intervene without appealing to what appears to be an unbiased view of what constitutes a harm. And male circumcision no longer remains a practice that can be assessed from the perspective of an agreed-upon standard of harm. If the claim that parents make is that circumcision is required in order to ensure that their child is put into proper relationship to God, on what basis could such a claim be questioned or challenged successfully? Certainly it could not be questioned without bias—in this case, a secular bias. The discussion above poses no problem for the position developed in the Benatars’ paper, since the empirical evidence to which they point describes no signiacant harm associated with male circumcision, and, in fact, suggests a beneat. Therefore, parental discretion does seem acceptable. The second issue, medical intervention that is not medically indicated but results from parental preference,

HIV and the obligation to treat.

The paper is an attempt to review the basis for the claim that physicians have a professional obligation to treat AIDS patients. Considered are the historical record, two professional codes of ethics, and several recent articles. The paper concludes that the arguments considered, which attempt to support the claim that physicians have an obligation to treat, fail. It is suggested, rather, that common humanity, which physicians share with those who suffer from AIDS, ought to be the basis for engaging in the care of AIDS patients.

Palliative care for an infant with short bowel syndrome and advanced liver disease.

Several physicians offer commentary on when it may be ethical to choose to not pursue life-prolonging treatments for terminally ill infants. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

I Want to See My Mother's Picture!

A case study is presented involving the propriety of releasing to a 17-year-old girl medical information about her now-dead mother, including a photograph taken of the mother when she was terminally ill. The physician to whom the request was made was unaware that the daughter herself had medical and psychiatric problems. Soon afterward, the daughter attempted suicide. Two commentaries explore the nature of the relationship between the physician and the former patients daughter, whether the dead patients photograph should have been released, and whether the physician bears any responsibility for the daughters subsequent suicide attempt.

Truth Telling in Medicine-Reply

In Reply.— I share many of the views expressed by Dr Boverman regarding the harmful effects that result from withholding the truth, and I agree that, in most cases, the truth ought to be disclosed. This was, for the most part, the point of my article. There are, however, two comments that I want to make regarding Dr Bovermans letter. The first is that I am not sure that I share Dr Bovermans faith in the ability of current scientific research to give clear answers in regard to what ought to be done in particular situations. Sometimes it appears that the use of this current research represents an attempt to avoid the anxiety of dealing with real moral dilemmas by turning to a sort of technology in which the responsibility of the acting individual is dissipated among other professionals who are also acting on the basis of current research. I