Helen Watt

Is it possible to donate unpaired vital organs, foreseeing but not intending one's own death? We argue that this is indeed psychologically possible, and thus far agree with Charles Camosy and Joseph Vukov in their recent paper on 'double effect donation.' Where we disagree with these authors is that we see double effect donation not as a morally praiseworthy act akin to martyrdom but as a morally impermissible act that necessarily disrespects human bodily integrity. Respect for bodily integrity goes beyond avoiding the aim to kill: not all side effects of deliberate bodily interventions can be outweighed by intended benefits for another even if the subject fully consents. It is not any necessary intention to kill or harm another or oneself that makes lethal donation/harvesting illicit but the more immediate intention to accept or perform surgery on an (innocent) person combined with the foresight of lethal harm and no health-related good for him or her. Double effect donation falls foul of the first condition of double effect reasoning in that the immediate act is wrong in itself. We argue further that the wider effects of such donation would be socially disastrous and corrupting of the medical profession: doctors should retain a sense of nonnegotiable respect for bodily integrity even when they intervene on willing subjects for the benefit of others.

Is it possible to donate unpaired vital organs, foreseeing but not intending one’s own death? We argue that this is indeed psychologically possible, and thus far agree with Charles Camosy and Joseph Vukov in their recent paper on “double effect donation.” Where we disagree with these authors is that we see double-effect donation not as a morally praiseworthy act akin to mar- tyrdom but as a morally impermissible act that necessarily disrespects human bodily integrity. Respect for bodily integrity goes beyond avoiding the aim to kill; not all side effects of deliberate bodily interventions can be outweighed by intended benefits for another even if the subject fully consents. It is not any necessary intention to kill or harm another or oneself that makes lethal donation/harvesting illicit but the more immediate intention to accept or perform surgery on an (innocent) person combined with the foresight of lethal harm and no health-related good for him or her. Double-effect donation falls foul of the first condition of double-effect reasoning in that the immediate act is wrong in itself. We argue further that the wider effects of such don- ation would be socially disastrous and corrupting of the medical profession: doctors should retain a sense of nonnegotiable respect for bodily integrity even when they intervene on willing subjects for the benefit of others.

Fetuses and their mothers (and other adults) share many objective interests. These include interests in disjunctive ways of achieving human well-being, including the formation and success of good projects such as particular friendships. Pursuing such good projects is in the individual’s interests and is what growing up is all about. Some interests are time-sensitive, and determining which interests apply at what stages in life requires asking which benefits are in some sense appropriate to the individual and still in his/her actual or possible or even hypothetical future. Human individuals not only have interests in unconditional benefits to them, including the welfare of existing family members, but in conditional benefits to them, including the welfare of possible future family members. Even if not all interests apply to the individual at every stage, if an adult-type benefit is still in the (long-term) future, the young individual including the fetus has a stake in that benefit, conditional as the benefit may sometimes be. Fulfilment is enhanced by pursuit and conscious enjoyment of ‘human goods’, but as with adults, the stake in these remains strong even if psychological links with the long-term future in which this happens are tenuous or non-existent.

Cooperation in wrongdoing is an everyday matter for all of us, though we need to discern when such cooperation is morally excluded as constituting formal cooperation, as opposed to material (unintended) cooperation whether justified or otherwise. In this paper, I offer examples of formal cooperation such as referral of patients for certain procedures where the cooperating doctor intends an intrinsically wrongful plan of action on the part of the patient and a medical colleague. I also consider a case of formal cooperation where the cooperator intends a choice on the part of another person that is not intrinsically wrong, but wrong in the circumstances because the person believes it will cause serious uncompensated harm.

Cooperation in wrongdoing is an everyday matter for all of us, though we need to discern when such cooperation is morally excluded as constituting formal cooperation, as opposed to material (unintended) cooperation whether justified or otherwise. In this paper, I offer examples of formal cooperation such as referral of patients for certain procedures where the cooperating doctor intends an intrinsically wrongful plan of action on the part of the patient and a medical colleague. I also consider a case of formal cooperation where the cooperator intends a choice on the part of another person that is not intrinsically wrong, but wrong in the circumstances because the person believes it will cause serious uncompensated harm.

Some laws cannot yet be entirely abrogated in a current political situation, though permitting grave injustices against some individuals; for example, unborn and/or disabled individuals. In supporting the passing of new ‘imperfect’ laws that protect only some of those who now lack protection, do we ourselves discriminate unjustly against those remaining unprotected? Or does that depend on factors such as our intentions – including what we intend that others intend? How may we collaborate with colleagues who intend, and perhaps explicitly defend, the continuation of remaining, closely-related injustices, although they are willing to join us in trying to improve some aspects of the status quo? This paper explores the moral constraints on our attempts to extend the law’s protection to some, but not to all, of those individuals currently deprived of such ­protection and at risk of serious harm.

Biological sex should be “acknowledged” and “accepted”—but which responses to gender dysphoria might this preclude? Trans-identified people may factually acknowledge their biological sex and regard transition as purely palliative. While generally some level of self-deception and even a high level of nonlying deception of others are sometimes justified, biological sex is important, and there is a nontrivial onus against even palliative, nonsexually motivated cross-dressing. The onus is higher against co-opting the body, even in a minor and/or reversible way, to make a false communication concerning one’s sex. Hardest to defend is the destruction of sexual–reproductive functions and causally downstream functions such as lactation: due to the transcendent nature of sexual–reproductive functions, an appeal to the “principle of totality” here is misplaced. This is not to say that social, and milder medical, transition is absolutely excluded even for severe unmanageable dysphoria, nor that subsequent to any transition, detransition is necessarily required.

The term “value of life” can refer to life’s intrinsic dignity: something nonincremental and time-unaffected in contrast to the fluctuating, incremental “value” of our lives, as they are longer or shorter and more or less flourishing. Human beings are equal in their basic moral importance: the moral indignities we condemn in the treatment of e.g. those with dementia reflect the ongoing human dignity that is being violated. Indignities licensed by the person in advance remain indignities, as when people might volunteer their living, unconscious bodies for surrogacy or training in amputation techniques. Respect for someone’s dignity is significantly impacted by a failure to value that person’s very existence, whatever genuine respect and good will is shown by wanting the person’s life to go well. Valuing and respecting life is not, however, vitalism: there can be good and compelling reasons for eschewing some means of prolonging life.

Is the “act itself” of separating a pregnant woman and her previable child neither good nor bad morally, considered in the abstract? Recently, Maureen Condic and Donna Harrison have argued that such separation is justified to protect the mother’s life and that it does not constitute an abortion as the aim is not to kill the child. In our article on maternal–fetal conflicts, we agree there need be no such aim to kill (supplementing aims such as to remove). However, we argue that to understand “abortion” as performed only where the death of the child is intended is to define the term too narrowly. Respect for the mother, the fetus, and the bond between them goes well beyond avoiding any such aim. We distinguish between legitimate maternal treatments simply aimed at treating or removing a damaged part of the woman and illegitimate treatments that focus harmfully on the fetal body and its presence within the mother’s body. In obstetrics as elsewhere, not all side effects for one subject of intervention can be outweighed by intended benefits for another. Certain side effects of certain intended interventions are morally conclusive.

A difficult task for politicians who want to fight injustice without doing wrong themselves is identifying where it is permissible to vote for and/or promote so-called “imperfect laws” which somewhat improve existing unjust legal situations but leave closely related injustices intact. One approach is to seek a “selective ban” on some injustices which are politically preventable. This approach is acceptable at least in principle, unlike the approach of “regulation”—i.e., permitting or instructing others to do, or prepare to do, the unjust act in specified ways. The latter necessarily involves us in formal cooperation with evil: wrongly intending that others choose wrongly; for example, that abortion doctors deliberately prepare for abortion, albeit in ways that make an abortion less risky or less likely. In relation to parental consent or parental notification, and to pregnancy counselling and provision of information to pregnant women, while there may be ways of requiring these without complicity in others’ wrongful choices, this is at least more difficult than is often recognised. There can also be problems of principle in seeking consensus with fellow-legislators who may positively intend and even promote the continuation of remaining injustices even as they collaborate with more consistent reformers in passing laws which mitigate injustice overall.

What does it mean to respect life and health in an innocent fellow-human being? Separating conjoined twins where one twin will die as a result need not involve the intention to kill or harm. Arguably, however, not all side-effects are “mere” side-effects which could, in principle, be outweighed by sufficiently good intended effects. Rather, foreseen serious harm for an innocent person we non-therapeutically affect can be morally conclusive when linked to the intention to affect the person’s body or invade the space it fills. In the case of infant conjoined twins, such as the Maltese twins Jodie and Mary, the twin who dies from separation has no unjust, or any, intentions as regards the twin saved. She thus has the moral immunity of any innocent person from lethal bodily invasions and other serious bodily harm. Neither the final act which killed Mary nor previous acts of cutting into Mary, including parts shared with her twin Jodie, were therefore morally permissible.

The “principle of double effect” is a vital tool for moral decision making and is applicable to all areas of medical practice, including (for example) end-of-life care, transplant medicine, and cases of conscientious objection. Both our ultimate and our more immediate intentions are relevant in making and evaluating choices— though side effects must be kept proportionate and can be morally conclusive when linked with some intentions. Intentions help to form the character of doctors, and of human beings generally. While hypocrisy is certainly possible in regard to this form (and other forms) of moral reasoning, double effect reasoning, sincerely practised, remains indispensable in identifying moral problems and solutions.

May a couple have the aim of conceiving as their primary purpose in having marital relations? In this paper, I argue against the view of Alexander Pruss that it is wrong to do this since it treats human beings as fungible in their creation when their unique features are not known to their parents. I argue that Pruss cannot separate seeking reproduction as part of a marital vocation from seeking the unknown, unspecified child who is part of what makes for success in this particular area. While neither spouse should treat the other as a mere tool for having a child, success in the shared goal of conceiving, as well as the goal itself and its pursuit, is very much part of the conjugal good. Existing human beings are morally irreplaceable in the sense that they must be individually valued and respected, but we may promote the lives of unknown existing people under a ‘catch all’ description—and may also deliberately conceive new people of some unknown, indeterminate kind.

Abortion for life-limiting foetal anomaly is often an intensely painful choice for the parents; though widely offered and supported, it is surprisingly difficult to defend in ethical terms. Abortion on this ground is sometimes defended as foetal euthanasia but has features which sharply differentiate it from standard non-voluntary euthanasia, not least the fact that any suffering otherwise anticipated for the child may be neither severe nor prolonged. Such abortions may be said to reduce suffering for the family including siblings – a consideration rarely stated so explicitly in defences of postnatal euthanasia – or for the woman who must in any case face the eventual loss of her baby, and for whom the abortion is seen as therapeutic in minimising pain. Finally, the abortion may be said to constitute the cessation of morally optional life support on the part of the woman, and/or to be a ‘social’ choice she is entitled to make, whether or not this in fact promotes her interests or those of her child. These defences need honest exploration: the intense parental suffering caused by the choice to end an often much-wanted pregnancy should not preclude but rather encourage the question whether this choice can indeed be ethically proposed to couples, especially compared with the neonatal palliative care (‘perinatal hospice’) approach so well received by parents who experience it.

The guidelines on Decisions Relating to Cardiopulmonary Resuscitation begin with a reassuringly objective view of medicine: its “primary goal” is to benefit patients by “restoring or maintaining their health as far as possible, thereby maximising benefit and minimising harm”. Some might want to add that medicine has several goals, not all of which relate to promoting health; however, those who see the aim of the profession as more than consumer satisfaction will welcome the suggestion here that not just any choice counts as medicine. In the same way, the statement which heads the next paragraph would be rejected by very few readers if “quality of life” were suitably defined. If all we mean by “quality of life” is the patient's level of wellbeing, with no suggestion that the value of his or her “being” can fall to zero or below, it is uncontroversial that “it is not an appropriate goal of medicine to prolong life at all costs with no regard to its quality or the burdens of treatment on the patient”. This is, however, an overly benign interpretation of “quality of life” observations as they appear in the guidelines.

What kind of interventions on the body of an innocent human being may be licitly intended? This question arises in relation to maternal–fetal conflicts such as ectopic pregnancy and obstructed labor, and to other cases such as organ harvesting and separation of conjoined twins. Many assume that harm must be intended for absolute moral prohibitions to apply; however, it is not always the case that foreseen harm is merely a factor to weigh against benefits we intend. On the contrary, foreseen harm (and absence of benefit) for someone we affect can be morally conclusive when linked to an immedi­ate intention to affect the person’s body or invade the space it fills.

What makes something an embryo—as opposed to what is actually, and not just in biotech parlance, a collection of cells? This question has come to the fore in recent years with proposals for producing embryonic stem cells for research. While some of those opposed to use of standard embryonic stem cells emphasise that adult cells have a clinical track record, others argue that there may be further benefits obtainable from cells very like those of embryos, provided such cells can be derived in new ways. Rather than deriving them in ways that kill or otherwise endanger a living human embryo, they could be obtained from an entity that merely resembles a human embryo sufficiently closely for its cells to be of use. Such an entity might be created after introducing genetic changes to an ovum before it is activated by, for example, a cloning-type procedure, such that a gene essential to embryogenesis will be either absent, blocked in its expression, or overexpressed.1,2 The claim is that the ovum could be made to give rise to embryonic stem cells—mere living parts—without ever giving rise to a whole embryo, who is killed to obtain them. Whereas cloning “proper” winds back the specialisation of the cell nucleus to a point where a whole embryo is formed who has not yet specialised its cells, oocyte-assisted reprogramming , it is claimed, would wind back the specialisation merely to an intermediate point at which no embryo is created. Other methods proposed for deriving pseudoembryonic cells include parthenogenesis, in which an ovum is activated without a sperm, or even the insertion of an adult cell nucleus.1MORAL STATUS OF THE EMBRYOIn this paper, I assume that a genuine …

In a world of rapid technological advances, the moral issues raised by life and death choices in healthcare remain obscure. _Life and Death in Healthcare Ethics_ provides a concise, thoughtful and extremely accessible guide to these moral issues. Helen Watt examines, using real-life cases, the range of choices taken by healthcare professionals, patients and clients which lead to the shortening of life. The topics looked at include: * euthanasia and withdrawal of treatment * the persistent vegetative state * abortion * IVF and cloning * life-saving treatment of pregnant women Clearly written and insightful, _Life and Death in Healthcare Ethics_ presupposes no prior knowledge of philosophy. It will be of interest to anyone confronting healthcare ethics for the first time, or seeking to develop his or her understanding of some core topics in the field