Zeljka Buturovic

In his article, ‘Non-consequentialist and egalitarian objections to the dead donor rule’,1 Lawrence Masek observes that ‘palliative care physicians sometimes may shorten a patient’s life as a result of relieving the patient’s pain, but transplant teams may never shorten a patient’s life as a result of procuring a vital organ’, calling these ‘inconsistent standards.’ He examines various principles used to justify the Dead Donor Rule (DDR): do-no-harm, do-not-kill and double effect and finds counterexamples to each. For example, living kidney donation seemingly violates do-no-harm, lethal palliation violates do-not-kill, etc. Having demonstrated these inconsistencies in application of principles, Masek concludes that ‘the burden of proof belongs to proponents of the DDR’ to defend the rule ‘without relying on principles of ethics that are too strict’. Let me take on that burden. The assumption that medical practice needs consistency based on overarching principles is questionable. What appears as inconsistency when judged against a principle is often cognitive sophistication of human judgement that includes extensive background knowledge and superb sensitivity to relevant contextual clues. Among philosophers, abstract principles, such as ‘do no harm’, are typically perceived as sophisticated reasoning. However, the very process of abstraction necessarily strips away contextual information, some or most of which is actually morally relevant. In addition, as John M. Ellis2 argues, high-level abstract terms are actually primitive linguistic tools because they lack the power of differentiation required to understand complex realities. Essentially, by trading off …

In his article ‘Bioethics and the value of disagreement’ 1 Michael J. Parker proposes ‘adversarial cooperation’ as a new model for bioethics. Inspired by the practice of adversarial collaboration in psychology, and antagonistic cooperation from the humanities, Parker recommends a structured, facilitated process that convenes opposed perspectives, maps facts and values, and culminates in co-authored outputs and ‘at least one morally significant action’. Parker’s adversarial cooperation would, ideally, integrate procedural and output-focused (eg, co-authored paper, recommended ethical act) features of adversarial collaboration with the tolerant, inclusive and open-minded culture of antagonistic cooperation. While clearly well-intentioned, Parker’s proposal overstates the problems in bioethics and risks making the field worse by imposing a kind of intellectual central planning atop its naturally vibrant ecosystem. As the history of bioethics, philosophy and law demonstrates, direct collaboration is not necessary for ethical insights or even broad and durable consensus. Insights, arguments and conclusions...

In his paper, ‘Patients, doctors and risk attitudes’, Makins argues that doctors, when choosing a treatment for their patient, need to follow their risk profile.1 He presents a pair of fictitious diseases facing a patient who either has ‘exemplitis’, which requires no treatment or ‘caseopathy’, which is severe and disabling and for which there is a treatment with unpleasant side effects. The doctor needs to decide whether the patient should pursue the unpleasant treatment, just in case he has caseopathy. Makins believes that rational-choice theory is a productive way to approach this problem. This theory frames all decisions as gambles. Each possible gamble (eg, not to pursue treatment) leads, probabilistically, to a set of outcomes (life with no disease and no side effects, but also, possibly, life with a disabling disease, since no treatment is taken). Utilities of these outcomes and probabilities that they will happen are combined to yield a number—expected utility. One is supposed to gamble—to make a choice—in a way that maximises this expected utility. Makins takes this framework for granted and is focused on an additional complication, the patient’s risk preference. He believes that, in his hypothetical example, even if expected utility were exactly the same, withholding treatment …

Bollen et al, replying to my own article, describe, in great detail, administrative and logistical aspects of euthanasia approval and organ donation in the Netherlands. They seem to believe that no useful lessons can be drawn from experiences of related groups such as euthanasia patients who cannot donate organs; patients who chose assisted suicide as opposed to euthanasia; patients in intensive care units and their relatives and suicidal young people as if we can only learn about organ donation in euthanasia patients by studying this exact group and no other, no matter how closely related and obviously relevant. However, it is not only permissible but also absolutely essential to gather evidence that goes beyond immediate point of interest and carefully study groups that share important features with it. Also, groups eligible for euthanasia are constantly expanding, theoretically, legally and practically, and it would be irresponsible to not foresee what are likely future developments. Finally, myopic focus on the technicalities of the procedure misses psychological reality that drives decisions and behaviours and which rarely mimics administrative timelines. Patients proceeding through euthanasia pipeline already face substantial situational pressure and adding organ donation on top of it can make the whole process work as a commitment device. By allowing euthanasia patients to donate their organs, we are giving them additional reason to end their lives, thus creating an unbreakable connection between the two.

In the past, a vast majority of medical assistance in dying patients were elderly patients with cancer who are not suitable for organ donation, making organ donation from such patients a rare event. However, more expansive criteria for MAiD combined with an increased participation of MAiD patients in organ donation is likely to drastically increase the pool of MAiD patients who can serve as organ donors. Previous discussions of ethical issues arising from these trends have not fully addressed difficulties involved in separating decision to end one’s life from the one to donate one’s organs. However, realities of organ donation logistics and human decision making suggest that this separation can be extraordinary difficult. The need to maximise quality of donated organs complicates dying experience of the donor and is likely in tension with the dying experience the patient envisioned when first considering MAiD. Furthermore, the idea that patients will think about MAiD first, and only when firmly decided to end their life, consider organ donation, runs contrary to organ donation policies in some countries as well as end of life and everyday decision making. This opens the door for organ donation to serve as an incentive in MAiD decisions. Dispensing with the simplistic assumption that organ donation can never be a factor in MAiD decisions is, therefore, essential first step to properly addressing ethical issues at hand.

An increasing number of bioethicists are raising concerns that young childless women requesting sterilisation as means of birth control are facing unfair obstacles. It is argued that these obstacles are inconsistent, paternalistic, that they reflect pronatalist bias and that men seem to face fewer obstacles. It is commonly recommended that physicians should change their approach to this type of patient. In contrast, I argue that physicians’ reluctance to eagerly follow an unusual request is understandable and that whatever obstacles result from this reluctance serve as a useful filter for women who are not seriously committed to their expressed requests for sterilisation. As women already disproportionally bear the birth control burden, less resistance that men might be getting in terms of voluntary sterilisation works to women’s advantage, providing a much needed balance. Societal attitudes towards women and motherhood should not be confused with individual physicians’ reasonable reluctance to jump at a serious elective procedure at fairly mild expression of interest.

In a recent article Joshua James Hatherley argues that, if physician-assisted suicide (PAS) is morally permissible for patients suffering from somatic illnesses, it should be permissible for psychiatric patients as well. He argues that psychiatric disorders do not necessarily impair decision-making ability, that they are not necessarily treatable and that legalising PAS for psychiatric patients would not diminish research and therapeutic interest in psychiatric treatments or impair their recovery through loss of hope. However, by erasing distinction between somatic and psychiatric disorders on those grounds, he also erases distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS should be available to all, for all reasons or, ultimately no reason. Furthermore, as psychiatric patients are much more likely to be a source of usable organs for transplantation, their broad inclusion would strengthen the link between PAS/euthanasia and organ donation, potentially undermining both as well as diminishing already declining general trust in medical authorities and professionals and public health authorities and activists.

A conditional survey establishes a preliminary case for believing that policy differences are to some extent driven by fundamental beliefs about empirical aspects of society and economics. The survey shows willingness in about a third of all respondents to shift their expressed policy preferences when asked a hypothetical question positing negative consequences of their initial preferences. This suggests that assumptions about the consequences of public policies may play as important a role in policy preferences, or a more important role, than do values, personality traits, or motivation. However, roughly a third of those with the strongest initial attitudes expressed even stronger attitudes—but in the same direction—when confronted with counterattitudinal hypotheticals. This may reflect attitude polarization of the sort encountered by previous researchers, such as Lord et al. (1979) and Taber and Lodge (2006). Or it may indicate a tacit objection to the very idea of basing policy preferences on policy consequences.

In his remarkably meticulous and even-handed 2005 book, Expert Political Judgment, Philip E. Tetlock establishes that the only thing we can count on in the political experts' predictions is that they will underperform-in some cases significantly-the predictions made by mechanical statistical procedures, including random chance. Experts have many uses and Tetlock does not claim that they have no value. However, Tetlock zeroes in on experts' important political role-as prognosticators. Tetlock does not attempt the impossible by trying to judge experts on their ability to prognosticate the effects of public policies; this would require that Tetlock himself could know what those effects were, and even in retrospect, it isn't that simple. Experts' failure to predict much simpler matters, however, such as GDP growth within a broad range, strongly suggests that technocracy is worse than putting dart-throwing chimps in charge of public policy.

The work of Daniel Kahneman and his colleagues has established that people do not always think and act “rationally.” However, this amounts to saying that Kahneman and his collaborators interpret people's behavior in experimental settings to be inconsistent with the narrow understanding of rationality deployed by orthodox neoclassical economists. Whether this means that people make poor decisions in the real world, however, has not been demonstrated, a fact that calls into doubt the significance of the list of heuristics and biases generated by behavioral economists. Dual-process theory was meant to give theoretical coherence to this list, but its empirical foundation, too, retains the premises of “rational” choice as an ideal.

Breastfeeding is analogous to pregnancy as an experience, in its exclusiveness to women, and in its cost and the effects it has on equitable share of labor. Therefore, the history of formula feeding provides useful insights into the future of full ectogenesis, which could evolve into a more severe version of what formula feeding is today: simplify life for some women and provide couples with a more equitable share of work at the cost of stigma, guilt and a daily diet of studies purporting to show the benefits of natural pregnancy. Making pregnancy an optional route to motherhood would make women's life trajectory more similar to men's and thus put pressure on women to compete with men on the ground shaped by men's preferences. Despite being a treasured experience of many women today, bearing children could become the luxury of the few, the province of the very poor and a choice working women will pay a high price for as women who choose pregnancy become stigmatized as self-indulgent or unprofessional and penalized for it in the workplace. At the same time, scarce societal resources that could be used to support pregnant women and working mothers would instead be directed toward proving to women or even forcing them to gestate children "the right way." While not necessarily threatening on its own, when added to formula feeding, IVF, stem-cell produced ova and sex robots, full ectogenesis could diminish men's stake in women's wellbeing and even existence.