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Cover: 'The Boat' 2 Essays in Bioethics Essays in Bioethics Prof. Pierre Mallia MD MPhil PhD MA(law) MRCP FRCGP DipCTherapeutics) ICGP, CBiol Email: [email protected] 3 .:::; Essays ill Bioethics Table of Contents Introduction ...................................................................... .. ..... 6 Graduation Ceremony November 2008 ................ .. ............... 9 Reproductive Health ........................................ 17 InVitro Fertilization 18 IVF and discrimination 20 IVF controversy ........................................................................................................... 25 Killing the baby to save the mother ......................................................................... 30 The morning after pill ................................................................................................. 33 National sexual health policy ................................................................................... 39 Are we inciting unlawful sex? .................................................................. 44 Primary Health Care ..................... '" ....................................................... 49 Primary Care Reform 50 Connection of health reform with values 60 Cross border health care 67 The morality of Vocational Training for Family Physicians 72 The House 75 The pandemic flu 80 When doctors dissent 85 Concern on antipsychotic treatment ....................................................... 89 Gender, Genomics and the Family ...................................................... 95 Genomics issues and privacy ................................................................................... 96 Problems facing biobanks ...................................................................................... 101 Gender issues 104 Bioethics and the 109 The morality of family practice ............................................................................... 114 Dumping children on grandparents ............................................. ,", .. " .. 119 Patients' rights ,.,", ........... ,"',."., ........... ,.,",.,', ........... ,"",.,." .......... ,.,',., 125 Biopolitics .................................................................................................................. 126 Informed Consent and the nurses' complaint ..................................................... 131 Disposing of dead people ................... ,.................................................................. 136 Ethics in psychiatry ................................................................... :............................... 139 When caring goes astray ........................................................................................ 143 Profits and research in the pharmaceutical industry ........ " ........ ", .. " .. " ..... 148 Issues in the Beginning and End of life ............................................... , 153 The Elderly ................................................................................................................. 154 Ordinary vs. extraordinary treatment 159 What is and what is not euthanasia 164 Treat me right - on Advance Directives , ... ,,,,, .. ,, .. , ... , .. ,, .. ,, .. , .. ,, .. ,,,,, ... , .. ,, 169 Doing Ethics""""""".""".""""",.".".".",.""""."",."."""",.".".""".", 175 Introducing the PUME matrix 176 Ethics matrices 180 Principles 182 Philosophy of Medicine 184 5 Essays in Biocthies Introduction This short book is a collection of selected articles published between 2008 and 201 0 in The Malta Independent and in the Medical journal The Synopse. They are not grouped chronologically but by subject and have been selected primarily upon their interest to the medical student and the mature reader wishing to know about current controversial bioethical issues in Malta. The articles are grouped under five main headings, but they must still be read in the context of what was going on at the time of writing. Nevertheless they carry significant thoughts which continue to apply, but which are nevertheless mine and my responsibility. I do however find that the main arguments serve a good basis for discussion both in class and over a good capucchino or meal. I have selected an oration I was asked to give at a graduation ceremony to set the scene. I had little time to write it and found myself lost. In writing it I touched aboutthe realities that were hitting us in our daily lives locally and internationally. Doing bioethics is not easy and indeed, before many debates, we 'sharpen our knives'. But we need to come together in dialogue not so much with open minds but with open hearts. The more we strongly feel about an argument, the less chance we have in dialogue. This does not mean compromising our values. It does mean opening one's attitude to understanding. The first section is on reproductive health. The writings here range from the discussions on legislating for assisted reproduction, to other areas of sexual health such as the use of the morning after pill and the national Sexual Health policy document. The second section deals with primary health care. At the time of going to print this issue is still being discussed, albeit at an advanced 6 Essays ill Bioethics stage. What underpins these articles are the moral values of family doctors and how these should be put into the context of a vaiable primary health scheme which can serve patient, doctor and country. The third section is on gender, family and genomics. These three topics are interrelated for obvious reasons, although, given more articles, could easily have merited a section each. Nevetheless, as stated above, issues were discussed as they arose and therefore reflect the weight (or moral weight) being given to the area during that period. Patients' rights naturally follow and various topics are dicussed here from informed consent to disposing of dead people and psychiatric ethics. The discussion of informed consent is a cornerstone of biomedical ethics and the student should tease this out of the main context of the article, which in and of itself carries also a different message. The Eluana Englaro case gave, for a while, heated controversy on end-of-life issues. When these articles were written I was being invited on a number of television discussion programmes. What is reflected here is that not all that we may consider as euthanasia, is in actual fact euthanasia and at the time I was intrigued by how much, as a Catholic country, we ignore the teachings of the faith and go off at a tangent, even though one has to admit that the issues are still very sensitive. Finally I thought a section on 'howto do ethcs', would be interesting. There are various models of thinking and discussion, but one often finds that in an argument many principles come into conflict with one another and we need to find a way of balancing within specific situations without falling into 'situational ethics', whilst conversely a tool of separating the moral issue being discussed from consequential issues of that same argument is discussed. I 7 Essays ill BioetTzics developed and used this tool both in class and on the media and find it a convenient way to stick to the main line of argument thus not allowing the discussion to wonder off in a direction differentfrom what we had intended to discuss in the beginning. These articles were reproduced on The Synapse, as they are more oriented to academic discussion, but they have seNed well on discourses on the media, and I feel that anyone with an interest in ethics may find them useful. The use of the matrix is illustrated with examples, which of themselves form, hopefully, interesting reading. Finally, I acknowledge that the field of bioethics is a controversial one. Even in those areas where we agree on principle, we may find differences in the specifics. The articles are in no way intended to be didactic and neither are they intended to carry scholarly authority other than the promotion of a general discussion. They are useful for my method of interacting with students and the public, which is always claiming that I do not know ethics any more than anyone else. I may know some rules and existent laws and regulations. But ethics is thought at home, at schools, within our cultures and during our upbringing. We move forward by discussing and reverting back to our first principles. By doing so we may enter a crises. We may find that the roots of our beliefs are based on faith at the end of the day. We know that it should be so, but this is only intuition. Nevertheless a challenge to our knowledge is a moment of opportunity and he who knows his weakness has indeed gained a strength. At the end of the day, in order to stand up to be counted, we may find no logical basis, but merely asserting a belief - such as the value of life. It is with such assertions after all that legislators have to deal, irrespective of whether they are backed by strong argument or faith in their universality. I hope that this selection can form the basis of interesting discussions and perhaps give a small insight into what makes us tick as a population when it comes to normative ethical values in biomedical ethics and health care. 8 Essays in Bioethics Graduation Ceremony November 2008 Graduation ceremony