Fleshing Out Vulnerability

In the literature on medical ethics, it is generally admitted that vulnerable persons or groups deserve special attention, care or protection. One can define vulnerable persons as those having a greater likelihood of being wronged – that is, of being denied adequate satisfaction of certain legitimate claims. The conjunction of these two points entails what we call the Special Protection Thesis. It asserts that persons with a greater likelihood of being denied adequate satisfaction of their legitimate claims deserve special attention, care or protection. Such a thesis remains vague, however, as long as we do not know what legitimate claims are. This article aims at dispelling this vagueness by exploring what claims we have in relation to health care – thus fleshing out a claim‐based conception of vulnerability. We argue that the Special Protection Thesis must be enriched as follows: If individual or group X has a greater likelihood of being denied adequate satisfaction of some of their legitimate claims to (i) physical integrity, (ii) autonomy, (iii) freedom, (iv) social provision, (v) impartial quality of government, (vi) social bases of self‐respect or (vii) communal belonging, then X deserves special attention, care or protection. With this improved understanding of vulnerability, vulnerability talk in healthcare ethics can escape vagueness and serve as an adequate basis for practice.     

Adversaries at the Bedside: Advance Care Plans and Future Welfare

Advance care planning refers to the process of determining how one wants to be cared for in the event that one is no longer competent to make one's own medical decisions. Some have argued that advance care plans often fail to be normatively binding on caretakers because those plans do not reflect the interests of patients once they enter an incompetent state. In this article, we argue that when the core medical ethical principles of respect for patient autonomy, honest and adequate disclosure of information, institutional transparency, and concern for patient welfare are upheld, a policy that would allow for the disregard of advance care plans is self‐defeating. This is because when the four principles are upheld, a patient's willingness to undergo treatment depends critically on the willingness of her caretakers to honor the wishes she has outlined in her advance care plan. A patient who fears that her caretakers will not honor her wishes may choose to avoid medical care so as to limit the influence of her caretakers in the future, which may lead to worse medical outcomes than if she had undergone care. In order to avoid worse medical outcomes and uphold the four core principles, caregivers who are concerned about the future welfare of their patients should focus on improving advance care planning and commit to honoring their patients’ advance care plans.     

Taking due care: moral obligations in dual use research

In the past decade, the perception of a bioterrorist threat has increased and created a demand on life scientists to consider the potential security implications of dual use research. This article examines a selection of proposed moral obligations for life scientists that have emerged to meet these concerns and the extent to which they can be considered reasonable. It also describes the underlying reasons for the concerns, how they are managed, and their implications for scientific values. Five criteria for what constitutes preventable harm are suggested and a number of proposed obligations for life scientists are considered against these criteria, namely, the obligations to prevent bioterrorism; to engage in response activities; to consider negative implications of research; not to publish or share sensitive information; to oversee and limit access to dangerous material; and to report activities of concern. Although bioterrorism might be perceived as an imminent threat, the analysis illustrates that this is beyond the responsibility of life scientists either to prevent or to respond to. Among the more reasonable obligations are duties to consider potential negative implications of one's research, protect access to sensitive material, technology and knowledge, and report activities of concern. Responsibility, therefore, includes obligations concerned with preventing foreseeable and highly probable harm. A central conclusion is that several of the proposed obligations are reasonable, although not unconditionally.     

Unformed minds: Juveniles,neuroscience, and the law

Recently, the question of adolescent culpability has been brought before the Supreme Court of the United States for reconsideration. Neuroscience, adolescent advocates claim, is teaching us that young people cannot be found fully responsible for their actions. The reason: their brains are not fully formed. Here I consider the history of the use of scientific evidence in the courtroom, a number of adolescent murder cases, and the data now emerging from neuroscience, and argue that when it comes to brains, judges, just like the rest of us, are unnecessarily impressed. Ultimately, how we determine culpability should rest on normative and ethical considerations rather than on scientific ones.     

Abnormal sweat electrolytes in symptomatic human immunodeficiency virus infection in a child.

A 3 1/2 year old girl presented with failure to thrive and a five month history of diarrhoea and recurrent cough. The results of sweat sodium tests suggested a diagnosis of cystic fibrosis; but atypical organisms were found (Haemophilus influenzae, Candida albicans, but no Staphylococcus aureus), she failed to respond to treatment, and her sweat sodium concentrations fell in response to fludrocortisone. She also had hyperglobulinaemia, neutropenia, and reduced numbers of T4 lymphocytes, which prompted the performance of a test for antibody to human immunodeficiency virus (HIV). This proved positive, and she was treated with co-trimoxazole, zidovudine, and human immunoglobulin. Both parents and two siblings were also positive for HIV, though all had normal sweat sodium concentrations. Children with symptoms suggestive of cystic fibrosis but who also show atypical features, as in this case, should have their HIV state checked.     

CONSCIENTIOUS OBJECTIONS IN PHARMACY PRACTICE IN GREAT BRITAIN

Pharmacists who refuse to provide certain services or treatment for reasons of conscience have been criticized for failing to fulfil their professional obligations. Currently, individual pharmacists in Great Britain can withhold services or treatment for moral or religious reasons, provided they refer the patient to an alternative source. The most high‐profile cases have concerned the refusal to supply emergency hormonal contraception, which will serve as an example in this article. I propose that the pharmacy profession's policy on conscientious objections should be altered slightly. Building on the work of Brock and Wicclair, I argue that conscientious refusals should be acceptable provided that the patient is informed of the service, the patient is redirected to an alternative source, the refusal does not cause an unreasonable burden to the patient, and the reasons for the refusal are based on the core values of the profession. Finally, I argue that a principled categorical refusal by an individual pharmacist is not morally permissible. I claim that, contrary to current practice, a pharmacist cannot legitimately claim universal exemption from providing a standard service, even if that service is available elsewhere.     

Anthropology and emotion

The centrality of emotion in thought and action is increasingly recognized in the human sciences, though basic questions of definition and scope remain unresolved. Where do emotions begin and end? How should we identify and analyse them? How should we write about them? Ethnographic fieldwork, as pioneered by Malinowski, offers powerful insights into the place of emotion in social life; but emotions are peculiarly difficult to capture in the generalizing format of case study and ethnographic summary. In this article I argue that semantic, structural, and discourse‐based approaches tend to miss what is most important – what counts for the persons concerned and therefore what makes the emotion. I review the conceptual and methodological issues and conclude that only a narrative approach can capture both the particularity and the temporal dimension of emotion, restoring verisimilitude and fidelity to experience.     

Increased extra‐pair paternity in broods of aging males and enhanced recruitment of extra‐pair young in a migratory bird

Despite keen interest in extra‐pair mating in birds, its adaptive significance remains unresolved. Here, we use a multi‐year dataset to test whether traits of a female's social mate influence her propensity to produce extra‐pair offspring in a population of house wrens, and whether producing extra‐pair young has consequences for a female's fitness through effects on offspring survival. Females were most likely to produce extra‐pair offspring when paired with old males and when paired with males on poor‐quality territories, although this latter effect was marginally nonsignificant. Among offspring, the cutaneous immunity of within‐pair young decreased as the age of their sires increased, but cutaneous immunity of extra‐pair young was not affected by the age of their extra‐pair sires or by the age of the males rearing them. Extra‐pair offspring were more likely than within‐pair offspring to return as breeding adults to the local population, with extra‐pair sons being more likely to return as a breeder for multiple years. Our findings support the hypothesis that females produce extra‐pair offspring to enhance their inclusive fitness beyond what they are capable of given the male with which they are socially paired.     

Distribution, timing of attack, and oviposition of the banana weevil, Cosmopolites sordidus, on banana crop residues in Uganda

Crop sanitation (removal and chopping of residue corms and pseudostems following plant harvest) has been recommended as a ‘best bet’ means of reducing banana weevil, Cosmopolites sordidus (Germar) (Coleoptera: Curculionidae), populations. However, it has been unclear when such practices should be carried out and what types of residues should be destroyed. Therefore, trials were conducted in Uganda to determine C. sordidus distribution, timing of attack, and oviposition on crop residues and growing plants. Assessments were performed in on‐station trials on different aged standing and prostrate residues by destructive sampling. Similar data were collected from farmers’ fields maintained at low, moderate, and high levels of sanitation. In the on‐station trial, oviposition occurred on up to 120‐day‐old residues, although most occurred within 30 days of harvest. In a second on‐station experiment, oviposition on standing residues was not significantly affected by residue age. By contrast, oviposition on prostrate residues was two times higher on 4‐week‐old than on 2‐week‐old residues, while the number of larvae on 8‐week‐old residues was three times higher than on 2‐week‐old residues. The number of adults was twice as high on 16‐week‐old residues as that on 2‐week‐old residues for both prostrate and standing residues. Farmers’ fields maintained at high sanitation had 50% fewer eggs per residue than farms with low sanitation levels. In general, the number of immatures per residue was 50% higher on banana corms than on pseudostems. Numbers of larvae per residue were three times more abundant at low than at high sanitation levels. Residues in fields with high sanitation supported 50% fewer adults than residues in low sanitation fields. The results suggest that removal and splitting of corms after harvest is effective and practical in destroying immature growth stages of the pest and that such practices should be carried out soon after harvest.     

In search of the missing subject: narrative identity and posthumous wronging

With the advanced methods of analysing old biological material, it is pressing to discuss what should be allowed to be done with human remains, particularly for well documented historical individuals. We argue that Queen Christina of Sweden, who challenged the traditional gender roles, has an interest in maintaining her privacy when there are continued attempts to reveal her ‘true’ gender. In the long-running philosophical debate on posthumous wronging, the fundamental question is: Who is wronged? Our aim is to find this ‘missing subject’ using narrative theory.Narrative identity emphasises the fact that no person is alone in knowing or telling their life story. People’s lives are entangled and parts of the life story of a deceased person can remain in the living realm. Since the narrative identity of a person does not necessarily end upon their death, and this narrative continues to relate directly to the person who once existed, it is the narrative subject that can continue to be posthumously wronged. Queen Christina can no longer maintain her own identity, but we maintain it by our research into her life. We propose three duties relevant for posthumous wronging: the duty of truthfulness, the duty of recognition and the duty to respect privacy.     

ORPHANS BY DESIGN: THE FUTURE OF GENETIC PARENTHOOD

Establishing the nature of genetic parenthood is an important task. This is, firstly, because many people desire that relationship and it is in their interest to know what that is, and secondly, because there is a view that it may incur certain moral obligations between the genetic parent and their child. Many theorists have made attempts to define exactly what genetic parenthood is. I show that these definitions are deficient if they wish to fully capture all reproductive scenarios in ways that are intuitive and/or meaningful. Through a series of cases involving technologies such as cloning and genome editing, we see that in lieu of the traditional two parents, there are possible beings who have no genetic parents, one genetic parent, or many genetic parents. Establishing these cases complicates our understanding of genetic parenthood. From this, we must reconsider current definitions, as well as the usefulness of defining genetic parenthood in these complex cases. Here I do not aim to establish a new definition, but rather to suggest that this complexity makes it necessary to re‐assess the importance of the connection between genetic parenthood and parental obligations and authorities.     

Arguing by analogy in the fetal tissue debate

In the debate over fetal tissue use, an analogy is often drawn between removing organs from the body of a person who has been murdered to use for transplantation, and collecting tissue from an aborted fetus to use for the same purpose. The murder victim analogy is taken by its proponents to show that even if abortion is the moral equivalent of murder, there is still no good reason to refrain from using the fetal tissue, since as a society we do not see any problem about using organs from murder victims. However, I argue that the analogy between murder victims and aborted fetuses does not hold — the two situations are not the same in all morally relevant respects. Thus the murder victim analogy does not provide an argument in favour of fetal tissue transplant. In conclusion, I point to some of the potential pitfalls of using analogies in ethical argument.     

Balancing the protection of marine ecosystems with economic benefits from land‐based activities: The quest for international legal barriers

The major threats to the health, productivity, and biodiversity of the marine environment result from human activities on land. National laws have failed to provide an adequate response. In conformity with the obligations contained in the 1982 Law of the Sea Convention, in recent years states have launched new legislative attempts that have as their stated objective to give more priority to protection of the marine ecosystem from land‐based activities. The 1995 Global Programme of Action as well as regional treaties and programs provide for a wide variety of alternative strategies, including monitoring, economic instruments, raising of awareness, and capability‐building that all as a matter or urgency need to be pursued. This article discusses what has become the dominant substantive strategy: development and imple‐mentation of best available techniques and best management practices. The article describes the rationale underlying the application of these approaches in international law and examines how recent treaties and action programs have incorporated them. The article concludes that in several respects the law is inadequate, but that the main problem is the lack of commitment of states to accept obligations to apply technology‐based standards or practices that are sufficiently responsive to the need for protection of the marine ecosystem.     

Carol Anne Bond v the United States of America: how a woman scorned threatened the Chemical Weapons Convention

The case of Carol Anne Bond v the United States of America stemmed from a domestic dispute when Ms. Bond attempted to retaliate against her best friend by attacking her with chemical agents. What has emerged is a much greater issue--a test of standing on whether a private citizen can challenge the Tenth Amendment. Instead of being prosecuted in state court for assault, Ms. Bond was charged and tried in district court under a federal criminal statute passed as part of implementation of the Chemical Weapons Convention (CWC). Ms. Bond's argument rests on the claim that the statute exceeded the federal government's enumerated powers in criminalizing her behavior and violated the Constitution, while the government contends legislation implementing treaty obligations is well within its purview. This question remains unanswered because there is dispute among the lower courts as to whether Ms. Bond, as a citizen, even has the right to challenge an amendment guaranteeing states rights when a state is not a party to the action. The Supreme Court heard the case on February 22, 2011, and, if it decides to grant Ms. Bond standing to challenge her conviction, the case will be returned to the lower courts. Should the court decide Ms. Bond has the standing to challenge her conviction and further questions the constitutionality of the law, it would be a significant blow to implementation of the CWC in the U.S. and the effort of the federal government to ensure we are meeting our international obligations.     

Should I want to live to 100?

Is it virtuous for someone to try to live to 100? Casting aside questions of intergenerational justice and internal obligations in families, what about the basic desire itself? Discussions of longevity and aging in bioethics are skewed to controversial end‐of‐life decisions, largely avoiding questions of how to age well before such decisions arise. Respected writers such as Atul Gawande, Daniel Callahan, and Ezekiel Emanuel champion accepting a natural life span and not trying to live beyond it. The Stoic Seneca says a desire to live to 100 is foolish because, however long people live, they waste most of their lives, so if they lived a thousand years, they would still waste most of it. Against Seneca and Emanuel, we argue that a functional, not a chronological, view of aging should guide us and that for some seniors, hoping to be centenarians may be neither foolish nor misguided. Using Cicero, we argue that the pleasures of seniors are not necessarily inferior to those of youth and may even surpass them. Finally, we agree with Emanuel that the “symptom burden” of some lives makes living to 100 unpalatable and with Seneca that, given life’s vicissitudes, we should not plan on living to 100, but heeding his wisdom, try to make the most of the time given to us.     

Pertussis in a vaccinated 12-year-old girl.

Pertussis, though uncommon in people older than 9 years, does occur (in girls and women primarily) and should be considered in the differential diagnosis of persistent cough. Earlier this year in British Columbia a 12-year-old girl contracted the disease, even though she had been fully vaccinated against it at the appropriate ages. The source of her infection was unknown. The clinical picture was classic except that the girl experienced intense headaches, lasting up to an hour, after the episodes of paroxysmal coughing. Canadian physicians and public health practitioners should encourage vaccination against pertussis.