This is the first of our monthly Journal of Medical Ethics digests; a great way for you to keep abreast of recent developments in bioethics when you are short on time! Each month, we will provide a brief overview of a few articles. This month, we will be covering:
Bozzo, A. (2018) ‘A challenge to unqualified medical confidentiality’, Journal of Medical Ethics, vol. 44, pp. 248-252
Jamrozik, E. (2018) ‘How to hold an ethical pox party’, Journal of Medical Ethics, vol. 44, pp. 257-261
Montero, A. and Villarroel, R. (2018) ‘A critical review of conscientious objection and decriminalisation of abortion in Chile’, Journal of Medical Ethics, vol. 44, pp. 279-283
The conflict facing doctors with regards to patient confidentiality versus the protection of endangered third parties is a complicated one. Bozzo highlights the position of Kipnis, that an absolute confidentiality policy is best, before opposing this and instead arguing for a qualified policy.
Kipnis argues that doctors should not give unqualified assurances where they are untruthful - I.e. in his example of a man seeking testing for STIs, if the man were to ask whether the doctor would keep any results confidential, it would be wrong for the doctor to say yes if s/he would in fact inform endangered third parties of any infection. He believes full openness is vital, and that doctors should inform patients of any exceptions to confidentiality. He defends this position on the basis that, in the long run, unqualified confidentiality policies save more lives.
Lives saved where patients consent to third parties being informed are no different under either policy. However, where a patient does not want their health status shared, more lives are saved under an unqualified policy, argues Kipnis. This is because under a qualified policy, such individuals will likely not seek medical attention out of fear of their healths status being shared. Under an unqualified policy, on the other hand, the doctor can at least try and persuade the patient to consent to the warning of endangered their parties. Overall, then, an unqualified confidentiality policy, according to Kipnis, is saving more lives overall.
Bozzo argues against Kipnis’ argument. Rather than patients being fully informed by the doctor, it is sometimes better to inform them of confidentiality policy in the form of literature which they are to read and sign before seeing a doctor. In such a scenario, those who do not want their health status shared may not all realise the nature of the policy, and thus seek medical attention under a qualified confidentiality policy. Therefore, the policy which saves more lives would depend on whether of those who do not want their health status shared more would be ignorant to the policy (qualified policy) or more could be persuaded to inform endangered third parties (unqualified policy). Given how there is no research into which of these is more likely, Bozzo concludes that Kipnis’ position is undermined.
Parents opting out of vaccinating their child based on non-medical criteria has long been criticised as problematic not only for that individual child, but for others, such as those who cannot be vaccinated. One controversial alternative to vaccination is pox parties. Jamrozik argues that where parents are permitted to opt out of vaccinating their child, pox parties should also be permitted as a preferable alternative to vaccination; whilst they still carry some risks, such risks are lower than those arising from not being vaccinated at all. He defends this position through three criteria to be met in order for a pox party to be deemed ethical.
Firstly, “riskiness”. Only diseases which are sufficiently low risk should be considered for pox parties. Jamrozik states that ‘the lower the mortality and permanent morbidity risks of a given disease, the more ethically acceptable it would be to hold a pox party’. Further, children should only attend pox parties when they are of the age where the risk of severe complications is the lowest possible for the disease in question.
Jamrozik’s second criterion is “consent”. There is a long established parental right to decide on the upbringing of one’s children and any risks they are exposed to (within reason, of course). As such, it is essential in a pox party being ethical that parents have consented. In order for them to consent, parents should be made aware of the risks associated and make their own assessment before consenting.
The final criterion to be met is the less obvious one according to Jamrozik. It concerns the prevention of onward transmission. He argues that parents have a moral duty to reduce the risks posed to other children even if they choose to expose their own children; whilst the risks may be mitigated by herd immunity from vaccination, there may still be some children at risk, such as those who are not able to be vaccinated. To achieve this, children who have attended a pox party should be quarantined for the incubation period of the pathogen, and isolated during the acute illness and postacute contagious period.
Montero and Villarroel
In September 2017, Chile relaxed their previously restrictive abortion laws, allowing the termination of pregnancy on three grounds: present or future endangerment of a woman’s life; embryonic or fetal anomaly or malformation incompatible with life; and pregnancy arising from sexual violence. Progressives, however, had only so much to celebrate, as conservatives had raised the obstacle of conscientious objection which the legislation makes a right of physicians except in life-threatening emergencies.
Therapeutic abortion was, for a significant chunk of the 20th-century, permitted in Chile. Though in 1989 all abortion practices were banned, resulting in women undergoing abortion procedures without anaesthesia, performing sexual acts in exchange for abortions, and choosing not to seek help if complications arose post-abortion for fear of prosecution. Calls for the issue to be revisited failed to produce results, until 2015. President Bachelet called for Chilean society to begin an ‘open-minded, informed, constructive policy debate’ which, eventually, led to the change in legislation. Objection from conservatives was significant, with Chile’s largest Catholic hospital claiming it would uphold an institutional objection. Opposition was heavily based on conscientious objection, which Montero and Villarroel suggest will now likely be used by conservatives to prevent women gaining access to what is now a legally guaranteed health service. Such a situation may well have been predicted, as it is noted that ‘Chile has long been a socially conservative society that generally tends to condemn and stigmatise abortion’.
Montero and Villarroel comment on the distinction between conscientious objection and civil disobedience. The difference initially comes in the latter often being defined as a public act of a political nature meant to impact on a government’s agenda or policy. Being uniquely individual and with no such political desire, conscientious objection is, as a concept, distinct; any publicity which may ensue is largely unintended. However, in having used conscientious objection as a means to target the bill, and, as the author’s predict, to fight to repeal the law, the actions of conservatives in Chile are perhaps more rightly categorised civil disobedience.