Access-to-Care and Conscience: Conflicting or Coherent?

"Intervention" is not synonymous with "care." For an intervention to constitute care-which patients should have a right to access-it must be technically feasible and licit. Now these criteria do not prove sufficient; numerous archaic interventions remain feasible and legally permissible, yet are now bywords for spurious care. Therefore, we propound another necessary condition for an intervention to become care: the physician must rationally judge the intervention to be conducive to the patient's good. Consequently, the right of access-to-care relies on physicians being free to practice medicine in accord with their consciences, conscience being the rational faculty with which they judge the reasonableness of even mundane medical decisions. Since physicians operate as part of a community, it is further necessary to consider when central bodies may reasonably compel physicians to engage in interventions that the physician believes are not consistent with the patient's good and/or are not congruent with the purposes of medicine.

The rule of right vs might: a reply to Wischik's 'Nazis, teleology, and the freedom of conscience'.

Wischik presents an extensive reply to our paper on conscientious objection, which explores the implications of distinguishing 'medical acts' from 'socioclinical acts'. He provides an extensive legal analysis of the issues surrounding conscientious objection, drawing on the concepts of professional practice and consequentialism. Invoking some of these concepts, we respond and demonstrate that Wischik does not seriously engage with our argument. Instead, he merely proffers his preference for legal positivism, which - when viewed as the fount of justice (as Wischik seems to hold) instead of a tool in its service - necessarily bases rightness on might rather than truth. We also argue that in several important areas, Wischik is factually mistaken.

Should parents be asked to consent for life-saving paediatric interventions?

Informed consent, when given by proxy, has limitations: chiefly, it must be made in the interest of the patient. Here we critique the standard approach to parental consent, as present in Canada and the UK. Parents are often asked for consent, but are not given the authority to refuse medically beneficial treatment in many situations. This prompts the question of whether it is possible for someone to consent if they cannot refuse. We present two alternative and philosophically more consistent frameworks for paediatric proxy consent. The first allows meaningful consent (parents may say 'yes' or 'no' to treatment), provided that parents are medically informed/competent and intend the health and well-being of their child. In the second solution, medical practitioners or the state consent for treatment, with parents only being consulted to help give insight to the child's circumstances. While we contend that either of these two options is superior to the insincerity of the present paradigm, we suggest that the first solution is preferable.

Medical Acts and Conscientious Objection: What Can a Physician be Compelled to Do?

A key question has been underexplored in the literature on conscientious objection: if a physician is required to perform 'medical activities,' what is a medical activity? This paper explores the question by employing a teleological evaluation of medicine and examining the analogy of military conscripts, commonly cited in the conscientious objection debate. It argues that physicians (and other healthcare professionals) can only be expected to perform and support medical acts - acts directed towards their patients' health. That is, physicians cannot be forced to provide or support services that are not medical in nature, even if such activities support other socially desirable pursuits. This does not necessarily mean that medical professionals cannot or should not provide non-medical services, but only that they are under no obligation to provide them.

To die, to sleep, perchance to dream? A response to DeMichelis, Shaul and Rapoport.

In developing their policy on paediatric medical assistance in dying (MAID), DeMichelis, Shaul and Rapoport decide to treat euthanasia and physician-assisted suicide as ethically and practically equivalent to other end-of-life interventions, particularly palliative sedation and withdrawal of care (WOC). We highlight several flaws in the authors' reasoning. Their argument depends on too cursory a dismissal of intention, which remains fundamental to medical ethics and law. Furthermore, they have not fairly presented the ethical analyses justifying other end-of-life decisions, analyses and decisions that were generally accepted long before MAID was legal or considered ethical. Forgetting or misunderstanding the analyses would naturally lead one to think MAID and other end-of-life decisions are morally equivalent. Yet as we recall these well-developed analyses, it becomes clear that approving of some forms of sedation and WOC does not commit one to MAID. Paediatric patients and their families can rationally and coherently reject MAID while choosing palliative care and WOC. Finally, the authors do not substantiate their claim that MAID is like palliative care in that it alleviates suffering. It is thus unreasonable to use this supposition as a warrant for their proposed policy.

Reasonable Parental and Medical Obligations in Pediatric Extraordinary Therapy.

The English cases of Charlie Gard and Alfie Evans involved a conflict between the desires of their parents to preserve their children's lives and judgments of their medical teams in pursuit of clinically appropriate therapy. The treatment the children required was clearly extraordinary, including a wide array of advanced life-sustaining technological support. The cases exemplify a clash of worldviews rooted in different philosophies of life and medical care. The article highlights the differing perspectives on parental authority in medical care in England, Canada, and the United States. Furthermore, it proposes a solution that accommodates for both reasonable parental desires and professional medical opinion. This is achieved by looking at concepts of extraordinary therapy, best interest, reasonable parenthood and medical objections. Summary: In cases where a child's treatment involves extraordinary therapy, there is often a conflict of opinion between the medical team and the parents with regard to the best course of action. The assumption should be that responsible, caring parents make reasonable and acceptable decisions for the good of their children. Rather than focusing on making a hypothetical best interest judgment, courts should in the first instance side with the parents. Only when parents act unreasonably or malevolently should their wishes be overridden. This should not affect the medics' right to conscientiously object towards carrying out procedures that they deem to be medically unnecessary or harmful.

Teleology and Defining Sex.

Disorders of sexual differentiation lead to what is often referred to as an intersex state. This state has medical, as well as some legal, recognition. Nevertheless, the question remains whether intersex persons occupy a state in between maleness and femaleness or whether they are truly men or women. To answer this question, another important conundrum needs to be first solved: what defines sex? The answer seems rather simple to most people, yet when morphology does not coincide with haplotypes, and genetics might not correlate with physiology the issue becomes more complex. This paper tackles both issues by establishing where the essence of sex is located and by superimposing that framework onto the issue of the intersex. This is achieved through giving due consideration to the biology of sexual development, as well as through the use of a teleological framework of the meaning of sex. Using a range of examples, the paper establishes that sex cannot be pinpointed to one biological variable but is rather determined by how the totality of one's biology is oriented towards biological reproduction. A brief consideration is also given to the way this situation could be comprehended from a Christian understanding of sex and suffering.