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Biomedical value conflict.

Biomedical Value Conflict

Western medicine and clinical practice draws much of its legitimacy, authority, and efficacy from a scientific tradition that makes claims to a universal validity. There is, however, another dimension to the practice of modern medicine--the ethical dimension--that seems more closely bound to the cultural context in which the medicine is practiced. The particularities of a culture and its traditions in part may explain differences in the medical practices of a country and the ethical values and dilemmas associated with those practices.

What should our attitude to this diversity be? Should we understand it as a form of inconsistency, and if so, is such inconsistency unacceptable? It would be absurd to suggest that international value conflicts on bioethical issues are a sign of logical inconsistency in medical ethics. It is more plausible to regard bioethical diversity among cultures as a reflection of the principle of personal autonomy exercised in moral matters in a larger social, cultural, and national context.

In individual ethics, the autonomy and integrity of persons in choosing moral precepts and principles is an important moral value, and requires respect for and tolerance of differences in positions and actions. A similar point can be made for the moral and political autonomy of nations (and for other independent and autonomous groups). It would appear immoral not to grant an autonomous party, be it a person, profession, or nation, the right to accept and reject moral values and principles in consonance with its own moral, political, and cultural traditions. Thus, the issue of transnational value conflict in bioethics is not so much one of logic and consistency as it is of morality and integrity.

Bioethical diversity can nevertheless generate real value conflict that must be managed effectively. This can be dramatically illustrated by several examples from Scandinavia.

Prenatal Diagnosis in Norway

and Denmark

In Norway and Denmark, genetic services including amniocentesis and prenatal diagnosis are provided under the national health services of both nations. Official policy in both countries forbids the provision of these services on a private basis, but within the public systems of health care, each country has established different limits. While Norway has by a policy decision imposed a limit of 500 amniocentesis tests per year (a figure that has grudgingly been expanded to 800 by the Norwegian Parliament recently), Denmark permits some 5,000 tests to be performed annually.

The difference in capacity is not an accident, but reflects considered policy choices. These policies in turn reflect differences between the two countries in ideological, moral, and religious outlooks among politicians, doctors, nurses, and the population at large. For example, church attendance rates among both Norwegian and Danish citizens are well below those in the United States. However, in contrast to Denmark, Norway has a powerful "moral minority" made up of "personal Christians" who are identified with Lutheran fundamentalism. The moral views of the personal Christians on issues in biomedical ethics tend to be rather conservative by Western standards. Although Norway (like Denmark) has legalized abortion on demand in the first trimester of pregnancy and for certain genetic indications in the second trimester, these Christians oppose abortion (except in cases where the mother would die were an abortion forgone, or when pregnancy results from rape or incest). In their view, amniocentesis and prenatal diagnosis are considered morally acceptable only in "qualified emergencies." They provide two prominent rationales for the severe restrictions on amniocentesis: fear of legitimating late abortions and fear of an ideology of eugenics that would deny full human rights to children with handicaps.

This "moral minority" is very definitely a minority; its political views are voiced primarily by The Christian People's Party, which claims approximately 8 to 10 percent of the electorate, although there are sympathizers in nearly all the other parties. More important, the personal Christians have considerable support among nurses and physicians. The Association of Christian Physicians in Norway has a membership of 900 out of a total 12,000 Norwegian physicians. Members of this association have played a leading role in public and intraprofessional discussions of medical ethics in Norway, especially on matters of abortion, in vitro fertilization (IVF), and prenatal diagnosis. Other Norwegian doctors have not been as active in formulating and expressing their views. In Denmark, meanwhile, there is no separate association of Christian physicians and the personal Christians in the medical profession have played a more modest role in bioethical debates.

It seems then that doctors belonging to the Association of Christian Physicians have been able to exert a conservative influence on the Norwegian policy debate over questions of amniocentesis and prenatal diagnosis. Interestingly, in the 1970s laws permitting first trimester abortion were argued for on moral grounds of women's rights, and continue to be supported by a majority of the Norwegian populace--especially among women--even in the more conservative parties. By contrast, amniocentesis, genetic counseling, and prenatal diagnosis have been debated more as scientific and technical medical issues, but with very strong moral over-and undertones.

Thus far, the striking difference between Norway and Denmark on matters of medical genetics and prenatal diagnosis, which could be understood as a value conflict between the health care systems of two "twin" countries (as they were once called), has not resulted in any perceptible social conflict. However, if e ach year the approximately 4,000 Norwegian women, who by Danish standards are denied a legitimate form of medical aid, were to arrange charter tours to Denmark's institutes of medical genetics, Norway and Denmark would indeed have to cope with a socially visible, real-life bioethical value conflict. Although this scenario is currently bio-science fiction, it is possible that there are a few Norwegian women who, thanks to personal acquaintances, draw on Danish resources when denied access to prenatal testing services in Norway. If a single case became public, a moral storm would be raised in both the Norwegian parliament and the media.

Artificial Insemination

Each Scandinavian country's national health service provides artificial insemination by donor (AID) and has done so for many years. In no instance has the practice of AID been instituted by an explicit legal or public policy provision. It seems to have grown "naturally" out of activities originally considered to be biomedical research initiatives and, as such, would not normally have come within the purview of public legislation. (This is itself is an interesting issue: there is a "gray zone" whereby biomedical research and experimentation shade into a silently recognized and eventually established practice under a public health service. In Scandinavia, IVF is on the verge of completing this transition). Until recently, sperm donors have been assured that their anonymity would be carefully protected. But in 1984, Sweden enacted a law requiring that at age eighteen, a child conceived through AID be able to learn the identity of its biological father. [1] The law brought the practice of AID in Sweden to a virtual standstill.

There now seems to be a near-consensus in all five Scandinavian countries that AID services should be provided only under the aegis of the national health system. The position on "privatization" of health care is quite firm. However, most couples who seek AID are strongly motivated, so Swedish doctors (who generally oppose the disclosure of information about the donor required by the law but must abide by it) now refer couples seeking AID to clinics abroad (or the couples--or individuals for that matter--seek AID on a private basis).

The Swedish law has ethical repercussions beyond the boundaries of Sweden. In one sense, the Swedish Parliament (Riksdag) has declared immoral certain practices that in neighboring countries are neither illegal nor by official decree immoral. The arguments for abolishing donor anonymity in Sweden were largely made on moral grounds, but the arguments for respecting donor privacy and confidentiality in Norway also appeal to moral values. Moreover, since in a certain sense Scandinavia is one medical market, in that aided by closely related languages, doctors, nurses, and patients travel between the countries as frequently as needs and convenience dictate, the following possibility is raised: Swedish couples may now turn to the neighboring countries with a moral plea that they are denied a medical service that is perfectly legal and not considered immoral elsewhere.

Several questions can be raised in response: Should the Riksdag have considered such perfectly predictable (and predicted) consequences before it passed the new law? Should countries like Norway and Denmark let Swedish couples come for AID services? Finally, to what extent and in what sense could a genuinely moral problem of this nature be a problem that concerns only Sweden?

Reimbursement

A related issue that has implications for several forms of medical services is who should pay the cost for treatment provided by a foreign country. A Norweigian citizen and a member of the National Health Service (NHS) went to the Federal Republic of Germany for a cancer operation. On his return to Norway, in addition to having the good news of a successful operation, he also brought a bill of NOK 300,000 (about $45,000 U.S). The NHS refused reimbursement, arguing that the operation could have been performed in Norway. In the end, the case was settled in favor of the patient, but the important point is the argument used by the NHS to refuse reimbursement. It seems to imply that if an important health service, in this case an operation, is not available in Norway, then the NHS may be prepared to pay for it elsewhere. And neither the denial of reimbursement nor its implication seems unreasonable.

Yet how should the Swedish NHS respond if a couple, happily pregnant after an expensive insemination excursion to London, presents a bill and argues that their trip abroad was necessary because what is for them a vital service is not provided in their home country? While it is easy to predict the answer they would receive, the morality of the case is not as easily determined.

Cases similar to this have already materialized in the area of in vitro fertilization. As mentioned, the status of IVF in Norway is now at the point of completing the transition from biomedical research to established practice under the NHS. The Trondheim University clinic has had significant success in its IVF program and its efforts have been recognized in neighboring countries. IVF is now available through the NHS, at several university clinics and one private clinic, though strictly rationed due to scarce funding.

The attitudes of The Christian People's Party as well as the Association of Christian Physicians have been influential in this area as well. Their position is that IVF should be provided only in publicly operated clinics or hospitals, and only for married couples who provide gametic materials. They are also opposed to research on fertilized eggs. A significant part of the Labor Party, Norway's largest political party, is sympathetic to this position, and Parliament has recently enacted a law forbidding IVF at private clinics.

In Sweden, however, official attitudes on IVF are not as restrictive as in Norway. An agreement has been concluded between the Regional Hospital in Trondheim (where the IVF clinic is located) and the corresponding health service region in Sweden. Annually, forty-five Swedish couples are accepted into the IVF program at Trondheim, and the bill is paid by the Swedish NHS. This arrangement has made it possible for the program to admit an additional number of Norwegian couples as well.

The arrangement as described here raises questions of consistency as well as conflict. Norway is hardly consistent in refusing to allow private "for-profit" clinics to offer IVF services--even under government supervision--to Norwegian citizens able to pay for it, while selling at a profit-making rate IVF services paid for by the Swedish NHS. What may be seen as Norwegian hypocrisy may also be realistic and sensible Swedish utilization of valued resources that otherwise might not be used. Who should be responsible for managing the bioethical value conflict between the attitudes and regulations governing IVF in Norway and Sweden, respectively?

A Rationality Requirement in Bioethics

Transnational diversity on bioethical issues seems unavoidable, and at times genuine conflicts of values may ensue. In this light it seems important to consider the possibility of an internationally over-arching rationality in the management of value conflict. While there must be limits to what we tolerate as acceptable diversity, there has perhaps been more progress in bioethical conflict management than in the matter of fixing the limits of acceptable bioethical diversity.

The major "consensus-awaiting issues" of international bioethics could be: abortion, sterilization, infanticide, treatment of impaired newborns, active and passive euthanasia, assisted voluntary suicide, IVF and related research, and perhaps the whole complex of high-tech reproductive biology and medical genetics. The consequences of an ethics of unlimited tolerance is (obviously) problematic in most of these fields. However, the prospects for consensus may not appear bright either. What may be required in biomedical ethics is a kind of "rationality requirement," understood as a pragmatic set of conditions, rather than a formal constraint of logic.

I wish to suggest four such conditions:

* A logical consistency requirement, such as "avoid contradictions."

* Nonviolent conflict management, which involves seeking consensus or compromise through argument and reasoning (IRBs, ethical commissions and committees of various kinds, or international conferences, CIOMS, or WHO, might be appropriate forums). What matters is that violence, deception, oppression, and the like are generally considered to be neither rational nor morally acceptable ways of handling disagreement and conflict. Dialogue and mediation with the aid of informed and benevolent but nonpartisan outsiders is already a prominent feature in contemporary bioethical conflict management.

* Tolerance within reasonable limits in the face of unavoidable and legitimate diversity of value commitments.

* A consensus on some substantive bioethical values and principles as well as on some procedural principles.

Assessment of these last two conditions depends on how we understand the notion of "consensus." Although we may not want (or ought not) to identify consensus with agreement, some kind of agreement is at least necessary to any kind of consensus.

Obviously, there now exists broad substantive agreement on one absolutely fundamental point: the union of medical science and medical practice is a major instrument in promoting human welfare, no matter where on earth that welfare is systematically pursued by politically organized groups.

To determine what the implications are, and are not, of this shared commitment is a major bioethical challenge.

References

[1] Bo Lemmholm, "Couples Seeking Artificial Insemination Referred to Clinics Outside Sweden" (in Swedish), Journal of Swedish Medical Association 82:9 (1985), 665-66.

Knut Erik Tranoy is professor of medical ethics at the University of Oslo, Norway, and an international fellow of The Hastings Center. This article is based on a longer paper prepared for The Hastings Center in 1986.
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Title Annotation:Special Supplement: International Perspectives on Biomedical Ethics; Scandinavia
Author:Tranoy, Knut Erik
Publication:The Hastings Center Report
Date:Aug 1, 1988
Words:2453
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