consent

Essay: A Non-Capitalist Approach to Biomedical Consent

R. Horton

Ask anybody about bioethics in the old days, like forty years ago, and they’ll talk all about autonomy and consent. It was all about how people didn’t have to do what you thought was good for them and how you couldn’t touch patients, even to help them, without it being some kind of battery or something. Everybody talked about all these famous examples where people were treated without wanting to, but most people only go to the doctor when they want and need to get treated. Most people these days only refuse treatment because they can’t afford it.

I’m sure a lot of them can’t afford the treatment but also don’t need it. It’s hard to argue with a doctor about that, though. If you want to feel better, stay healthy, live longer, or whatever; you’re going to listen to the doctor. You are paying the doctor to know more about it than you do. And the doctor may or may not be making money off every service you buy. It’d be good to know who makes money off what, wouldn’t it? It would also be good to know in advance exactly what everything would cost. It would be even better to be able to prepare costs.

In the early days of bioethics, it wasn’t all about costs, because most people could afford their healthcare bills. Money was a concern, of course, but people didn’t panic from fear that their life savings would be wiped out anytime they got sick. It wasn’t at the front of everyone’s mind, so when someone refused treatment, it was because they didn’t want to live longer, didn’t think the treatment worked, or something like that.

But now it’s all about costs. Can a doctor ethically prescribe you treatment knowing you can’t afford it? Can a doctor ethically not tell you about treatments you can’t afford? Should doctors help patients set up Go Fund Me accounts? How can anyone just stand by and let people die because they can’t afford insulin?

In the past, we didn’t notice how much autonomy and consent were tangled up in financial concerns. Most patients didn’t know doctors received so much money from industry. Most patients trusted their doctors, hospitals, and so on to have their best interests in mind, not to be focused on profit front and center. But things have changed, and bioethics can’t afford to have many debates that don’t deal with patients’ ability to access needed care.

So, if you are dealing with public health ethics and planning for pandemics, you might want to consider how many patients will walk around shedding viruses simply because they can’t pay for a visit to the hospital. And if people are forced into quarantine at hospitals, you might want to consider who will get the bill for that. It’s the same with vaccines. At least some people are opposed to vaccines because they think, right or wrong, that they are just being made to create more profit for pharmacy companies, clinics, and doctors. It’s just another way, they think, to get in people’s pockets.

I’m not saying that no one writing in bioethics is dealing with these topics. Great work is being done. What I’m saying is that all work in bioethics must include a discussion of economics and an expressed concern for how access to medicine can be guaranteed for everyone who needs it. You can have lots of detailed and technical disagreements over how much medicine is actually needed and what are the best ways to deliver needed medicine without bankrupting an entire country, but the focus should be on creating a society of healthy, financially secure people. That’s all anyone wants, I think, and anyone who doesn’t want it isn’t really worth my trouble.

adult doctor girl healthcare
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Baptist Primer: Backsliding Versus Non-Practicing

R. Horton

A non-practicing Catholic, I guess, is someone born into the Catholic faith who no longer adheres to any of it’s prescribed behaviours or rituals, and I would suppose some people don’t feel they need to practice it once they know how to do it. Practicing Catholicism must be for newbies.

But Baptists are a different beast all together. Technically, if you follow the letter of Baptist convention, no one is born into the Baptist faith. No one, no matter the circumstances of birth, can become a Baptist without actively choosing to do so, though the age of consent for such a choice is surprisingly low. This is why you see so many Baptist preachers dunking little kids in the water—it shows those children have chosen of their own free will to live their lives for Jesus. And if you check the news of late, you’ll find some preachers seem a little confused about what other things children are or are not able to consent to, under the laws constructed by good old human beings.

Once your accepted in the fold, you are saved, and there’s not much you can do to get kicked out, and you don’t have to practice, either. If you don’t keep up your Godly work by staying clean and pure and avoiding all the temptations the earth has to offer, you’re only human and no one should throw stones at you (according to New Testament law).

If you’ve slipped a little, you’re officially a backslider. Baptists believe that a truly saved person can’t genuinely fall out of favor with God. If you actively reject God and all God’s work, you are not a backslider but a reprobate, and God will surely turn against you, because when you said you wanted to devote your life to Jesus when you were six, you must have been a lying little demon.

two girls standing on grass field
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If She Didn’t Like It (#poem cw/tw)

R. Horton
photo of woman wearing red striped shirt
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She spotted him across the bar,
And her pulse quickened.
She wasn’t surprised to see him;
She knew he would be here,
But she stepped outside to finish
The joint she had started earlier.
After a few long drags, she
Went back in, downed a
Shot of tequila, and walked over.

She looked him straight in the eye,
Took his hand, and led him outside.
She firmly guided him to a dark spot,
Stared blankly into the dark, and
Unzipped his pants. He was full
Of confidence. “She couldn’t get
Enough, eh? Had to come back
For more of the good stuff.”

She was numb.
He was nothing.
He meant nothing.
It meant nothing.
It was only mechanical.
She wasn’t damaged.
She was strong,
Because she could
No longer feel.

If anyone accused him of
Rape,
He would say,
“If she didn’t like it,
Why’d she come back for more?”

On Bodily Autonomy and Geriatric Femininity (#poem #NaPoWriMo)

R. Horton
grayscale photography of man carrying baby
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They never ask, the old ladies.
They just hug, pinch, kiss and
Cuddle at will. Babies are theirs,
You know, and they do love them
So much. I guess it isn’t their fault,
No one ever told them they aren’t
Free to touch at will. I once told
A woman to get her hands out of
My hair, and she said no man
Had ever asked her to stop
Touching him before. As an old
Lady, I’m sure she became another
Of the baby grabbers, the snogglers,
The unwanted snugglers, making
Babies turn away and stretch
For Daddy’s protection and loving
Embrace. And the Daddies will say,

“Don’t touch the babies. They are not
Yours to soil with dry lipstick and crepe
Paper skin. You may have thought your
Hands were never unwelcome, but
My babies know the master of their fate.”

 

Uses and Abuses of Autonomy

R. Horton1 Comment

If you’ve studied bioethics, you know that the principles of bioethics are autonomy, beneficence, non-maleficence, and justice. You also know that autonomy, especially in the early days, got most of the press. I was one of the people who saw bioethics and autonomyethics generally, really, as a matter of respecting autonomy. And I still think it is typically wrong to do things to people that they wouldn’t reasonably want done.

As it often happens when changing points of view, I first began to question the value of autonomy in the most extreme cases—those where someone had no autonomy at all. How do you show the proper respect to a cadaver for example? How should we go about respecting the autonomy of someone who is no longer conscious and may never regain consciousness? It seems that showing respect for a person’s life may not always mean respecting the person’s autonomy.

Even in those cases, though, we still try to preserve the notion of autonomy by calculating what would have been correct for that person if that person were a conscious being with autonomy. To what would a rational person want or be entitled? And here is a bit of muddy water already. Kant described respect for autonomy as respect for universal laws, not respect for individual wishes, for respecting someone’s wishes might only be to help them use themselves as a means (see: physician-assisted suicide). For Kant, respect for autonomy would mean that no one could morally choose to die, so certainly no one could morally help someone to die.

But we don’t adhere to Kant so closely, do we? So, respecting someone’s autonomy has come to mean respecting that person’s wishes by getting their consent before doing anything to them or not doing anything to them, as the case may be. But even having someone’s full-throated consent does not make it okay to do whatever we please, and we mostly recognize that. We have laws against doing things to children, for example, or to people with limited cognitive abilities because we recognize that some people are extremely vulnerable to exploitation.

We spend a lot of time trying to identify vulnerable populations, but my problem comes with trying to figure out who might not be subject to exploitation. It seems to me that even the most mature and intelligent people in the world are subject to exploitation at least some of the time. I can think of many examples, but one example is certainly whenever anyone gets sick.

I would say that anyone with even a minor illness has lost a degree of freedom. If I have something as simple as a stuffy nose, I will make decisions I would otherwise not make. You know, I may decide to give money to some stranger who promises that some chemical or other might make my breathing easier. If I will give away my money to avoid slightly congested breathing that will likely correct itself in a short time, what might I do to avoid rapidly approaching death?

If I’m frightened enough of dying, and most of us do want to avoid an early death, I might agree to almost any treatment dangled in front of me, and I might go to extreme measures to procure the treatment. Getting my consent to give me my only chance of relief seems a little strange, which is why neither healthcare providers nor their clients pay much attention to the whole informed consent process in routine cases. We generally go to healthcare providers with the intention of making use of the services they provide.

Yes, I know patients do need the information that makes up the “informed” part of informed consent, and sometimes genuine decisions must be made in collaboration with the doctor or other caregiver. Even in those cases where decisions must be made, most patients assume the doctor is in a better position to know what choice is best. Which is why so many of us respond with, “What would you do, Doctor?”

What we don’t say, though, is, “No, I don’t want any treatment. I only came in because I had a bit of free time and thought I’d spend it in an examining room.” It is only suffering, whether minor or extreme, that drives us to see a doctor. And it is that suffering that makes us vulnerable to exploitation, and that vulnerability renders the concept of free consent or undiminished autonomy questionable.

So I don’t think autonomy can shoulder the moral burden it is expected to carry. In fact, autonomy may not mean anything useful at all. Respecting a person’s wishes, especially in situations where wishes are so easily manipulated, may not be of any moral value at all.

The Problem with Telling Boys to Never Hit Girls

R. Horton

First, I should clarify that I do not think it is acceptable for boys to hit girls, but the admonishment to “never hit a girl” has two problems. 1. It gives tacit permission to hit other boys. 2. It tells boys they have no right to complain when someone hits them. Under this one maxim, boys are certified as aggressors and negated as victims of violence.

If parents and teachers simply told boys not to hit, it would go against everything masculinity represents, unfortunately, in our culture. Fathers would worry that their sons would never toughen up, “grow a pair,” or be able to attract mates. Surely, they say, if boys don’t enter the rough and tumble world of male aggression they will all grow up to be homosexual. Rather, they really mean they will grow up to be “feminine” (I use the quotation marks to show that I do not believe any particular traits are feminine or masculine, but these words are used in stereotypical fashion), which is the real fear. Misogynists assume feminine boys are gay without understanding the difference between orientation and identity or the simple human spectrum of personality traits. It is misogyny that drives the rage against non-conforming boys. It is hatred of who they are more that what they do.

To avoid recriminations, boys with take and give punches and other forms of violence on a regular basis as practice for adulthood. The boy who grows up in this environment isn’t shamed for being violent. Rather, he is shamed when he is passive. If you are a boy who has been told he must never hit girls, when someone hits you, the aggressor has done nothing wrong. In fact, if you don’t hit back, you have done something wrong. You are lacking. Violence is an obligation of masculinity.

If you fail to stand your ground, you will be reprimanded for letting some bully push you around. You will likely be put in self-defense classes. You will likely be told you must toughen up and learn to take care of yourself. While a girl in your position might be given the opportunity to learn self-defense, her status as victim protects her from similar shaming. Violence may be an option of femininity, but it is not an obligation. Boys are denied the status of victim. Boys are told they can only be bullied if they don’t stand up for themselves.

And if a girl hits a boy, the boy is in a double bind. The shame of being hurt by a girl is far greater than the shame of being hurt by a boy, but the opportunity of self-defense or retaliation is taken away. The boy will face shaming such as: “How could you let that happen? She’s just a girl. Don’t hit her! She’s just a girl. Be a man! Just walk it off!” We wonder how adult men become victims of domestic violence, but this pattern is carried into adulthood. The man who is physically assaulted by a woman is rarely recognized as the victim he is. A woman half his size (of course, not every man is married to a woman half his size) couldn’t possibly hurt him. Surely, a grown man can take care of himself? If he strikes back, he earns the label of abuser for himself. His explanations are unlikely to be believed.

In addition to teaching boys that they are acceptable victims of male-on-male violence and that aggression against other boys is expected, it does little to protect the physical integrity of girls and women. Some time back, a video PSA against domestic violence went viral. The video shows boys standing in front of a passive girl as a man off-camera tells them to touch her and caress her. The boys do not hesitate to touch her until the man tells them to to hit her. All the boys refuse, inspiring tears and celebrations around the world. At the end of the video, a boy is told to kiss her. He asks only, “On the mouth or the cheek?” The message, it would seem, is that girls, passive and beautiful beings that they are, should never be hit but should also never have agency over their bodies. They boys say they are against violence, but they appear to have no concept of consent. They are willing to touch her body without her invitation but with the approval of an adult male. Before venturing a kiss, the boy asks the man, not the girl, how to proceed. I find the message of the PSA disturbing.

We could instead teach boys and girls to respect the bodies of all others. Sure, teach the children self-defense techniques but teach them also that aggression is an assault on the bodily integrity of another. Furthermore, this aggression can come in the form of a slap, a kick, or a kiss. We can teach children to respect all bodies and that touching others requires consent, and we can begin by showing respect for the bodies of children. It is not all right to hit girls because it is not all right to hit people. And, as the video below shows, it is not all right to hit animals, either.