Medical Ethics, History of Europe: Contemporary Period: V. Republic of Ireland
V. REPUBLIC OF IRELAND
"Ireland" here refers to that part of the island of Ireland (twenty-six of the thirty-two counties) that achieved independence from British rule in 1921 and was declared a republic in 1949.
Ireland's moral traditions and its history in ethics are inextricably linked with centuries of religious history that are primarily rooted in the nineteenth-century Roman Catholic Church. After experiencing religious persecution under British rule, the government of the new Irish State reinforced the traditional religious ethos in its laws and institutions, particularly education and healthcare. The Irish Constitution of 1937 recognized the "special position" of the Holy Roman church as guardian of the faith of the great majority of Irish people. This constitutional recognition was deleted in 1972 when Ireland was preparing for membership in the European Economic Community; the deletion signaled recognition for a religiously pluralist state.
In what follows, bioethics in the Republic of Ireland is discussed in two time periods: 1922–1982 and 1983–forward. The period division marks a development of appeals to legal resolution to negotiate ethical diversity. Four areas of national development frame the discussion: reproductive ethics, research and ethics committees, obligations to prolong life, and establishment of the Irish Council for Bioethics.
Between 1922 and the early 1980s, a religious homogeneity of tradition and practice largely prevailed. While cultural changes are never abrupt, a change in Irish political and social conditions was initiated on January 1, 1973, when Ireland became a member of the European Economic Community (now known as the European Union). Ireland increasingly interacted with other countries whose philosophies of life were based on secular viewpoints. Moral questioning in the society, in politics, education, and healthcare practice became more sustained, open and tolerated.
In the early 1970s, women's groups actively protested a prevailing legal ban on contraceptives and the complete ban on elective abortion even in cases where women were victims of rape or incest. Women who could afford private healthcare could get contraceptives and abortion advice. Women who sought prenatal genetic testing generally could not be accommodated within the hospitals of the Republic of Ireland. The concern was that some test results might contribute to pro-abortion decisions. But private patients were often accommodated by referral outside the country. The justice of a two-tier health system came under moral and political scrutiny. A private citizen, Mrs. McGee, challenged the Irish government's long-standing prohibition of the sale and importation of contraceptives. Her efforts led to the Health (Family Planning) Act of 1979, in which the Irish state allowed restricted access to contraceptives. Outsiders may be incredulous at Ireland's preoccupation with reproductive ethics. However, this area of morality is central in Irish traditional religious teachings, which have consistently reaf-firmed the primacy of women's procreative capacity and fetal life.
Until the 1980s, the topic of abortion was largely a closed moral and legal issue. Ireland had never rescinded the complete ban on abortion specified under the British Offences Against the Person Act of 1861. In practice, termination was permitted under the principle of double effect in exceptional cases, such as ectopic pregnancy. Yet Irish women did (and do) procure abortions. On average, six thousand Irish women a year go to England to have abortions under the provisions of the 1969 British abortion legislation. Irish women gradually became more politicized and organized public demonstrations, claiming their rights to control fertility. Serious polarization of views developed as other groups in society feared that elective abortion might be legalized in Ireland. A national campaign began to guarantee protection of embryonic life by means of constitutional amendment.
In 1983, the eighth amendment to the Irish Constitution gave "the unborn" the same rights to life as other citizens. Since then, this amendment has generated a complex series of political, legal, and moral challenges, leading to a Supreme Court judgment of 1992, Attorney General v. X and Others, which argues that abortions may lawfully be carried out in Ireland where continuance of the pregnancy constitutes a real and substantial risk to the life of the pregnant woman. A threat of suicide was specified as such a risk. Following the Supreme Court Judgment of 1992, it remains for the Irish government to provide legislation to specify the conditions under which it is lawful to have abortions in Ireland.
Moral concerns to protect fetal life also influenced the development of guidelines for in vitro fertilization (IVF) issued by the Institute of Obstetricians and Gynecologists. The guidelines specified that IVF should be offered to married couples who have been appropriately counseled and have given informed consent. Only sperm and ova from the consenting couple may be used, and all resulting fertilized ova should be placed in the potential mother's uterus. However, with the Government's establishment of a Commission on Assisted Human Reproduction in 2000, existing IVF guidelines and policies on all forms of assisted procreation began being researched and ethically assessed. Submissions from the public, service providers, and consumers were invited. The Commission consists of four working groups studying topics from the status of the embryo to gamete donation, anonymity or disclosure, access to assisted reproduction, and embryo research. The working groups draw on the expertise of fertility experts, lawyers, ethicists, geneticists, social theorists, and theologians. The debates on the Commission are evidence of the growing diversity of ethical and legal views on reproductive matters. The Commission's report is expected to form the basis for legal decisions on the status of the pre-implanted embryo, and implementation of policy recommendations or regulatory mechanisms for all forms of assisted reproduction and embryo research.
Research and Ethics Committees
For years, medical research and clinical trials in Ireland were assessed by Institutional Review Boards whose composition and procedures lacked any nationally agreed-upon guidelines. The ethical norms from the Declaration of Helsinki were applied. The death of a male participant in a nontherapeutic drug trial in Ireland resulted in the government's issuing of the Control of Clinical Trials and Drugs Act 1990. The principal features of this legislation are that, with certain exceptions, the minister for health must authorize all proposed clinical medical trials and members of the ethics committees examining protocols must be approved by the minister. Ethics committees have the responsibility for ensuring that participants in any trial give their informed consent personally or by proxy. The latter provisions allow for clinical trials with psychiatric patients who might not be considered competent to consent. To avoid a conflict of interest, investigators involved in any clinical trial are not allowed to give proxy consent.
Ethics committees in Irish public hospitals traditionally were given the job of adjudicating requests from doctors for female sterilizations. Women's groups and gynecologists are now rejecting this role for ethics committees, and criticize what is judged to be unwarranted religious influence on decisions of ethics committees in public hospitals. While doctors are increasingly trying to minimize intrusions into the privacy of the doctor–patient relationship, ethics committees are still established throughout the state for educational purposes and for consultation by patients, families, and healthcare practitioners.
Irish patients are now requiring more communication about diagnoses and prognoses, and also expect increased participation in medical decision making. The value of respect for patients and the importance of securing consent is a corollary of expectations for a role in decision making. In efforts to reinforce the values of respect for personal autonomy and informed consent, in 2001 the Irish government set up an inquiry into policies and practices surrounding post-mortems in the state since 1970, particularly with regard to the removal and retention of organs by hospitals. The stimulus for the inquiry came from parents of children who had died in hospital and whose organs had been removed and retained by hospitals for research without the consent of parents. The public, parents, hospital management, and scientific institutions recognize that the value of trust can be readily undermined if ethical guidelines are not in place to reassure relatives that consent will be sought for post-mortem tissue or organ procurement. While parents do not dispute the need for research, they argue that the issue is the informed consent of relatives and accountability of institutions in receipt of public money.
Since the 1980s, doctors in Ireland have experienced increasing lawsuits for alleged malpractice or negligence. Further analysis is required to determine the multiple causes for such an increase, but the Medical Defence Union, an indemnity insurer for doctors, continues to urge doctors to reflect on the quality of their relationships with patients and to work to improve levels of communication. The previously dominant model of strong paternalism characterizing the doctor–patient relationship and more general practices of healthcare institutions are under challenge due to changing educational experiences of doctors and nurses and a more questioning Irish population. Courses in ethics are taught in Irish medical schools, where almost 30 percent of students are now non-Irish. In their required university work, nurses are encouraged to reflect on reasons for their moral views and to consider the possible validity of diverse ethical positions. Religious orthodoxy is no longer taken for granted. Such courses are usually required of medical students and nurses, and vary in length from several weeks to a full year.
Obligations to Sustain Human Life
Public debate about moral obligations to prolong human life came to the fore in 1995. The family of a woman who was in a persistent vegetative state (PVS) for over twenty years appealed to the Irish courts to have a gastrostomy tube removed and to allow her to die naturally. The patient was made a ward of court because the healthcare institution responsible for her care had, many years earlier, differed ethically with the family concerning what life support measures were morally justified. In 1995, in Re a Ward of Court, the High Court and, on appeal, the Supreme Court judged that in the best interests of the woman, it would be legal to remove the feeding tube. Following the Supreme Court judgment, the Irish Medical Council and the Nursing Board issued statements for members, in effect disagreeing with the ethical basis of the Supreme Court decision and claiming that access to nutrition and hydration is one of the basic needs of human beings. The Re a Ward of Court case raised difficult questions about active and passive euthanasia, withholding and withdrawing life support systems. Who should be involved in life and death decisions is a concern with arguments to the effect that decisions about withholding life-support systems for the terminally ill are areas of medical decision making where patients and family members ought to have more voice. In trying to determine moral boundaries in the prolongation of life, the Roman Catholic tradition distinguishing obligatory and nonobligatory treatment (ordinary and extraordinary) may be justly recognized as a well-argued basis for granting patients considerable voice in their treatment decisions.
The Irish Council for Bioethics
In 2002, concerns about ethical questions in modern biotechnology and genetic engineering prompted the Irish government to establish the first Irish Council for Bioethics. Members are invited by virtue of their personal expertise and not as representatives of particular bodies or professions. The members range in specialty areas from genetics, molecular biology, nursing, fertility, theology, law, and ethics. The Council operates under the aegis of the Royal Irish Academy but is an independent body. The aims of the Council are to identify and interpret ethical questions raised by biological and medical research and to examine and report on a range of questions with a view to promoting public discussion and understanding. Where appropriate, the work will contribute to the formulation of new guidelines in areas such as genetically modified products, stem cell research, biological samples, Ethics Community and human genetic research.
As Ireland continues to be more actively integrated into the European Union, ethical pluralism is being acknowledged as a reality requiring open debate. The hope is that such efforts at public discussion will yield a stronger, because more consensual, public morality that will signal respect for the now undeniable differences of ethical viewpoints among Irish people. In the years ahead, the work currently under way should yield policy developments in assisted reproduction, research protocols, biotechnology, and debates about advance directives and obligations to prolong human life.
dolores dooley (1995)
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