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Medical Complicity: A New Normative Account and Its Implications for Three Study Cases

Final Report Summary - MEDCOM (Medical Complicity: A New Normative Account and Its Implications for Three Study Cases)

Traditionally, discussions in medical ethics have focused on ways in which medical professionals may do wrong by directly harming or wronging patients or research subjects, for example, by violating their autonomy. However, medical professionals may also act wrongly in indirect ways, by being accomplices to the wrongdoing of others. For example, by taking part in torture, even if to reduce the health risks to the torture victim, a physician may become complicit in the torture itself. It is, of course, impossible for medical personnel to completely dissociate themselves from all wrongdoing by others (No one can do this.) Important philosophical questions arise: what sort of association with others’ wrongdoing makes one complicit in that wrongdoing? Is complicity always wrong, or can it sometimes be justified? How do we determine different degrees of complicity? The main objectives of this project were (i) to develop a philosophical account of complicity that will allow us to better tackle problems of medical complicity and (ii) to deploy this account to yield guidance for medical professionals and policymakers confronted with dilemmas of medical complicity.

The Fellow began her research by investigating whether, and if so, how benefiting from past wrongdoing can make one complicit in that wrongdoing, and how one could reduce or offset this complicity. She dealt with this question by an in-depth investigation of the horrific medical experiments conducted by Japanese doctors in occupied China during WWII, and the cover-up of these atrocities by the US government in return for obtaining the results of the experiments. The US government has remained silent on this cover-up, up until today. Building on work by Professor Jing-Bao Nie, the fellow argued that this cover-up makes the US government heavily complicit in a grave injustice, as well as expectably complicit in future unethical research. She also formulated concrete recommendations for how President Obama’s Bioethics Commission (in line with its actions with regard to the US government’s involvement in unethical medical experiments in Guatemala), as well as other relevant institutions (e.g. the NIH), could minimise this complicity. As a result of her paper, two members of Obama’s Bioethics Commission discussed setting the experiments on the Commission’s agenda, but one of them decided against it. However, shortly after the publication of the Fellow’s research in the American Journal of Bioethics, the Japanese Medical Experiments were added to the National Institute of Health (NIH) Research Ethics Timeline. ( This was picked up by Tatsuya Tsujimura, a Japanese journalist from Kyodo News (a news agency that distributes news to almost all newspapers, and radio and television networks in Japan) who plans to publish a newspaper article on the Fellow’s research.

The Fellow also investigated the ethics of medical complicity in suspect social norms. She focussed on medical complicity in discrimination, and investigated how doctors who conscientiously object to providing particular medical services to certain patients (e.g. fertility treatment for lesbian patients) may become complicit in maintaining discrimination. She focused on one concrete policy proposal developed by Walter Sinnott-Armstrong and Aaron Ancell to provide financial incentives to discourage discriminatory conscientious objections, rather than making them illegal. The Fellow argued that this proposal could be expected to result in doctors’ complicity in maintaining discrimination, and suggested that , therefore, invidious discriminatory conscientious objections should remain illegal. She also proposed to apply aspects of Ancell and Sinnott-Armstrong’s proposal to a wider range of conscientious objections that it was intended for, as this would respect (to some extent) doctors’ freedom to refuse certain treatments, while protecting patient’s right to access legal treatments. (This aspect of the Fellow’s research is currently under review.)

The Fellow also investigated a case of medical complicity in problematic religious norms: that of psychiatrists proscribing anti-depressants to certain Jewish communities, to help their members suppress their sex drive. The conclusion here was that though this would make the psychiatrist somewhat complicit in maintaining problematic norms, this complicity would be minor and outweighed by reasons for proscribing the drugs. This research was published in David Edmonds’ Philosophers Take On The World (OUP 2016), which is targeted at a non-specialist audience interested in contentious societal issues.

The Fellow also investigated the ethics of complicity in ongoing or future wrongdoing, more in particular, a case of medical complicity in torture or unethical incarceration practices. She investigated two different cases of such medical complicity. The first case is that of Belgian Frank Van Den Bleeken (VDB). In 2011, VDB was the first detainee in Belgium to request euthanasia for psychological reasons under the Belgian Euthanasia Act of 2002. What makes his case special is that his request was partly motivated by the inhumane circumstances of his incarceration.The fellow first investigated whether it would be lawful for a doctor to accede to VDB’s euthanasia request, and concluded that it would be. She then investigated whether it would be morally permissible for a doctor to accede to the request. She concluded that complicity-based reasons against fulfilling the euthanasia request (complicity in maintaining unjustified incarceration practices by removing the state’s incentives to improve these practices) did not outweigh autonomy-based reasons for fulfilling it (This research was published in the Cambridge Quarterly of Healthcare Ethics.)

The second case the Fellow investigated concerns the use of neurointerventions to prevent crime, with a focus on the chemical castration (CC) of incarcerated sex offenders to prevent sexual recidivism. There is an increased interest in offering CC to sex offenders as an optional alternative to continued incarceration. Many have objected to this on the ground that the offender’s consent to undergo it would be coerced and therefore invalid. The fellow has argued in earlier work that, even if valid consent cannot be obtained, it is presumptively permissible for the state to offer CC as an optional alternative to continued incarceration if we can expect that this offer will increase the offender’s autonomy as compared to simply requiring further incarceration, and if the incarceration is justified. However, questions arise whether an appeal to this argument from autonomy would be acceptable if the incarceration, or the manner of its imposition, were unjustified. The Fellow, together with Thomas Douglas (Oxford), investigated four potential explanations for why an appeal to respect for autonomy in defence of offering CC as an alternative to unjustified incarceration is problematic, one of which focuses on the fact that it ignores the fact that those who participate in providing CC thereby become complicit in maintaining unjustified incarceration practices. They conclude that only the appeal to this and one other explanation may succeed in establishing that offering the choice between CC and unjustified incarceration is objectively worse, morally, to imposing unjustified incarceration without the option of CC, but that even this argument will fail in many cases. (This research is under review.)

The Fellow also investigated the concept of complicity by engaging in the debate about the use of controversial logos by sport clubs, and the taking-down of statues that glorify contentious historical men. This research was published in venues targeted at a wide interested audience. After publication of her article, KAA GENT (the Ghent football club) arranged a meeting with her to discuss the issues and to see whether she had any recommendations for how to reduce complicity in maintaining discrimination against Native Americans. The Fellow’s recommendations have now been implemented by the Club (e.g. new football related initiative in the US to help poor Native Americans, provision of historical context on the club’s website, reaching out to fans to urge them to treat the logo with respect, no merchandising that is disrespectful towards Native Americans.