Refusing to provide a prenatal test: can it ever be ethical?
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38950.645799.55 (Published 16 November 2006) Cite this as: BMJ 2006;333:1066All rapid responses
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International (IHA) and European Huntington Association (EHA) board members have followed with interest the discussion raised by the article of November 18th 2006. The guidelines for predictive testing in HD have been set up by professionals and representatives of HD families and § 7.2 has been vehemently supported by the latter. We also are in line with Delatycki, and like Evers-Kiebooms et al. we are convinced that prenatal testing in the present case is comparable to predictive testing for Huntington s disease of a minor child. To our knowledge the paragraph in question did not represent major problems and as stated in the reaction of Kiebooms et al. "In the genetic clinic of Leuven (Belgium) and Manchester (United Kingdom)” and in Maastricht (The Netherlands) "no parent with the Huntington mutation has ever requested prenatal diagnosis with the intention to continue the pregnancy after an unfavourable result".
Competing interests: None declared
Competing interests: No competing interests
Response to Duncan et al. in BMJ of 18 November 2006
Prenatal testing for late-onset disease: ethical issues and support of the reproductive decision making process.
Duncan, Foddy and Delatycki (1) discuss parental requests for prenatal diagnosis (PD) with the intention to continue the pregnancy when the foetus has the Huntington mutation. The article is framed as a debate between two opposing professional views and is almost exclusively focused on principles. It pays insufficient attention to the fact that such a request can not be isolated from its context and that adequate counselling - tailored to the specific needs of the prospective parents - should be offered before conception.
In line with Delatycki it is our view that prenatal testing in the present case amounts de facto to predictive testing of a minor child for an untreatable late-onset disorder. Since we hold the conviction that the latter is unjustified, the former is unjustified as well. Ethical objections are that an unfavourable test result may well have adverse consequences for the child and that testing is a violation of the future child's right to decide for himself (a so-called anticipatory autonomy right).
Duncan and Foddy’s argument that the mother's right to information is of paramount importance seems to presuppose what has to be proven: that the mother does indeed have this seemingly unqualified right - even when she considers the information sought to be irrelevant for the decision whether or not to continue pregnancy. Their argument that a restrictive policy regarding PD for HD may encourage some applicants of PD to lie about their real intention, is not a strong argument in favour of a 'laissez faire'-approach, neither is the fact that people can/should not be forced to terminate pregnancy after a positive test result. The issue/dilemma should not be framed in terms of paternalism (vs anti- paternalism). After all, paternalism is, by definition, limiting the freedom of a person in his/her own best interest - but that is not applicable in the present case, as critics of performing PD in this case refer to the rights/interests of the future child.
The situation in the article of Duncan et al. is very exceptional. In the genetic clinic in Leuven and Manchester, no parent with the Huntington mutation has ever requested prenatal diagnosis with the intention to continue the pregnancy after an unfavourable result. A European study (2) collected data about all prenatal tests for HD (full prenatal tests and prenatal exclusion tests) in Belgium, France, Greece, Italy, The Netherlands and U.K. between 1993 and 1998. A total of 305 prenatal tests were reported and 131 revealed an increased risk. Apart from eight couples (including two couples with an exclusion test), all parents with an unfavourable prenatal test result decided to terminate the pregnancy. Based on all available data it is highly probable that these eight couples “changed their mind” after the disclosure of the unfavourable result.
For couples with a high risk of transmitting the Huntington mutation it is important to consider all reproductive options that may be relevant for them. Thoughtful preparation is needed before conception to diminish the emotional trauma associated with an unfavourable outcome. After the communication of an unfavourable prenatal test result prospective parents are very vulnerable. Time pressure and stress usually impede informed decision making. Issues related to the possibility and implications of prenatal diagnosis and preimplantation genetic diagnosis (PGD) are usually part of the counselling sessions before and after predictive testing, usually long before conception. After an unfavourable predictive test result parents usually need time and more than one counselling session to make their own decision about a pregnancy with or without PD or PGD. It is our clinical experience that parents are generally able to consider all the issues that are important for them and to make “informed and anticipated decisions” before engaging in a pregnancy.
We refer to publication (2) for a more detailed discussion of counselling issues and ethical aspects of prenatal testing and preimplantation genetic diagnosis for HD and other neurogenetic late-onset diseases, as well as for case presentations illustrating its psychological complexity.
References
1 Duncan RE, Foddy B, Delatycki MB. Refusing to provide a prenatal test: can it ever be ethical? BMJ 2006; 333: 1066-88 2 Evers-Kiebooms G, Zoeteweij M and Harper P (Eds) Prenatal testing for late-onset neurogenetic diseases. 2002; BIOS Scientific Publishers Ltd, Oxford UK.
Authors
Evers-Kiebooms Gerry* de Wert Guido° Decruyenaere Marleen* de Die Christine** Craufurd David°° Kimberly Quaid°°° Fryns Jean-Pierre*
*Centre for Human Genetics, University Hospital of Leuven, Belgium °Research Institute GROW, Dept of Health Ethics, University of Maastricht, The Netherlands **Clinical Genetics Centre, University Hospital of Maastricht, The Netherlands °°Academic Unit of Medical Genetics and Regional Genetic Service, University of Manchester, UK °°°Dept of Medical and Molecular Genetics, Indiana University School of Medecine, Indianapolis, USA.
Competing interests: None declared
Competing interests: No competing interests
As an individual who has an auto-dominant condition and has had late onset problems and this also includes making decisions such as those described above.
10 years ago, I was supportive of finding a diagnosis for my son. Indeed, I was anxious to avoid a future pregnancy. I have made decisions that prehaps now I regret and the IVF PGD programme is fraught with problems.
I now feel totally differently about the subject of genetics and its role in society today. I fear a future whereby people with genetic disorders are discriminated in every single field, in employment, in insurance and in health that we will be second class citizens with no rights.
Indeed I am now at the stage of 'knowing about my disease' that in fact that I should not know and do not want to know the final outcome and it is interesting to know that doctors 'tramline' your diagnosis into this, this and this when, in fact, you have nothing of the sort. I really wish I did not know because it comes with a stigma of 'having a syndrome'.
Competing interests: None declared
Competing interests: No competing interests
Thank you for an excellent discussion of a perennially difficult issue. One issue that hasn’t been discussed however, is why would the parents want to test during the pregnancy if they were going to continue with it anyway? Why risk the very thing they want to continue? Tests during pregnancy (most usually, amniocentesis or chorionic villus sampling) carry a risk (quoted as between 1-5 in every 100 pregnancies) of miscarriage. Testing the newborn would not carry any such risk and would still allow ‘reassurance’ or ‘preparation’ well in advance of any symptom appearing. There may be more guidelines suggesting we should not test the newborn, because the issue is less confused with the mother’s right to decide about her fetus during pregnancy, but risky testing during pregnancy simply because there are fewer guidelines saying one should not, does not seem appropriate either. Detailed and open discussion with the parents, avoiding “can’t” and “won’t” test but exploring the pros and cons of testing will, in our experience, usually result in a decision that all parties are satisfied with.
Competing interests: None declared
Competing interests: No competing interests
The society we live in is full of goddamn hypocrisy. A woman can "request" termination of pregnancy, ie kill the unborn child to which most doctors agree to on the premise that it is her Autonomy. On the other hand a sensible couple cannot know what is wrong with their son or daughter when they are the ones who will look after the child once he or she is born. Is this ethics?.
Competing interests: None declared
Competing interests: No competing interests
Huntington's disease is a genetic disorder with an autosomal dominant inheritance, implying that a child would have a 50% chance of acquiring the disease if he/she has one affected parent. Though the mean age of onset of symptoms is 35-44 years, the irreversibility and the progressive nature of the disease makes prenatal diagnosis indispensable if the foetus has an affected parent. In addition, 5-10% (mostly of paternal inheritance) are of juvenile onset, appearing in the second decade.
In my opinion, prenatal diagnosis of Huntington's disease is no different from the prenatal diagnosis of Down's syndrome. Both are irreversible conditions which can be avoided by termination of pregnancy.
According to studies, a majority of patients suffer from depression and some, with bipolar disorders. It is also known that patients with the disease and even those with a risk of the disease have an increased risk of suicide. So in addition to the progressive physical illness, the child would be under a lot of mental stress as well.
Also, speaking of ethical issues, if there is one affected parent, both parents would realise the morbidity and mental trauma involved once the child becomes symptomatic. Denying prenatal tests would be denying parents of rights towards their child. As with young children where parents take decisions for them until they are considered fit enough to take decisions themselves, it is for the parents to decide for their child at the prenatal stage. The British Medical Association states that there is no legal age for taking decisions or giving consent as long as the person is considered competent to do so. Competency however, is understood in terms of the patient's ability to understand the choices and their consequences, including the nature, purpose and possible risk of any treatment (or non- treatment). In this situation, however, since the child would have no control over the course of the disease, it is only right for the parents to be informed of the child's inheritance of the disease, so that it gives them the opportunity to reconsider their earlier decision not to terminate the pregnancy. If the child is affected, it would be the responsibility of the consulting doctor to inform the parents of the risks and complications involved with the disease - those that have manifested in the father and also those that have not. That would allow the parents to at least consider termination.
Reference:
1. Fredy J Revilla, MD et al, Huntington’s disease, emedicine Specialities.
2. www.bma.org.uk/ap.nsf/Content/Confidentialityunder16
Competing interests: None declared
Competing interests: No competing interests
This debate can go on for years and then no final decision can still be made. The aim must be to reach a consensus between the parents and the screening doctor. Nobody can force the patients to undergo testing without their consent, no matter what. Focus could be placed on prenatal and postnatal counselling .
Competing interests: None declared
Competing interests: No competing interests
Both the positions taken by Martin Delatycki and RE Duncan and B Foddy provide quite cogent reasons for their differing stances of “not testing” and “testing” to see whether a child would be born with Huntington’s disease (18 Nov, p 1066) [1]. However, there are at least two other aspects that I would have liked brought up, which link to a third vital consideration.
First, Delatycki could have added to his ammunition Insurance companies’ recent tendency to ask the question “Has anyone tested you for a genetic disease, and why?” If the person had been antenatally tested years before, he/she can hardly refuse to answer Insurance company’s probings [2]. Delatycki would be right to refuse testing because of this.
Secondly, the opinion of a sufferer, not just the person who knows the gene is present, but one who is beginning to have symptoms, would be most valuable, and I suspect RE Duncan and B Foddy might find such opinion siding with them. The 45-year old Civil Servant I referred to in the BMJ in 1984 with Huntington’s disease [3] was the kind of person whose opinion about these guidelines [4] would be invaluable, which leads me to a third consideration that I thought should have been stressed more on both sides of this present ethical debate [1], but which hardly had a mention.
It is this: What the debate has dealt with so far has been about details, when the prior consideration should have been the principle of selective abortion for any hereditary condition which allows its unfortunate possessor 45 years of useful life; in some cases more useful life than that of siblings who do not suffer from the disease [5]. For a Huntington disease patient, or anyone else with hereditary disease for that matter, to rise to the lofty heights in the British Civil Service, they must have inherited alongside the damaging gene admirable genes from the same parents. Would they rather have been deprived of useful service to their country by being aborted 45 years earlier, in order to be spared suffering 45 years later? Difficult question, but we need to slot the opinion of actual patients with hereditary disease into this ethical debate.
Why should we accept without question the following guideline of the International Huntington Association and the World Federation of Neurology, recommendation 7.2 of which states: “The couple requesting antenatal testing must be clearly informed that if they intend to complete the pregnancy if the fetus is a carrier of the gene defect, there is no valid reason for performing the test” [4]? Do we know what a successful 45 -year old person suddenly diagnosed with Huntington’s disease, would have said about this guideline?
My own family history, recent and remote, which teems with genetic pathology, illustrates this principle. The history contains names of sick relatives who were geniuses in this and that. For example, my younger brother Tei, seen in generation VIII on http://www.konotey- ahulu.com/images/genration.jpg [6], who had sickle cell disease, was far better at Maths than any of his ten siblings; and I myself was not at all bad at Additional Maths. Have we not known other hereditary disease patients who were more brilliant, if not more successful, than their healthy siblings until their life was shortened by a particular unkind inheritance? [5]
To illustrate further the ethical import of what I am saying, and at the risk of being misunderstood, I reproduce a lengthy quote about myself from arguably the greatest British clinician/geneticist/molecular biologist of modern times, Oxford University’s Professor Sir David Weatherall [7].
“The attitude of many doctors and others to the avoidance of genetic disease by screening and selective termination of pregnancy was eloquently summarized in 1984 in a letter to the British Medical Journal by a highly respected African physician, Felix Konotey-Ahulu. He wrote as follows: ‘I was born in the Krobo tribe with extra digits – a Mendelian dominant condition with a 1% incidence at birth in Ghana. Had I been born a few miles south east across the Volta River, there would have been great rejoicing because the local tribesmen had it that I was destined to be rich. If my mother had given birth to me a few miles northwest beyond the hills, I would not be here to write to you – I would have been drowned soon after birth. Fortunately the Krobo’s were neutral to extra digits but until the government forbade the practice some tribal elders took it on to themselves to decide which genes ought to be allowed to survive! My fellow Krobo tribesmen did not spend time debating details like the most humane way to drown me at birth to cause least hurt to my mother, nor did they ever ponder how my three siblings with sickle cell disease could have been identified in utero and got rid of. No, they got hold of the vital principle that I was literally more than 12 digits and my two brothers and sister with sickle cell disease had other genes which endeared them to my parents.’ In the same letter [3] the author voices the fear that history has shown that often a few pressure groups or even a single person can decide what is right for an entire society – Nazi Germany was the prime example; now, he argues, it is the turn of the molecular geneticists.” [7]
The letter Sir David Weatherall quotes from the BMJ, was the same letter in which I mentioned the 45 year old patient with Huntington’s disease (“Ethical issues in prenatal diagnosis”), but in their communication in this debate (1), apart from the title, the word ‘ethics’ or ‘ethical’ hardly jumps out of the pages.
I am most intrigued by the difference between Professor Sir David Weatherall FRS (clinician first before molecular geneticist) and Professor Steve Jones FRS (geneticist qua geneticist) in their differing reactions to my personal extra digits genetic history. The former, Sir David, places my story in the chapter he called: “Ethical issues and related problems” in his magnificent book 'The New Genetics and Clinical Practice', underlining the great importance he attaches to Ethics in Genetics. The latter, Steve Jones, on the other hand uses my BMJ genetic history account anonymously. In his best selling book 'The Language of the genes: Biology, History and the Evolutionary Future', page 285, he states: “In Ghana, children are sometimes born with an extra finger or toe. Some tribal groups take no notice, others rejoice as it means the child will become rich; but others, just a few miles away, regard such children with horror and they are drowned at birth” [8]. No reference to where he got this information from, nor to the ethical reasons relating to why I revealed my genetic defect of extra digits. Ethics did not come into Steve Jones’ account of what I said [3]. Rather, he used the story, my genetic history, to embellish the running theme of his whole book: Genetics in Darwinian Evolution. There is no chapter on Ethics in Steve Jones’ 347-page book, and the word “ethics” is not found within his Index of 16 pages, whereas Sir David Weatherall devotes no less than 21 pages to Ethics in his 376- page book, and we see on page 371 in the Index "ethical issues 347-68” [7].
In this regard, I wonder, what proportion of the members of Committees, national and international, that produce guidelines for us in Genetics are clinicians? Did we leave the following fiat: “There is no valid reason for performing the test to find out if the fetus carries a Huntington disease gene unless the parent agreed to selective abortion” (did we leave this) to Committees with a majority of non-clinicians?
I must declare an interest here. My ancestry is full of genetic defects [6, 9]. I was the first in the world to trace hereditary disease in 9 consecutive generations, for three centuries, with names of sufferers from 1670, and the defects run to the present day in my family tree – thanks to polygamy in my forebear, and known tribal names of hereditary rheumatism (Ache/Ache or Sickle Cell disease – Hemkom/Chwechweechwe) [6, 9]. What would have been of great concern to me was that many of my named relatives eg Angmorter, [Generation III on my father side] born around 1751, and who died at the age of 18 from the Ache/Ache syndrome, is remembered to this day not only because he ached a lot in the rainy season but because of some admirable qualities inherited from his non-rheumatic Norm/Ache parents. Angmorter died far younger than the age at which Huntington disease patients here in the UK began to suffer, and would have been recommended for elimination before they lived to exhibit the useful genes that we now remember them by [Reference 6 http://www.konotey- ahulu.com/images/generation.jpg].
The other genes of these patients were often superior to what their siblings without Ache/Ache had [6]. In addition to clinicians, therefore, we need the sufferers themselves, and their relatives to add their voice to this debate. Genetics without a genuine ethical dimension becomes Eugenics, and should be discouraged [3].
Finally, anyone who has never seen the Mendelian Dominant extra digits phenomenon prevalent in West Africa with a 1% incidence at birth, and who wishes to inspect my hands is free to do so at no charge. I refuse to state whether any of my offspring has got this gene, but being quite aware of the high male procreative superiority index, MPSI, in Africa [10], I have VOLUNTARILY limited the size of this particular gene pool by sticking to one wife, my beloved Rosemary [6] who, being Caucasian, does not possess it.
1 Duncan RE, Foddy B, Delatycki MB. Refusing to
provide a prenatal test: can it ever be ethical?
BMJ 2006; 333: 1066-88.
2 Konotey-Ahulu FID. Insurance and genetic testing.
Lancet 1993; 341: 833.
3 Konotey-Ahulu FID. Ethical issues in prenatal
diagnosis. BMJ 1984; 289: 185
4 International Huntington Association and the World
Federation of Neurology Research Group on
Huntington’s Chorea: Guidelines for the molecular
genetics predictive test in Huntington’s disease.
J Med Genet 1994; 31: 555-9.
5 Konotey-Ahulu FID. Missing the wood for one genetic
tree? The First International Symposium on
the role of Recombinant DNA in Genetics –
Proceedings – Chania, Crete, Greece, May 13 – 16
1985. Eds Loukopoulos D, Teplitz RL. Athens, P
Paschalidis 1986, pages 105 –116.
6 Konotey-Ahulu FID. The Human Genome Diversity
Project (HGDP): Cogitations of African
Native. Politics and the Life Sciences 1999:
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7 Weatherall DJ. The New Genetics and Clinical
Practice. Oxford University Press (Third Edition)
Oxford 1991, pages 347-48.
8 Jones S. The Language of the genes: Biology,
History, and Evolutionary Future. Flamingo 1993,
London, page 285.
9 Konotey-Ahulu FID. The sickle cell diseases:
Clinical manifestations including the sickle
cell risis: Arch Intern Med 1974; 133: 611-619.
10 Konotey-Ahulu FID. Male procreative superiority
index (MPSI): the missing co-efficient in African
anthropogenetics. BMJ 1980; 280: 1700-1702.
Competing interests: I come from a family with loads of genetic defects.
Competing interests: No competing interests
Thank you for this interesting article on a highly emotive topic. Delatycki’s argument against testing is based on the premise that if the parents were having the baby anyway, it would be a breach of both the child’s future autonomy and right of confidentiality. Let us say then, as he seems to suggest, that testing is offered to those parents who have yet to make a decision as to whether or not to go through with the pregnancy. In this situation, however, if the test is negative and the parents subsequently choose to have the baby, has not the child suffered the same breach of rights and confidentiality even though the result itself is negative? Surely the ethical implication is the same.
I find that this makes the whole idea of judging the relative autonomy of parents versus the autonomy of the child rather beside the point. In a system where we have given parents the precedence to decide on the right to exist of the child, it is, as Duncan and Foddy have suggested, unrealistic to set terms on their decision. Despite the breach of the child’s rights, this is not where the ethical difficulty stems from – this is no different to other situations when we as a profession have to decide on the ascendancy of rights, e.g. the rights of the patient versus public interest. Instead, what Delatycki is effectively suggesting is that we only provide this test in cases where it validates the medical profession by allowing it to take further action in the lives of the parents and future family. Where our medical knowledge is powerless to intervene or prevent the inevitability of Huntington’s disease, then the knowledge of the possibility of that disease is categorised as potentially harmful and therefore irrelevant to the parents.
This goes a bit further than mere paternalism or abuse of power. It reveals the darker underbelly of medical assumption. The offering of the test is being based on the argument that the medical profession has the right to control not just the immediate clinical scenario but the disease entity and its psychosocial impact. Duncan and Foddy cannot entirely avoid this either. Indeed both sides refer to research on the psychological implications, whether for or against testing. This underestimates the value that should be placed on parents themselves having the right to determine how these very factors inform their decisions. Knowledge is in our power to divulge and it is not necessarily up to the profession to define all of its wider impact.
Competing interests: None declared
Competing interests: No competing interests
To offer or not to offer : is that (actually) the question ?
Introduction
Have physicians the duty to prenatally offer a predictive genetic testing for Huntington disease (1) ? The question wouldn’t even be raised if future parents would systematically refuse it. But, as for other untreatable conditions, some people want to know the truth before it only happens. Nevertheless, diagnostic knowledge is not danger-free. Obviously knowing that her fetus bears the anomaly doesn’t compel a pregnant woman to termination. However, she has access to a knowledge that her fetus, when born, may not want to know about. Indeed, many people don’t want to know about a possible pathological future. But how will parents deal with hiding to their child such a knowledge on his neurological fate ?
Respect of autonomy and beneficence
According to the principle of autonomy (2), patients must be thoroughly informed before any decision. All the more so as, in our very situation, it is likely that other members of the family have already been affected. If the patient ask for up-to-date state-of-the-art scientific knowledge, nobody and nothing can prevent him from getting it. Of course, the physician can provide his own opinion about, for example, the opportunity of having the test. And of course the patient can be advised and adequately prepared to the would-be unfavorable result (3).
The attitude of a couple facing this prenatal situation widely depends on his representations of the disease, according to the family history, the society’s beahaviour, and the medical speech (4). Some doctors will insist on the very late expression, life being worth living it until then. Others will believe that physical and neuropsychiatric damages are not worth taking the risk. From these different perceptions, they will be inclined to indirectly and unconsciously promote (or deny) termination of pregnancy. Because of this variety of perceptions, there is no univocal solution, indeed. Nor can any recommendation be given. An ethical choice cannot be solely based on a rational and scientific demonstration, because decision- making is also about intuitive reactions (5). Reasoning can occur “a posteriori”, but emotions, and not reason, basically reveal our belonging values (6). If the fear of having an affected child is strongly persists, scientific arguments against termination of pregnancy will hardly prevail. The second major ethical principle, i.e. beneficence, tell the physicians always to look for the patient’s greater Good. A beneficent behavior can be to inform the couple of the existence and implications of the test, and to help them choose and assume this choice, whatever it is, including welcoming this child in the better environment.
The French position
In France, the decision to terminate a pregnancy for medical reasons must strictly follow the Law texts which assert that the condition « is particularly severe, and untreatable at the time of diagnosis (7) “, miles away from giving a list of involved diseases. First because this “black” list would certainly lead to the stigmatisation of individuals. Second because thanks to technical advances, untreatability is not temporally stable. Last but not least because clinical expression of genetic conditions is highly variable, both in severity and timing, including for Huntington disease.
French lawmakers consider that performing the test should only be motivated by giving the possibility to terminate the pregnancy, even if the couple eventually doesn’t choose this option. Having the test in the only goal of getting major information that could modify the future child’s destiny or change his own parents attitudes to him is ethically very questionable. The more determining is the biologically intimate knowledge about the future child, the more questionable is the legitimacy of his parents to access this very knowledge. Information per se is not valuable when it concerns a third person who has the right not to know. For example, there is no cognitive amniocentesis. It is medically performed only with the perspective of a possible termination, that by the way some couples will not ask for, from time to time.
One could argue that future parents cannot take a fully informed decision without knowing everything, including the genetic information, and of course information is the corner stone of decision. However we do not agree with Duncan and Fody’s suggested lies. Surgeons have a clear-cut reasoning about paraclinic exams : they have to modify the therapeutic management, otherwise they’re not needed. This kind of attitude can be suitable in our context, letting to the future child the choice not to know, even against his parents’ inclination.
Conclusion
We argue for one’s right not to be transparent to the other one, at a time when genetic knowledge will be increasingly easier to obtain. When autonomy and paternalism are face to face, showing the limits of the ethics of principles, a more casuistic type of ethics can find its place, where the physician’s role is not lessened, on the contrary, but is re- positioned towards helping people to identify the individual and collective components of the problematic they’re facing, and assuming together the decisions they took.
(1) Refusing to provide a prenatal test : can it ever be ethical ? Duncan RE, Foddy B, Delatycki MB. BMJ 2006 ; 333 : 1066-1068
(2) Beauchamp TL, Childress J. Principles of Biomedical Ethics (fifth edition). New York/Oxford: Oxford Univ. Press. 2001
(3) Elster, J., Herpin, N., (eds) "The Ethics of Medical Choice." In The Ethics of Medical Choice. Social Change in Western Europe, London & New York: Pinter/St. Martin's Press. 1994
(4) Elster, J. Strong Feelings: Emotion, Addiction, and Human Behavior, Cambridge, MA: MIT Press. 1999.
(5) Greenspan, PS, Emotions and Reasons. An Inquiry into Emotional Justification, New York, Routledge and Kegan Paul. Chapman and Hall. 1988
(6) Livet P., “Emotions, Revision, and the Explanation of Emotional Actions”, European Review of Philosophy 2002 ; 5 : 93-07.
(7) Law n° 2004-800 , Aug 2004 6th, on Bioethics. Official Journal of the French Republic, 2004 ; 182 : 14040
Competing interests: None declared
Competing interests: No competing interests