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Julian Sheather

Julian Sheather: Taxing the fat

4 Dec, 12 | by BMJ Group

To the evident frustration of the Danish Medical Association, Denmark has repealed the world’s first tax on saturated fats. The climb-down came after just over a year, the government citing strong public hostility. According to the Economist, “retailers and shoppers whooped with joy” at the announcement. Given that so much of the world is struggling with the public health effects of saturated fat consumption, a long look at the Danish experience could be helpful. Tackling the diseases of lifestyle presents an almost paradigmatically “wicked” problem. Untangling the complex interplay of economics, politics, and ethics is not for the faint-hearted. At the centre of the problem lies the state’s desire to restrict people from doing what they seem to want to do: in this case consume saturated fats to the detriment of their physical health. Some of the state’s desire—though I question how much—probably is paternalistic: healthy lives are straightforwardly preferable to unhealthy ones and the state has some interest in promoting the one over the other. Paternalism has a bad name in liberal democracies—at least in theory, practice varies widely—with liberals citing JS Mill’s ringing defence of adult liberty: that harm only to others justifies an interference with an adult’s liberty. But only some of the state’s interest here is paternalistic in that strict sense. What about the burden of obesity falling on children? What role does that state have here? And what about what the economists call externalities? What about those costs not directly born by parties to the transaction—health costs for example in a publicly-funded health system? These are the dispersed costs that a tax attempts to bring back into the pricing of the goods. There is also a steep income gradient, the burdens of poor diet falling predominantly on the less-wealthy. Such structural injustices suggest that the fruits of liberty may not be equally enjoyed. more…

Julian Sheather: Should parents be compelled to vaccinate their children?

27 Nov, 12 | by BMJ Group

I was recently asked to give a talk on vaccination and potential conflicts between the rights of parents and the interests of their children. A few years back when my boys were bonny wee things some bohemian friends announced that they would not be vaccinating their children, they would rely instead on homeopathic remedies. Although this was not long after the MMR scandal they were not provoked into their decision by media tittle-tattle, the father at least having long been a champion of the little white pills—and a healthy chap he was too. His decision was an expression of a long-term distrust of mainstream or “allopathic” medicine. It did create a small stir at the time. Pregnant friends were uneasy: if the unvaccinated children did contract any of that unwholesome trio of infections, would they present a risk to their unborn children? They also travelled to countries with far shakier public health infrastructures than ours. In my more uncharitable moments I also carped about free-riding and population immunity: the chances of their unvaccinated children coming to harm being significantly reduced by the decisions of myriad others. I did not doubt that my friend was acting in good faith. His feelings for his children were no less substantial than mine. But try as I might I could not see the difference between us as a straight value clash. Values do not float free of evidence; they are informed by it. Seeking to realise our values we turn to the facts of the matter. And the facts, when it comes to the benefits and burdens of vaccination are incontrovertible. The nearest route to protecting your children from measles, mumps, and rubella is to vaccinate them. The world is more than the sum of our value judgments about it. more…

Julian Sheather: Medical electives—laying the ghosts of empire?

19 Nov, 12 | by BMJ

I was at Brighton Medical School recently, talking ethics to third years, and a lively and engaging bunch they were too. Among the many things we talked about were electives, particularly in resource poor countries. It is no surprise that students look forward to their electives. The travel appeals of course; the ability also to escape the tourist rat-runs, tourists having a terrible tendency to denature the places they tour. I certainly know from experience that there is nothing like a visit to a psychiatric hospital in sub-Saharan Africa to remind you that there is more to the world than you will find between the covers of a Lonely Planet guide. There will almost certainly be interesting clinical opportunities: the chance to see creative responses to extreme resource shortages. Depending on the location there will be conditions that you are unlikely to see at home. There may also be opportunities to learn from non-traditional carers. I have also heard it said they can be a good opportunity to take on more clinical responsibility than students are ordinarily given in the UK. And this is where things can get troubling. It was students who first alerted me to the problem. A few years ago, on returning from their elective, a group of students wrote to the BMJ describing the behaviour of a student colleague. Released from oversight he saw an opportunity effectively to practise on a captive population. He altered a prescription written by a local doctor; he photographed patients undergoing intimate procedures without consent, and he performed an unnecessary lumbar puncture because he fancied “having a go.” You would need to be deaf to history not to hear unsavoury echoes of colonialism in his behaviour: a western medical student practising techniques well beyond his competence on patients who thought him a western doctor. As the students wrote: “The local healthcare professionals sometimes perceived white skin to be synonymous with expertise, placing unprecedented levels of trust in us and allowing us to make decisions and perform procedures that would be unacceptable in the United Kingdom.” An extreme case no doubt but it points to a necessary moral: medical students are not qualified doctors and they have no greater licence abroad than at home. It should also be said that these students did precisely the right thing: when they saw unethical behaviour they confronted it and they spoke out. And not just locally. Writing to the BMJ on their return ensured the problem was given wider exposure. more…

Julian Sheather: Time to claim kin with the volcanologists?

30 Oct, 12 | by BMJ Group

No, I am not about to declare myself a closet trekkie. I have in mind the decision by Judge Marco Billi to jail six Italian seismologists for giving ‘false assurances’ before an earthquake hit L’Aquila in 2009, a decision, as the BBC just couldn’t help saying, that sent “shockwaves” through the scientific community. What made the alleged assurances false was not scientific mendacity but the complexity and unpredictability of the world. As Bill McGuire, professor of geophysical and climate hazards at University College London, put it: “Most of the time, small seismic shocks, such as were experienced in the L’Aquila region for months before the ‘big one’, are not indicative of a larger quake to come. Franco Barberi was absolutely correct, therefore, to announce – a few days before the magnitude 6.3 quake that flattened much of the city – that there was “no reason to believe that a swarm of minor events is a sure predictor of a major shock.”‘ Personally I cannot spot an assurance there, false or otherwise, just an honest statement of scientific uncertainty. more…

Julian Sheather: Safeguarding adults—respecting freedom, maximising welfare

18 Oct, 12 | by BMJ

I was in Bromley recently at an adult safeguarding conference. It was in some respects a melancholy day. We heard about Brent Martin, a 23 year-old with learning disabilities and a mental disorder beaten to death by members of a gang who temporarily befriended him, though largely for access to his benefits. He had been in psychiatric care since 16 and was discharged three months before he was killed. The proximate cause was a five pound bet on a 16 year old being able to knock him out with a single punch. We heard a lot about “hate crime,” where attacks are motivated at least in part by the victim’s membership of a particular social group. Being black, being disabled, even being a “goth” were enough to make people targets. We were also given a copy of The little book of big scams. I have grown accustomed to the phishing emails that drop with tedious regularity into my inbox. I had no idea quite how ingenious the fraudsters had become. It reminded me of something VS Naipaul said about our capacity to see human beings as prey. It also reminded me how easy it is, viewed in a certain light, to fall out of love with our kind. more…

Julian Sheather: What’s wrong with moral enhancement?

12 Sep, 12 | by BMJ

The question of whether biotechnology should be deployed to improve human beings morally is starting to climb out of the pages of recondite publications and dip a quizzical toe in mainstream media. A recent article in the Telegraph quotes Professor Julian Savulescu from the Oxford Uehiro Centre for Practical Ethics saying that, should it ever become possible, the use of genetic technology to screen out morally unworthy characteristics should be morally obligatory. “When it comes to screening out personality flaws, such as potential alcoholism, psychopathy, and a disposition to violence, you could argue that people have a moral obligation to select ethically better children.” “We’re routinely screening embryos and foetuses for conditions such as cystic fibrosis and Down’s syndrome,” he continues, “and there’s little public outcry.” more…

Julian Sheather and Vivienne Nathanson: Todd Akin, rape, and “doctors”

3 Sep, 12 | by BMJ

Vivienne Nathanson

According to the historian Tony Judt, the Red Army, after raping and brutalising its way across Europe in the closing stages of the Second World War, left behind, in Germany alone, somewhere between 150,000 and 200,000 “Russian babies.” These figures, he writes, “make no allowance for untold numbers of abortions, as a result of which many women died along with their unwanted foetuses.” Recently, asked his views on whether abortion should be banned even if the pregnancy resulted from rape, Todd Akin, a US Republican congressman running for the Senate, replied that such pregnancies were “really rare.” Despite being a member of the House Committee on Science he stated that “from what I understand from doctors…if it’s a legitimate rape, the female body has ways to try to shut the whole thing down.” It is tempting just to leave those juxtaposed sentences standing there, to permit the fatuity of that last statement to speak for itself, but the more you think about it the more the buried assumptions in it, the more the meretricious misuse of science and morality clamour for a voice.


Julian Sheather: Doping in sport—thoughts on another Olympic legacy

16 Aug, 12 | by BMJ

Every once in a while I dust off my old road bike and head out onto the North Downs to take in a few hills. Panting up a short sharp rise is about as close to elite athleticism as I get—and it is not unusual for me to get off and push. It is from these foothills that I look across to the distant Himalaya of Olympic sports. Draw a veil over the grubby politics, forget about the ticketing problems—I only got three in the end, for the men’s volleyball—inure yourself to the corporate takeover: the heart of the matter surely lies in that look upwards—here is a kind of human excellence at its fullest reach, perhaps the one excellence that in these egalitarian times we are permitted to contemplate without misgiving. This is what a human being at full stretch is capable of. more…

Julian Sheather: Anders Breivik and the social uses of psychiatry

16 Jul, 12 | by BMJ

I have been gripped by the trial of Anders Breivik and was intrigued to see the BMJ hosting a Maudsley debate this week about, loosely speaking, Breivik’s “sanity.” The debate ran under the headline question of whether fanaticism is a form of madness which gave a slightly odd spin to the proceedings. As Tom Fahy hints, given that few football fans are incarcerated in secure institutions I am not sure fanaticism in and of itself is necessarily the problem. If political and religious fanaticism are the real problems—mortal threats to the west—then what follows if fanaticism is diagnosed as a mental disorder? What advantage, analytical or practical, could it possibly bring? Can medicine really help frame this debate? more…

Julian Sheather: Happy-ology

12 Jul, 12 | by BMJ

It is possibly the oldest of all philosophical questions. Although academic specialisation has tended to brush it to the wings—embarrassed perhaps by the sheer indeterminate unwieldiness of it—the question of what constitutes a good or flourishing life and how we can live one will not, for good human reasons, go away. And if academic philosophers have tended to ignore it, politicians, particularly liberal ones, have often been embarrassed by it. For if there is such a thing as a good life, rather than just an infinite variety of lives each of them good according to its lights, then surely society has some role, however attenuated, in promoting it? And this can give liberals a headache. To give a domestic example, should I acquiesce in my son’s decision to forego school today in favour of spending fourteen hours playing Halo—should I see it as the autonomous expression of a legitimate lifestyle choice—or am I justified in telling him that if he doesn’t haul his backside off the sofa I’ll throw his X-box out the window? more…

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