I’ve reached an important milestone: the first case of Pig Aids swine flu among people I know.  It’s quite exciting.

She’s been told to stay in, avoiding contact with others, for five days by one person, for 10 by another.  I’m wondering why this is.

In the early days of the illness, there might have been a point.  When we were dealing with a few tens of sniffly people, it might have been possible to contain the virus (assuming, of course, that we were willing also to close all ports and build a big glass dome over the UK just in case).  For the sake of public protection, there might have been some warrant for this.  Let’s not forget, of course, that not so long ago we were much more worried that’d it’d be a really serious illness - much more serious than it would appear to be at the moment.

But, at this stage, I’m wondering whether quarantine is any use - or justified at all.  Apparently, there were an estimated 50 thousand new cases in the UK last week.  Why quarantine someone to contain a disease that’s infecting fifty thousand a week?  That does seem a bit pointless.  Even if the worst predictions about the disease come true - the Chief Medical Officer for England and Wales predicts up to 65 000 UK deaths, but even that’s deaths associated with , not from, H1N1 - it’s hard to see how keeping people sort-of-isolated (until they’ve run out of coffee and have to nip to the shops, at least) would make any difference at all.

Actually - it will make a difference, come to think of it.  It’ll cause unnecessary worry and distress.

Besides - isn’t quarantine 40 days, by definition?

Fascinating, but perhaps not best viewed while eating…

Lord Falconer’s amendment to the Coroners Bill, which would have made specific legal provision for those helping others to travel to places like Dignitas, was rejected by the House of Lords last night.

Oh, well.  As Falconer admits, it’s not obvious that it’ll make all that much difference on the ground, because few, if any, have the stomach to prosecute in such cases, and it’s not a given that the public interest’d be served anyway.  So the limbo continues.

For quite a while now, I’ve had the idea that I’d like to write something about the purpose of medicine - it’s something I’ve been adding on job applications for about 5 years, but I’ve not got around to doing all that much about it yet.  The question as I saw it was whether medicine is properly concerned with making us well, or with assisting us in our projects.  The latter may be a condition of the former - indeed, it may be a criterion of the former - but it’s not the same, because we could have all kinds of odd projects that’re only tenuously health-related.  For example, cosmetic surgery - and here I mean potentially quite extreme body modification - might potentially belong to medicine if we go for the latter option.  It might not be the sort of thing that medics should prioritise, but it could still be on their list of concerns.

Where’s this preamble leading?  Well, Alice Dreger has been considering a similar sort of question over on the Hastings Center’s blog.  It’s cosmetic surgery that worries her:

I’m not naïve; as an historian of medicine, I know that medicine has always advanced itself by offering improvements of patients’ social status, primarily by making patients healthier, but also by legitimizing their complaints.

But the noble profession has historically been primarily about something nobler than boob jobs and Botoxing wrinkles. The medical profession’s primary goal, historically speaking, has been prevention and relief of real suffering.

I can’t believe I even have to assert that. If the great men and women of medicine could come back from the dead and watch television today, what would they make of the fact that a large percentage of the medicine that is represented is cosmetic?

They might conclude, reasonably, that this reveals medicine’s success. Only in a world of astonishingly good anesthetics, infection management, and surgical technique would patients dare seek these procedures. But they might also reasonably conclude that something very strange has happened.

There’re some interesting considerations raised in the piece - I do recommend it.  However, there’s also a couple of things with which I’d pick a dispute.  The conclusion doesn’t strike me as powerful, for example.

Let’s just call these practices what they are: barber surgery. That way, when one of my idealistic, smart, principled students hears that the student next to her is going into “cosmetics,” she can just answer, “Really? And here I thought we were in medical school.”

Dreger is fairly clear that she goes along with the first of my options above - that medicine is about wellness - but I’m not sure that that’s right: I don’t think I see wellness as an end in itself.  Rather, I see it as something that’s valuable (and comprehensible) only within the context of a certain set of projects.  So it’s those projects that do the work - in which case, cosmetic medicine (or barber surgery - call it what you will) is, if not exactly back on the menu, at least chalked up on the “Specials of the Day” board.  The “and I thought we were in medical school” retort wouldn’t stick.

And I think that the tone of the article more generally suggests something important and interesting about the cultural background of bioethics as pursued on the other side of the Atlantic. more…

There’s been a lot of ink sneezed recently on how we should organise our response to H5N1 and, latterly, H1N1 - on questions of who should be top of the Tamiflu distribution list and on how the distribution should be organised.  (To give a recent example, Dan Sokol touches on the question here.)

However, one aspect of our policy has possibly been overlooked - that the more prophylactic Tamiflu we distribute, the greater the chances of the virus developing resistance to it, thereby undermining the whole vaccination project.  If reports from Denmark are to be believed, there seems to be some evidence that this is happening:

On 29 June, Denmark’s National Board of Health announced the first known case of H1N1 swine flu resistant to [Tamiflu]. The woman was in contact with an infected person and was put on low-dose Tamiflu as a precaution, but she developed flu anyway.

She has now recovered after taking the antiviral Relenza, and the drug-resistant strain appears not to have spread. The State Serum Institute in Copenhagen assumes resistance emerged during treatment with Tamiflu, as low doses can favour the emergence of resistant strains.

If health authorities continue to hand out prophylactic treatments, further resistant cases are likely to emerge. As many countries have stockpiled Tamiflu, and a specific vaccine is unlikely to be available in time for the next wave of swine flu, this could prove disastrous.

Presumably, there’s a similar risk of the virus developing Relenza resistance, too.  So there seems to be an interesting dilemma generated: while governments presumably ought to take steps to ensure the availability of prophylaxis, this also generates a risk that they’re creating a much bigger problem further down the line.  I don’t think that this is an argument against prophylaxis per se - of course governments should deal with the threat as it stands at the moment (and anything else would be a counsel of despair), and the threat of resistant H1N1may never be realised - but the point would stand that, in doing what they ought to do now, they may be making things worse in the long run.  And that means that meeting the present danger isn’t nearly as morally straightforward as it would seem at first.

It was only a matter of time before people started to come up with “evidence” that swine flu is all a hoax cooked up to allow the lizard illuminati Bildeberg New World Order freemasons to take over the world… and it’s happening now - this time courtesy of someone using the same name as a BMJ reporter (I’m not sure that it is the same person - but the page I’ve cited here makes the link).

(Actually, come to think of it, we’ve been here before… remember this?)

Here’s a sample of the claim: more…

For the few reprobates among our blog readers who are not regular visitors to our parent journal’s web-site I thought that I should point out that this months issue of the JME contains the first instalment of our new medical ethics “soap” Eyewitness in Erewhon academic hospital

So, if you think that moral philosophy is too dry and complicated click on http://jme.bmj.com/cgi/content/full/35/7/400

The Institute of Medical Ethics is currently revising the Core Curriculum in Medical Ethics and Law. This is arguably the only document laying out in any kind of detail what medical students in the UK should learn about ethics in medical school, and is therefore not unimportant!

A consultation on the revision in now open (until 31.07.09) and the draft Core Curriculum and consultation document can be found at: http://www.instituteofmedicalethics.org/edu_consult.php

So, provide your comments now to the IME or forever be silent (or at least be silent until the next revision).

Rowan Williams, Vincent Nichols and Jonathan Sacks wrote to the Telegraph on Tuesday to voice opposition to the Coroners and Justice Bill currently making its way through Parliament.  They allege that the amendment dealing with assisted suicide introduced by Lord Falconer (and reproduced here, on the Dignity in Dying website) is a step on the road to legalisation of euthanasia:

Now, by way of an amendment to the Coroners and Justice Bill, the legality of assisting people to end their own lives is once again to be debated. The proposed amendment seeks to protect from prosecution those who help friends or relatives to go abroad to commit suicide in one of the few countries where the practice is legal.

It would surely put vulnerable people at serious risk, especially sick people who are anxious about the burden their illness may be placing on others. Moreover, our hospice movement, an almost unique gift of this country to wider humankind, is the profound and tangible sign of another and better way to cope with the challenges faced by those who are terminally ill, by their loved ones and by those who care for them.

This amendment would mark a shift in British law towards legalising euthanasia. We do not believe that such a fundamental change in the law should be sought by way of an amendment to an already complex Bill. It should be rejected.

I’m not backwards in coming forwards in my support for the legalisation of euthanasia - but the C&J Bill, if it really is a step in that direction, is a very small one indeed.  So, while the Bill is very compex - “sprawling” would be a better word - that the amendment concerning assisted suicide is really not nearly as big a deal as I think the trio makes out.  Nor is it clear to me that there would be any greater risk to the vulnerable generated by the Bill than there is already.

On top of that, it’s curious how these men of the cloth have very little regard for the plight of those who are not vulnerable - for those, that is, who have simply had enough and would like help in bringing about an end to a life that is no longer worth the fight.

Little regard?  What about the reference to hospices?  Well, that’s just it.  Hospices are great things - but the letter commits the fallacy of thinking that hospices count as a cure-all for the distress of the dying.  They aren’t.  Some people have just had enough, and pointing out how great the hospice movement is misses the point, because for them, hospice treatment would not be the better option.  Worse, to shunt people towards hospices when hospice care is not what they want is good neither for the patient nor the hospice - and it ignores the distinct possibility that the people who are being so shunted are, by the letter’s own lights, likely to be vulnerable.  If it’s the unwelcome pressure that is the backbone of the Archbishops’ and Rabbi’s concern, then pressuring the ill into a care pathway that they do not want seems like a very strange way of going about things indeed.

Just as a point about the rhetorical strategy adopted, I’d add to these points that using the word “Surely” is frequently a shorthand for “I have this gut feeling but I can’t be bothered trying to present an argument for its plausibility” - and the use of the word in the letter here strikes me as conforming to the rule.  And the patriotic appeal to the “almost unique gift of this country to wider humankind” (is that “almost unique” as in “not unique”, then?) is simply nauseating.

Incidentally, a letter to The Times from a number of members of the House of Lords deals with the possible legal and jurisprudential implications of the amendments.  It’s still against the amendments - but it is so in a much more considered manner.

Wouldn’t you know it, my favourite religious commentator (and I favour one religious commentator over another in the sense that I favour a hangover over a migraine or burst aneurysm) George Pitcher has weighed into the prayer on the wards coverage.

Guess what?  His opinions aren’t impressive. more…