You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our Group site.

Bye-Bye Saatchi Bill?

1 Mar, 15 | by Iain Brassington

It would appear that Lord Saatchi’s Medical Innovation Bill is toast.

The Lib Dems, who are reportedly the ones to have vetoed it, are nevertheless being mealy-mouthed about something they should be proclaiming from the rooftops: the Bill is/ was needless at best, and possibly dangerous.  But, hey: there’s an election coming up, and cancer treatment is politically important; meanwhile, the party isn’t popular, and could probably have expected a set of “Lib Dems veto miracle cure” headlines had they made that move.

Which, when you read the Graun‘s article, isn’t a million miles away from Saatchi’s response:

“By killing the bill they have killed the hopes of thousands of cancer patients. It is as simple as that. Nick Clegg has handed down a death sentence to cancer patients.”

Which is, of course, untrue.  But, hey: whatever else he may be, Saatchi’s a great ad-man, and there’s an election coming up…

Autonomy and the Circumcision Wars

27 Feb, 15 | by Iain Brassington

Guest Post by Akim McMath

In December of last year, the Centers for Disease Control and Prevention (CDC) released its proposed new recommendations on male circumcision.  The verdict?  Circumcision provides major benefits with minimal risks.  These benefits accrue whether circumcision is performed in infancy or later on in life.  Circumcision may even help to stem the HIV epidemic in the United States.  Perhaps you should do something about that foreskin.

The resulting firestorm was swift, fierce, and predictable.  Critics of infant circumcision blasted the CDC, accusing it of trampling the child’s right to bodily integrity.  Defenders of circumcision fired back, extolling the prophylactic virtues of the procedure.  Subtle questions about autonomy were lost in the maelstrom.  Yet these questions lie at the heart of the conflict, as I suggest in a new article.

Let’s look more closely at the debate over circumcision and HIV.  Defenders of circumcision tout studies showing that circumcision reduces female-to-male sexual transmission of HIV.  Critics retort that there exists a more effective and less drastic means of achieving the same end – namely, condoms.  Perhaps, concede the defenders, but many men don’t use condoms consistently and effectively – hence the enduring problem of STIs.  That’s their choice! say the critics.  So? say the defenders.  And so on, ad infinitum.

The foregoing squabble is essentially a disagreement about autonomy. more…

Does religion deserve a place in secular medicine?

26 Feb, 15 | by bearp

By Brian D. Earp

The latest issue of the Journal of Medical Ethics is out, and in it, Professor Nigel Biggar—an Oxford theologian—argues that “religion” should have a place in secular medicine (click here for a link to the article).

Some people will feel a shiver go down their spines—and not only the non-religious. After all, different religions require different things, and sometimes they come to opposite conclusions. So whose religion, exactly, does Professor Biggar have in mind, and what kind of “place” is he trying to make a case for?

more…

Physicians and Euthanasia: What about Psychiatric Illness, Dementia and Weltschmerz?

18 Feb, 15 | by BMJ

Guest Post by Eva Bolt

In the Netherlands, requests for euthanasia are not uncommon. A physician who grants a request for euthanasia in the Netherlands is not prosecuted if the criteria for due care (described in the Euthanasia Act) are met. An example of one of these criteria is the presence of unbearable suffering without prospect of improvement. Almost all physicians in the Netherlands can conceive of situations in which they would perform euthanasia. However, each request for euthanasia calls for careful deliberation. When confronted with a request, a physician needs to judge the situation from two perspectives. The first is the legal perspective; would this case meet the criteria for due care? To judge this, a physician can fall back on the description of the Euthanasia Act and receives help from a consulting physician. The second perspective is personal; how does the physician feel about performing euthanasia in this situation? Is it in line with his personal values?

Our study shows that cause of the patient’s suffering is one of the aspects that influence the physician’s decision on euthanasia. This is interesting, because the Dutch euthanasia act does not make a distinction between different diseases. In case of suffering with a clear physical cause like cancer, most physicians can conceive of performing euthanasia. However, there are also people who request for euthanasia without suffering from a severe physical cause. In these cases, there are not many physicians who would consider complying with this request. As a consequence, people suffering from a psychiatric disease and early stage dementia with a euthanasia wish will rarely find a physician who would grant their euthanasia request. The same is true for people who are tired of living but who do not suffer from a severe physical disease. Also, most physicians will not consider following advanced euthanasia directives asking for euthanasia in case of advanced dementia.

Concluding, while most Dutch physicians can conceive of granting requests for euthanasia from patients suffering from cancer or other severe physical diseases, this is not the case in patients suffering from psychiatric disease, dementia or being tired of living. This distinction is partly related to the criteria for due care. For instance, some physicians describe that it is impossible to determine the presence of unbearable suffering in a patient with advanced dementia. Other explanations for the distinction are not related to the criteria for due care. For instance, it is understandable that physicians do not agree with performing euthanasia in a patient with advanced dementia who does not fully understand what is happening, even if the patient has a clear advanced euthanasia directive.

Each physician needs to form his or her own standpoint on euthanasia, based on legal boundaries and personal values. We would advise people with a future wish for euthanasia to discuss this wish with their physician in time, and we would advise physicians to be clear about their standpoint on the matter. This can help to prevent disagreement and disappointment.

Read the full paper here.

 

Strange Happenings in Belgium

3 Feb, 15 | by Iain Brassington

There’s a part of me that recognises this story as having been in the news before – but I don’t think I’ve written on it, so here we go.  It’s from the Telegraph, under the headline “Son Challenges Belgian Law after Mother’s ‘Mercy Killing'” – which is a reasonably pithy summation of what’s at issue.  A man, Tom Mortier, is attempting to bring a case before the European Court of Human Rights that would have Belgian laws on euthanasia scrutinised and – he hopes – declared contrary to the ECHR:

A Belgian man is going to the European Court of Human Rights after his depressed mother was killed by lethal injection under the country’s liberal euthanasia laws. […]

Mr Mortier is trying to take his mother’s case to the Strasbourg court under the “right to life” legislation in the European Convention of Human Rights. He hopes, at the very least, to trigger some debate in his country, and secure greater oversight in the way the existing rules are applied.

OK – so it’s not clear whether he’s actually got the Court to agree to hear his case (which is what “going to the ECtHR” suggests in ordinary usage), or whether he’s still attempting to get it to agree to hear it.  If it’s the latter, then he might be going to the ECtHR in the sense of being physically present – but that’s not going to achieve much.  The Telegraph isn’t clear on this.  Oh, well.  But is there anything of substance to his case?  It might have substance and still fail, of course – it’s perfectly possible for a court to say that they can see a person’s point, but that it’s not sufficiently powerful; but if it has no substance, then it ought to fail.

Based on the Telegraph‘s report, it seems that there really isn’t much substance to it.  This is not to say that there’s none – but there’s not much.  And, as we’ll see, it’s a bit strange in some ways. more…

In the Journal: The Ethics of Molecular Memory Modification

8 Jan, 15 | by BMJ

Guest post by Katrina Hui

What if memories could be enhanced or erased, not through traditional pharmaceuticals, but directly, through manipulation of the molecular processes that govern memory?

Several years ago, scientists thought they had found a single molecule believed to be the key to memory editing. This molecule, called protein kinase Mζ (PKMζ), appeared to play a crucial role in the preservation of specific long-term memories. Though its actual molecular mechanism remains unclear, the discovery demonstrates that memory is governed by molecular processes and can possibly be manipulated through such means. Though research is still in its early stages, the example of molecular memory modification raises some interesting questions about the ethics of memory that merit consideration.

According to current frameworks of memory, memories are made temporarily unstable after recall and are “rewritten” each time they are summoned before being stored again. Early research seemed to indicate that specific memories could be enhanced by increasing levels of PKMζ, then recalling the target memories. On the flip side, memories could be “erased” by interfering with the expression of the molecule at a similar point in time in the recall process, thus destabilizing and preventing the re-storage of previously held memories. To add to the excitement, modifying specific memories with PKMζ seemed to have few side effects on other memories or processes.

However, more recent research has called into question PKMζ’s involvement in long-term memory storage and maintenance, and it remains unclear if PKMζ really is as powerful as it was once thought to be.

Nonetheless, the possibility of manipulating memory through molecular means will continue to be investigated. Molecular memory modification (MMM) provides a new perspective on some unresolved ethical questions regarding memory. For instance, is there a “the duty to remember” certain valuable memories? This duty could have a place in the courtroom, for example, where eyewitness testimony, while notoriously unreliable, is also frequently used and sometimes essential. On the other hand, while requiring or perhaps even forcing people to remember might appeal to those with an authoritarian bent, in reality, the mechanism of action of MMM in particular requires active recall from the participant, illustrating how subject participation, a previously neglected topic in ethical debates about memory, could be essential.

More broadly, the example of MMM illustrates that the idea of “enhancing” memory, rather than a monolithic process, is multifaceted. The folk intuition of enhancing memory, generally implies remembering more, for a longer time. However, a closer examination of the molecular processes underlying memory functions, the term “enhancement” is shown to be vague, as there are many dimensions along which memory could be enhanced, such as fixing incorrect associations, eliminating temporary memory blocks, or even erasing memories in cases such as Post-Traumatic Stress Disorder. What ethical concerns are relevant and we mean when we use the term “enhancement” ultimately depends on how memories are altered. As research continues, new mechanisms for improving memory will emerge, and more precision about the ethical calculus will be required.

 

Read the full paper here.

Free Speech and the CMF

5 Jan, 15 | by Iain Brassington

Despite a slight reticence when it comes to quoting Mill approvingly, I do have to admit that sometimes he does articulate a thought clearly and pithily, and sometimes it’s a thought in which all right-thinking people ought to see the merit.  Like, for example, this, from the opening paragraph of chapter III in On Liberty:

An opinion that corn-dealers are starvers of the poor, or that private property is robbery, ought to be unmolested when simply circulated through the press, but may justly incur punishment when delivered orally to an excited mob assembled before the house of a corn-dealer, or when handed about among the same mob in the form of a placard.

The general point ought to be clear: whatever your prima facie right to say what you want, it doesn’t mean there’re no limits on the circumstances in which it can be said.  Mill is concerned about excitable mobs, but the basic principle could, I think, be extended without too much difficulty: if your free speech causes severe inconvenience or distress or inconvenience to others, you ought to moderate it or take it elsewhere.  Having the freedom to make a point is, and ought to be, compatible with others’ freedom not to be bothered by your making it.

I think that that’s pretty reasonable: your liberty is one thing, but it’s not the only thing.  There’s the liberty of others to avoid you to consider, for one thing.  Pushing things a bit further, we might be inclined to argue that liberty is a good because of its relationship with, and contribution to securing, the general welfare – but that there’re other things that contribute to that, too, which therefore ought also to be considered good things worth protecting.  Basic civility might be one such good.  Mill doesn’t make much of that, but there’s no reason why we couldn’t say that that’s a good worth preserving – and why we couldn’t fit that into a modified Millianism, should we so desire.  On Liberty isn’t Holy Writ: its good ideas might be extendable.

Keep that in the back of your mind for a moment.

Many readers will have seen the video posted a few weeks ago by Sunny Hundal in which a woman berates a group of pro-life protesters outside an abortion clinic.  The background detail is that there is reportedly an increasing prevalence in the UK of pro-life protesters congregating outside such clinics.  Sometimes those protests take the form of prayer vigils; sometimes – as in the video – they’re more direct, with posters of babies and foetuses, sometimes quite graphic.  Occasionally there’s barracking; I think that this is more common in the US, but I suspect that the trend may appear here soon enough, not least because these things do tend to escalate.  Yvette Cooper has apparently mulled the idea of buffer-zones around abortion clinics, within which pro-life protesters would not be allowed to protest.

Writing on the CMF blog, Cheryl Chin is not happy about Cooper’s idea; she thinks that “It would appear that once again, liberties are under threat of being curtailed by the proponents of the pro-abortion brigade”.* more…

A Bit More on Nonhuman Persons

23 Dec, 14 | by Iain Brassington

A bit of a followup to my last post: sometimes, nonhumans are granted habeas corpus:

Orangutans have been granted the status of “non-human persons” with legal rights in a landmark court ruling in Argentina. The decision clears the way for Sandra, a shy 29-year-old, to be freed from Buenos Aires Zoo after spending her entire life in captivity. […]

The ruling came after animal rights campaigners filed a habeas corpus petition – a document more typically used to challenge the legality of a person’s detention or imprisonment – on behalf of the Sumatran orangutan, who was born at a German zoo and was transferred to Buenos Aires two decades ago.

Sandra will, unless there’s a successful appeal, be moved from the zoo to a sanctuary.

In practice, this might not make all that much difference.  She’ll still be confined in a sanctuary; it would be utterly indefensible just to turf her out onto the streets, and she wouldn’t last long.  And in some cases, it’s quite possible that a well-run zoo is the best possible place in which to look after her or others like her.  Zoo, sanctuary: tomayto, tomahto.  Meh.

What matters primarily is that a point of principle is established, and secondarily that there would be some guidance about the kind of facilities that would be minimally decent.  It’s likely to be wholly acceptable, morally and legally, to keep great apes in some form of captivity if it’s in their interests, in rather the same way that we might provide a human child or an adult with an intellectual disability with sheltered or supervised accommodation, and might even limit their time away from it.  (The family home is a kind of sheltered and supervised accommodation!)  If a creature – human or orang or chimp or whatever else – can’t deal with the world around them, that seems to be morally required.  Let’s call this “soft captivity”, as opposed to the “hard” captivity of some zoos, prisons, laboratories, and so on.  The point is that, rather as we wouldn’t deny that a child or adult disabled human is a person and thus protected by the law, it does seem reasonable to extend that protection to members of other species.

I wonder how much further we could push it: it’s one thing to have a great ape in soft captivity for its own protection; and it’s one thing to say that if a great ape is in captivity, it ought to be soft captivity.  But could we make a similar claim about keeping a member of a species in soft captivity for the sake of protecting the species?

Orangs are under threat.  Now, a threat to the species is almost always a threat to the members of the species, too – and so we would almost always be unable to distinguish acting to protect individual orangs and the species as a whole.  But this needn’t be the case.  Imagine that there are two small colonies of the animal left; a genetic bottleneck means that neither is viable on its own, but, if they were combined, the species may be rescued and flourish in the future.  Furthermore, each colony is in a confined area that cannot support a bigger population.  There is no direct threat to either colony, though.  It so happens that a busy road separates the colonies, which means that they are to all intents and purposes isolated.

Would it be permissible to swing into action to take all these orangs into a sufficiently big sanctuary, and maybe to keep them there for the sake of increasing the population?  It wouldn’t obviously be in the interests of any particular living orang; but it could be in the interests of the species.  Even if the captivity is soft, it is still captivity.  Would it be justified?

Part of me thinks that it might be; but this does rely on thinking that the species qua species has a moral value and interest, aside from the value and interest of its members.  And that does seem like a bit of a stretch – especially if (as seems plausible) individual orangs have no concept of species with which they can identify.

 

Admittedly, this isn’t a medical ethics post in the strict sense – but it’s a nice story, so ner.

Rights, Duties, and Species

19 Dec, 14 | by Iain Brassington

A little earlier this year, there was a case brought before the New York courts concerning a chimpanzee called Tommy: the matter was the lawfulness of keeping Tommy confined.  Acting on Tommy’s behalf was an organisation called the NonHuman Rights Project.  The legal documentation filed is available here.  The basis of the case was not so much that Tommy was being harmed by his treatment as that he was wronged by it: to keep a chimpanzee in such conditions s a violation of certain rights, and ought not to be allowed granted a plausible application of habeas corpus, even the most comfortable of cages still being a cage – or so the claim went.  Essentially, the legal question under consideration was this: does a chimpanzee have any of the legal rights that a human has; and, if so, which?

Perhaps predictably, the suit was rejected; Justice Karen Peters found that habeas corpus did not apply to chimpanzees, and the other judges agreed.  Whatever legal restrictions there may be on primates, they do not fall under the rights paradigm.

The reasoning here strikes me as being a touch… well, wonky.

A significant part of the argument revolves around what kind of thing counts as a person, and so ought to have the rights of a person.  It’s not difficult to see why this is important in bioethics, because it’ll impinge on what happens in laboratories, and – potentially – on what happens in a human uterus or neonatal unit.  If the definition of “person” extends to chimps, the suit goes, then habeas corpus should apply.  If it doesn’t, then there’s no reason to suppose that it would.  The judgement is that personhood does not apply to chimps.  The term has, the court found, never been explicitly defined; and habeas corpus relief has never been granted to any nonhuman.  This wouldn’t mean that it shouldn’t be; the question then would move on to examining the ought question.

For Peters, there is no ought here, and this conclusion is based on an appeal to a particular definition of “person”.  It’s worth quoting the ruling at length here: more…

Would the Falconer Bill Increase the Suicide Rate?

8 Dec, 14 | by Iain Brassington

This is just a quickie – I promise.

A tweet this morning from Kevin Yuill raises what he sees as a scary prospect:

The Falconer bill will treble suicides amongst the terminally ill, according to Dignity in Dying. Is that what we want? Reject this bill.

He bases his claim on two things, both from Dignity in Dying: first, this document, which estimates that 332 of the 4513 suicides in the England in 2012 (p 1); second, this document, which estimates that there would be 1000 assisted deaths in England and Wales under an Oregon-like law (p 10).

Dignity in Dying has disputed his interpretation of the figures, and I’ve spotted a couple of problems with them.  Some of those who committed suicide while terminally ill may not have committed suicide because they were terminally ill; that might skew the figures.  So might the leap from “England” to “England and Wales”.  And, most importantly, we don’t know how many people would have killed themselves but for the current legal setup.  (Neither does DiD.)  Hence the trebling rate is at best an educated guess, but probably not even that.

But I’m going to allow that Yuill’s interpretation is reasonable for the sake of the argument.  I’ll also allow – in keeping with the Falconer Bill – that all legal assisted deaths in the UK would be assisted suicides, rather than allocides.  It occurs to me, though, that his claim still doesn’t do quite what he thinks it does, or wants it to do.  Importantly, he assumes that an increase in suicides would be a bad thing – and that DiD has therefore blundered in admitting that the rate would rise.

I’m not so sure.  Suicide may be a bad thing, but it isn’t necessarily bad in the way Yuill thinks.

Here’s one consideration.  Assume that some people who are terminally ill would take assistance to kill themselves were it available, but don’t kill themselves under the current regime.  Maybe they’re housebound and can’t procure the means, for example.  Something like the Falconer Bill would make suicide easier for them; and so we’d expect the rate to increase.  But we oughtn’t to forget the alternative, which is not not dying, but dying from a different cause.  This being the case, it isn’t necessarily going to matter too much to a defender of assisted dying that the suicide rate would increase, since his whole position would be that being able to end your own life in the way you choose is preferable to dying without any control.

In other words, the defender of assisted dying could, I think, accept that the suicide rate’d increase, and point out that, in a way, that is the whole point.  An increase in the suicide rate may be, in a certain light, a welcome development, not something to be feared.  I don’t know whether DiD would endorse that view, but it seems coherent, and not obviously vicious; hence Yuill seems to have committed an ignoratio elenchi.

And this leads to another consideration, which is that you don’t – as far as I can see – have to deny the badness of suicide to defend assisted dying.  All you have to think is that there are circumstances in which it’s less bad than the alternative.  Being the better option doesn’t mean it’s a good option, in just the same way that amputation of a limb may be preferable to dying from gangrene without that meaning that amputation is a particularly good thing in its own right.

Even if Yuill’s use of the figures is statistically sound, his claim doesn’t have any of the normative punch he thinks it does.

 

Latest from JME

Latest from JME

Blogs linking here

Blogs linking here