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R-E-S-P-E-C-T

24 Dec, 15 | by Iain Brassington

Here’s an intriguing letter from one John Doherty, published in the BMJ yesterday:

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes, but such constructs are culture bound.

When I worked in outback Australia the patients called me “Mate,” which is what I called them.

They still wanted me to be in charge.

Intriguing enough for me to go and have a look at what this Kennedy person had written.  It’s available here, and the headline goes like this:

The Title “Doctor” in an Anachronism that Disrespects Patients

Oooooo-kay.  A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all.  (Don’t ask me why I detest that so; I don’t know.  It’s just one of those things that I will never be able to tolerate, a bit like quiche.)  But let’s see…  It’s not a long piece, but even so, I’ll settle for the edited highlights: more…

Pro-Lifers’ Arguments Might be their Greatest Gift to Pro-Choicers

19 Dec, 15 | by Iain Brassington

Abortion is always going to be a controversial topic.  For what it’s worth, I hold that there’s nothing wrong with it.  That’s me speaking from my habitual non-consequentialist position.  From a more utilitarian perspective, I’m willing to concede that, given the choice between world A, in which abortions happen, and world B, in which they don’t because noone gets pregnant without wanting it, and everyone is perfectly happy to continue with her pregnancy, A is worse.  But A is nevertheless a whole lot less bad than world C, in which women are compelled to continue with pregnancies they don’t want.  In other words, there’s no need or desire for abortion in super-happy-fluffy world, and super-happy-fluffy world is better than the real world – but we live in the real world, and having abortions available makes the real world better than it could be.

I’d like to think that I’m doughty enough to have my mind changed on this, though.  Should someone have a really good argument for the wrongness of abortion, or the overwhelming badness, I’d like to think that I could be persuaded – that I’d let the argument go wherever it takes me.  I think that that’s just intellectual honesty.  It’s just that I have yet to come across an argument that I find persuasive, and I don’t even know what such an argument would look like.

What I can say is that, while I find even the best pro-life arguments unpersuasive, some are worse than others, though.  There’s a guy who keeps posting to the Bioethics Facebook group with links to lamentably bad arguments.  And, of course, there’s the CMF.

On their blog, Philippa Taylor has been getting herself into a tizzy about the recent ruling that Northern Ireland’s very restrictive laws contravene human rights legislation, and suggests that there is a whole range of reasons why the law should not be changed there.

Let’s have a look… more…

Stop What You’re Doing: This is Important.

14 Oct, 15 | by Iain Brassington

I’d not realised it, but the latest iteration of the erstwhile Medical Innovation Bill – colloquially known as the Saatchi Bill – is up for debate in the Commons on Friday.  This is it in its latest form: to all intents and purposes, though, it’s the same thing about which I’ve blogged before.

In a nutshell, the Bill does nothing except remove protections from patients who would (under the current law) be able to sue for negligence in the event that their doctor’s “innovative” treatment is ill-founded.

Much more articulate summaries of what’s wrong with the Bill can be found here and here, with academic commentary here (mirrored here on SSRN for those without insitutional access).  There have been amendments to the Bill that make the version to be discussed on Friday slightly different from that analysed – but they are only cosmetic; the important parts remain.

Ranged against the Bill are the Medical professional bodies, the personal injuries profession, patient bodies, and research charities.  In favour of the Bill are the Daily Telegraph, a few people in the Lords who should know better (Lord Woolf, Lady Butler-Sloss: this means you), and Commons MPs who – understandably – don’t want to be seen as the one who voted against the cure for cancer.

Gloriously, Christ Heaton-Harris, who introduced the Bill, did so only after winning the ballot for Private Members’ Bills.  In a nutshell, he was allotted Parliamentary time, and then began the process of wondering what to do with it – which suggests that even the Bill’s sponsor doesn’t have a burning commitment to the cause – or, at least, didn’t when he took it on.

Still, the Bill has the support of Government; as it stands, there’s a good chance that it’ll pass.

SO: Take a few minutes to look up your MP’s email address – you can do that by following this link – and drop him/ her a line to encourage them to vote against the Bill.

Do it.

Psychology Is not in Crisis? Depends on What You Mean by “Crisis”

3 Sep, 15 | by bearp

By Brian D. Earp
@briandavidearp

*Note that this article was originally published at the Huffington Post.

Introduction

In the New York Times yesterday, psychologist Lisa Feldman Barrett argues that “Psychology Is Not in Crisis.” She is responding to the results of a large-scale initiative called the Reproducibility Project, published in Science magazine, which appeared to show that the findings from over 60 percent of a sample of 100 psychology studies did not hold up when independent labs attempted to replicate them.

She argues that “the failure to replicate is not a cause for alarm; in fact, it is a normal part of how science works.” To illustrate this point, she gives us the following scenario:

Suppose you have two well-designed, carefully run studies, A and B, that investigate the same phenomenon. They perform what appear to be identical experiments, and yet they reach opposite conclusions. Study A produces the predicted phenomenon, whereas Study B does not. We have a failure to replicate.

Does this mean that the phenomenon in question is necessarily illusory? Absolutely not. If the studies were well designed and executed, it is more likely that the phenomenon from Study A is true only under certain conditions. The scientist’s job now is to figure out what those conditions are, in order to form new and better hypotheses to test.

She’s making a pretty big assumption here, which is that the studies we’re interested in are “well-designed” and “carefully run.” But a major reason for the so-called “crisis” in psychology — and I’ll come back to the question of just what kind of crisis we’re really talking about (see my title) — is the fact that a very large number of not-well-designed, and not-carefully-run studies have been making it through peer review for decades.

Small sample sizes, sketchy statistical procedures, incomplete reporting of experiments, and so on, have been pretty convincingly shown to be widespread in the field of psychology (and in other fields as well), leading to the publication of a resource-wastingly large percentage of “false positives” (read: statistical noise that happens to look like a real result) in the literature.

more…

“Our lives are not actually our own”

23 Jul, 15 | by Iain Brassington

Long-term readers of this blog will know that, every now and then, I have a look at the CMF’s blog.  This is largely because of my interest in the ethics of assisted dying, and the blog is actually a pretty good way into developments on the other side of the lines.  There is rarely, if ever, anything new produced that’d move the argument on – but then, those of us who’re sympathetic to legalisation really aren’t doing any better.  It’s become rather a sterile debate.

I do tend to blank out the apologetics; bet every now and again, something catches my eye: a part of this recent post, about the latest attempt to introduce an assisted dying Bill into Parliament, is one such.  There’s a part where Peter Saunders claims that the Sermon on the Mount moved away from a literal take on the prohibition of murder to something more in keeping with the spirit of the law.  This, though, prompts a question for me: why can’t we accommodate a person’s desire to die within the general law against killing?  Might that desire mean that assistance is properly described as something other than murder?  It is tempting to infer from what Saunders says elsewhere that he is at least not too worried about some forms of intentional killing: writing about the Kermit Gosnell story a couple of years ago, his headline noted that Gosnell may face the death penalty – but the body text did not mention that at all, let alone take a position on it.  Yet if all deliberate killing is so straightforwardly wrong, we might expect that killing at least to be noted.  If deliberate killing by means of the death penalty doesn’t raise a peep of objection, then we might wonder why assisting in someone’s death at that person’s behest is more of a worry.

Saunders does have an answer to this query, though: more…

On the other hand…

20 Jul, 15 | by Iain Brassington

… the phenomenon of apologising for the wrong thing comes alongside people taking umbrage at the wrong thing.  Last week, the BMJ ran a head-to-head feature on the “question” of whether doctors should recommend homeopathy.  This was the latest in a series of articles in which a question is posed, apparently strictly on the understanding that it’ll accommodate a polarised debate, and one person is invited to give a “yea” response, and another to give “nay”.  I won’t bother here with a screed about homeopathy: Edzard Ernst does a good job in the BMJ piece, as have many others across the blogosphere.  (You could do worse, for example, than to have a wander through the Anomalous Distraction blog, which is written by an ex-schoolmate of mine, and which also has lots of pretty pictures of proteins and things.)  Since it’s a nice day, and I’m in a reasonably good mood, I’ll even admit that when Hahnemann was working, something like homeopathy was probably as good a punt as anything else that medicine had to offer.  But… y’know.

Aaaaaanyway…  A rather angry letter appeared.  I think it’s worth examining, because it makes a number of normative and value claims; and if norms and values aren’t the meat and veg of an ethicist’s life, then we might as well go home. more…

Apologising for the Wrong Thing

11 Jul, 15 | by Iain Brassington

A little addendum to yesterday’s monster post.

Ivan Oransky reports that, before deleting her Twitter account, Hope Amantine had apparently also said in a tweet that the story was “not meant to offend”.  I’ve noticed that a lot recently: a person does something wrong, is publicly called out for it, and apologises for any offence caused.  Greenpeace apologised for any offence caused when they trampled over the Nazca lines.  Gary Barlow apologised for any offence caused by the stories about his tax-dodging.  (Not for offence caused by tax dodging, but for offence caused by the world having come to know of it, natch.)

I hate it when people say that.

It reduces moral discourse to one of whether or not Smith was sufficiently courteous.  Moral discourse is richer than that.  Hell, moral discourse has got almost nothing to do with that.

More, I doubt anyone was offended in any of those cases.  That wasn’t the problem.  Lying was; trampling humanity’s patrimony was; dodging tax was.  Apologising for causing offence is a non-apology, and leaves the real moral problem utterly unremarked.

I just wanted to get that off my chest.  As you were.

Bad Surgeons and Good Faith

10 Jul, 15 | by Iain Brassington

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear.  It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links.  It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going.  It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted atKevinMD.com, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today.  This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear.  That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble.  Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow.  I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me.  This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole.  No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

[…]

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

[…]

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment.  However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now.  I’ll also note that I can’t check the flow of the original post, because it no longer exists.  Indeed, Hope Amantine’s whole blog would seem to have been taken down.  In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more.  This is noteworthy, because, as I said, the OP has now gone.  If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone.  Where it was, there’s this message: more…

On Being a Hypocrite

1 Jul, 15 | by Iain Brassington

A piece appeared in The Atlantic a few days ago that aims to prick the perceived bubble of professional ethicists.  In fact, the headline is pretty hostile: THE HYPOCRISY OF PROFESSIONAL ETHICISTS.  Blimey.  The sub-headline doesn’t pull its punches either: “Even people who decide what’s right and wrong for a living don’t always behave well.”

I know that headlines are frequently not written by the person whose article they head, and so these won’t tell us much about the article – but, even so, I’m beginning to twitch.  Do I decide what’s right and wrong for a living?  I don’t think I do.  I possibly thought that that’s what an ethicist does when I was a fresher, or at school – but I’m not certain I did even then.  And even if I did, I discovered pretty quickly that it’s quite a bit more complicated than that.  For sure, I think about what’s right and wrong, and about what “right” and “wrong” mean; and I might even aspire to make the occasional discovery about right and wrong (or at least about how best to think about right and wrong).*  But as for deciding what is right and wrong?  Naaaah.

Anyway: to the substance of the piece, which – to be fair – is more moderate in tone, pointing out that “those who ponder big questions for a living don’t necessarily behave better, or think more clearly, than regular people do”.  That’s probably accurate enough, at least a good amount of the time.  I’d like to think that I’m thinking better about a particular problem than most people when I’m working on it; but I’m also thinking better about in that context than I would be at other times.  (Ask me about – say –  genetic privacy while I’m drafting a section of a paper on genetic privacy, and I’m your man.  Ask me while I’m making pastry… not so much.)  If we allow that I’m better at dealing with (a) specific moral question(s) while “on duty”, that won’t mean I’m not susceptible to the same intellectual shortcuts and fallacies as everyone else at least most of the rest of the time.  I’m probably almost as susceptible to them even when I am on duty.  I’d assume that the same applies to others in the profession, too.

The article does make great play of the apparent inconsistencies between what ethicists say and what they/ we do.  So there’s the finding about how many more say that eating meat is morally problematic than actually avoid it, and the chestnut about how ethics books are the ones most frequently stolen from libraries.**  At least there are decent sources cited – peer-reviewed papers like this one that are philosophically informed, to boot.

So: ethicists aren’t reliably better behaved than others.  I don’t think that should surprise us, though.  But, there’s a couple of questions into which we might still want to dig more deeply. more…

Flogging and the Medic

3 Mar, 15 | by Iain Brassington

You must, by now, have heard of the Saudi Arabian blogger Raif Badawi.  Just in case you haven’t (really?), here’s a potted biography: having set up the secularist forum Free Saudi Liberals, he was arrested for insulting Islam and showing disobedience.  Among the formal charges he faced was one for apostasy, which carries the death penalty in Saudi.  The apostasy charge was dropped, but he was convicted on other charges and sentenced to seven years in prison and 600 lashes.  He appealed, and this sentence was changed: it became 1000 lashes and 10 years in prison.  Why?  Does it matter?  Because Saudi Arabia.  The latest update is that the apostasy charge may be renewed, so for a second time, he faces beheading.  Part of the evidence against him is that he “Liked” a post on a Facebook page for Arab Christians.  (Remember: Saudi is one of our allies against religious extremism.)

The lashes were to be administered in batches of 50, weekly, after Friday prayers.  As I write this, he has only been flogged once; doctors have attested that he is not well enough to be flogged again.  And – with thanks to Ophelia for the link – it’s  not hard to see why:

Dr Juliet Cohen, head of doctors at Freedom from Torture, explained: “When the cane strikes, the blood is forced from the tissues beneath… Damage to the small blood vessels and individual cells causes leakage of blood and tissue fluid into the skin and underlying tissue, increasing the tension in these areas.

“The more blows are inflicted on top of one another, the more chance of open wounds being caused. This is important because they are likely to be more painful and at risk of infection, which will cause further pain over a prolonged period as infection delays the wounds’ healing.”

There is also the long-term damage done to the victim’s mental health caused by flogging.

“Psychologically, flogging may cause feelings of fear, anxiety, humiliation and shame. Anticipation of the next scheduled flogging is likely to cause heightened emotions especially of fear, anxiety and difficulty sleeping… pain and fear together over a prolonged period have a deeply debilitating effect and recovery from such experiences may take considerable time,” said Cohen.

At the beginning of February, Vincent Iacopino had a post on the main BMJ blog in which he claimed that health professionals should play no part in Badawi’s flogging: more…

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