Via MedicalTranscription.net, here’s a rather fabulous little infographic about the value – well, the price – of transplant organs.

Finder’s credit goes to Otago’s Bioethics Centre.

Wow.

Steve Fouch has, on the Christian Medical Fellowship’s blog, offered advice on how to vote in the BMA ballot on industrial action.  Now, Fouch isn’t the same as the CMF, and I don’t suppose what he writes indicates the CMF’s position any more than what I write here represents the BMJ’s.  Even so, what he suggests is pretty remarkable; and, in keeping with a lot of stuff from the CMF, the general advice is that the solutions to all modern problems can be found in a set of writings edited and selected – highly selected – around 1900 years ago by men with beards.

Notably,

I would lay out the following biblical framework for thinking through the way we approach this dispute:

Firstly, industrial relations:

Col 3:22 ‘Slaves obey your earthly masters in everything’

1 Peter 2:18 ‘Slaves, submit yourselves to your masters with all respect, not only to those who are good and considerate, but also to those who are harsh.’

1 Timothy 6:1 ‘Let all who are under a yoke as slaves regard their own masters as worthy of all honour, so that the name of God and the teachings may not be reviled’.

Philippians 2:14-16 also encourages us to not be grumblers and moaners in the workplace, but to be a positive influence.

It is clear that Paul and Peter, in writing these messages were urging slaves not just to do their jobs, but to be exemplary, going over and above the call of duty, and to have a positive attitude and spirit in so doing. While this is referring to the institution of slavery, the principles apply equally to modern employment.

Do they apply equally to modern employment?  There’s no obvious reason to suppose that they do – not least because modern employment practices don’t generally rely on slavery.  more…

Hattip to Nathan Emmerich for speculating about this on Facebook and then blogging about it here: Organ Donation: Why isn’t there an App for that?

There are a number of ways you can volunteer to donate your organs when you die in the UK, you can sign up when you get a drivers license, you can even sign up when you get a rewards points card at Boots – a pharmacy chain.

You can now sign up online to donate your organs directly at the NHS website, but as Emmerich points out there seems to be a gaping hole in the current system’s security. It appears that the only information you have to provide to prove your identity is your name and date of birth – both relatively easy pieces of information to find out. This means that you could sign up anyone as long as you have this information. They do send out a letter to confirm their consent but seeing as you can enter any address this doesn’t seem to be likely to prevent potential abuses.

I’m honestly surprised I haven’t heard about this already from the Daily Mail, it seems such an obvious and easily criticisable mistake for the NHS to make. Perhaps they don’t have any stock images of people looking confused as their organs are being removed…

Still now that we are here let’s discuss organ donation. There is considerable debate about whether we ought to have an opt in or opt out system of organ donation – this appears to be a new option “an others opt you in system…” And there doesn’t seem to be any way to change your mind and opt out using the online system. This seems well short of any appropriate standard of informed consent, or a useful system for organ donation.

Personally I suspect there is much to recommend changing the default setting to organ donation rather than not donating – think of it as nudging if you will. Certainly if this is all that respecting autonomy requires a robust opt out system will not violate it.

That said I suspect rather than concentrating on the head line question of opt in vs opt out, a fair number of lives could be saved simply by refining and improving the current system.

This also seems to present a moral dilemma for any consequentialists out there, think about all the lives you could save by volunteering your friends organs…

So what kind of system should we have for organ donation?

Some very strange papers have just appeared in Bioethics regarding homeopathy.  Not so long ago, the journal published a paper by Kevin Smith that advanced the claim that homeopathy is not only ineffective, but ethically problematic.  The position taken was that homeopathy “ought to be actively rejected by healthcare professionals”, and that it is in fact ethically unacceptable, not least because of concerns about it reducing the likelihood that people would seek effective healthcare, and wasting resources.  The analysis is overtly utilitarian, but I don’t see any particular reason why a non-utilitarian theory wouldn’t come to essentially the same conclusions about using homeopathy, especially by public bodies.  (For example, there seems to be a reasonable justice-based claim that could be made on behalf of taxpayers, that it’s wrong to spend their money on stuff that lacks an evidence base: it should either be redirected to stuff that has evidence in its favour, or refunded.  This doesn’t have to be utilitarian in flavour.) 

But while I have no particular dispute with Smith’s paper, neither do I have any dispute with homeopaths getting a right to reply in the same journal.  They should have this right.  Papers could be wrong or need refining, and disinterested argument is a good way to correct errors.

Still: scientifically speaking, homeopaths have their work cut out.  And without the science, the ethics is going to be tricky. more…

This post is inspired by this excellent and challenging article by Carl Elliot where he asks why should students study bioethics at scandal plagued institutions such as his own University of Minnesota (I said it was challenging).

One of the problem he notes is that bioethicists in scandal plagued departments such as medical schools rarely speak out publicly or critically about the scandals and suggests in this lovely paragraph that there might just be a conflict of interest at play:

“Many university administrators seem to think that leaving a stack of cash on the table for the bioethicists is a good way to make amends for wrongdoing. Bioethicists don’t usually complain.  When the Presidential Commission for the Study of Bioethical Issues looked at the issue of making reparations to victims of unethical research, it suggested that reparations do not necessarily have to mean monetary compensation to victims. Instead, they may mean more funding for bioethics. For example, when the Clinton administration apologized on behalf of the federal government for the Tuskegee syphilis study in 1997, it also announced a grant initiative to establish a bioethics center at Tuskegee University.  Whether the victims of unethical research see a bioethics program as fitting compensation is not for me to say.”

Relatively recently we have seen an explosion of new bioethics centres in the UK, fuelled in part by funding bodies desires to establish Centres of excellence, which saw much funding in bioethics consolidated into very large amorphous grants. I wondered at the time whether this was good for the discipline – since it effectively left isolated ethicists out in the cold in regards to seeking funding.

With no disrespect intended for those in Centres funded in this way it doesn’t seem to me that this has worked as a strategy – those who were doing good work continued to do good work, those who weren’t… So it seems the idea of an Ethics Centre is in twilight, after what happened at Keele, and in other places the idea itself seems to be going out of fashion. I doubt we will see the end of ethics centres altogether, no doubt Oxford will keep inventing new ones to get even more pots of money, and some of the strongly established ones will survive, but will we see new ones? Or more posts at existing ones?

Outside of centres there seem to be three main places where work in bioethics is located in UK universities (I’ve excluded sociology since with rare exceptions most of the work carried out in bioethics by sociologists is either non-normative in nature or at least ought to be non-normative in nature):
1. Medical Schools
2. Law Schools
3. Philosophy departments

And while each of these has strengths they also have significant weaknesses. The first challenge bioethics faces is that it lacks an obvious home in regards to the REF – without a specific category people will tend to be submitted under whichever department they are associated and there are legitimate concerns about whether bioethics will be fairly evaluated under any of these categories.

Medical Schools offer the advantage of being at the coalface – however as Elliot notes this face can be pretty ugly. I know in my times at the coalface I was asked (and refused) to do some fairly questionable things – including trying to bias the outcome of a supposedly independent audit. They can also be academically isolating – unless you are in a centre that is part of a medical school you are unlikely to have colleagues who are directly interested in your research. Even in such a centre you can expect to be a small part of the overall school – the sort of money, respect and influence a bioethics centre can bring in pales in comparison to other units in a medical school typically.

Law Schools are where many of the existing centres are based and can be fruitful homes for bioethics since they facilitate a particular approach to bioethics – namely a case driven legal analysis approach. There can be some strong synergies here between lawyers and philosophers and good collaborative work. However there is also the risk that bioethics is not typically central to the concerns of a law school or more importantly its undergraduate students, so without a strong postgraduate offering it is unlikely that law will be a comfortable home for a bioethicist.

Philosophy departments are where historically most bioethics was based, and given that many approach bioethics from this perspective it provides a natural home for bioethics. Except of course there are worries about how well applied ethics will do in a philosophy REF submission, a risk of being too “philosophical” ie losing touch with the coalface and perhaps a certain amount of snobbishness about the topic area – I’ve heard it suggested by colleagues that the courses I teach mustn’t be as hard as their courses since three times as many students take mine.

So it seems like there isn’t an easy natural home for bioethics – perhaps unsurprising given the inter-Disciplinary nature of the topic area. I have some sympathy for the idea of a virtual centre – where individuals in the institution in different schools or departments form an alliance and come together regularly to discuss papers, apply for grants and work together, but that typically requires some institutional support to make it work.

So what do you think? Where should bioethics be based?

BioNews asked me to write something about Matthew Liao, Anders Sandberg and Rebacca Roache’s paper on engineering humanity to minimise global warming.  I’d been meaning to for a while, so this was the prod I needed.  Anyway: my take on their paper is here; but I thought I’d also reproduce it on this blog.  What follows is the version I submitted; it’s substantially the same, save for a few tweaks that BioNews made to conform with their house style.  (They didn’t like the Latin…)  I am massively grateful to the student who made the point about small people taking more steps to get anywhere.  I’d also like to think that the idea of making people smaller led me to Lilliput, thence to Gulliver, thence to the voyage to Laputa.  It didn’t.  I’m not that clever.  Laputa made its appearance quite unbidden.  But – hey, it works.

 *     *     *     *     *

There’s a part of Gulliver’s Travels where Gulliver visits the grand Academy at Lagado, wherein one of the academicians is trying to derive sunbeams from cucumbers.  It’s tempting to wonder at first glance whether there’s something of the Academy to Liao, Sandberg and Roache’s proposed strategy for combating climate change: that we could engineer humanity to be less of a drain on the environment.  Their paper, “Human Engineering and Climate Change” (forthcoming in Ethics, Policy and the Environment, with a pre-publication version here), has already attracted a reasonable amount of media interest, and it’s not hard to see why.  The headline proposal is that we could engineer people to be smaller, on the grounds that smaller people require less food and fuel: a population that is smaller on the whole would have less environmental impact.  (A small part of this – and I’m genuinely fond of this idea – is that heavier people wear out shoes and carpets more quickly, so are more resource-hungry.  On the other hand, as one of my students has pointed out, short people take more steps to get across the room; the carpet might actually suffer more.  Moreover, a small person has a greater surface-to-volume ratio, and so would lose heat more quickly, possibly requiring more central heating and more food.) more…

Remember a little while ago there was a rash of proposals in the US that’d force women to see a sonogram of the foetus, or to listen to detailed descriptions of it, before having an abortion?

Yeah: them.  Well, via Ophelia, here’s an account of what really happens.

Halfway through my pregnancy, I learned that my baby was ill. Profoundly so. [...] “I’m worried about your baby’s head shape,” she said.  “I want you to see a specialist—now.”

[... B]efore I’d even known I was pregnant, a molecular flaw had determined that our son’s brain, spine and legs wouldn’t develop correctly.  If he were to make it to term—something our doctor couldn’t guarantee—he’d need a lifetime of medical care.  From the moment he was born, my doctor told us, our son would suffer greatly.

So, softly, haltingly, my husband asked about termination.  The doctor shot me a glance that said: Are you okay to hear this now?  I nodded, clenched my fists and focused on the cowboy boots beneath her scrubs.

She started with an apology[...]

That’s not a good start, is it?  An expression of sympathy, maybe.  But an apology?  It’s as if she knows that things are about to get worse.  And they are. more…

I did mention last week that I’d post links to sites that mentioned Giubilini and Minerva’s paper as they crossed my radar; but it turned out very quickly that there’d be no way to keep up.  And, to be frank, a lot of the blogosphere’s response has been fairly scattergun outrage rather than dispassionate engagement with the paper, and directed at Giubilini and Minerva themselves rather than at the argument they put forward.  There’s been much more heat than light.

This is perhaps unsurprising, as considered responses are almost certainly going to take a while to materialise.  However, they have begun to appear.  Here’s the first that I’ve spotted; I’ll post links to more in this thread as and when.  And if any readers have responses on academia.edu or SSRN that they’d like mentioning, or if anyone spots anything of interest, do let me know. more…

When we decided to write this article about after-birth abortion we had no idea that our paper would raise such a heated debate.

“Why not? You should have known!” people keep on repeating everywhere on the web.  The answer is very simple: the article was supposed to be read by other fellow bioethicists who were already familiar with this topic and our arguments.  Indeed, as Professor Savulescu explains in his editorial, this debate has been going on for 40 years.

We started from the definition of person introduced by Michael Tooley in 1975 and we tried to draw the logical conclusions deriving from this premise.  It was meant to be a pure exercise of logic: if X, then Y.  We expected that other bioethicists would challenge either the premise or the logical pattern we followed, because this is what happens in academic debates.  And we believed we were going to read interesting responses to the argument, as we already read a few on this topic in religious websites.

However, we never meant to suggest that after-birth abortion should become legal.  This was not made clear enough in the paper.  Laws are not just about rational ethical arguments, because there are many practical, emotional, social aspects that are relevant in policy making (such as respecting the plurality of ethical views, people’s emotional reactions etc).  But we are not policy makers, we are philosophers, and we deal with concepts, not with legal policy.

Moreover, we did not suggest that after birth abortion should be permissible for months or years as the media erroneously reported.

If we wanted to suggest something about policy, we would have written, for example, a comment related the Groningen Protocol (in the Netherlands), which is a guideline that permits killing newborns under certain circumstances (e.g. when the newborn is affected by serious diseases).  But we do not discuss guidelines in the paper.  Rather we acknowledged the fact that such a protocol exists and this is a good reason to discuss the topic (and probably also for publishing papers on this topic).

However, the content of (the abstract of) the paper started to be picked up by newspapers, radio  and on the web.  What people understood was that we were in favour of killing people.  This, of course, is not what we suggested.  This is easier to see when our thesis is read in the context of the history of the debate.

We are really sorry that many people, who do not share the background of the intended audience for this article, felt offended, outraged, or even threatened.  We apologise to them, but we could not control how the message was promulgated across the internet and then conveyed by the media.  In fact, we personally do not agree with much of what the media suggest we think.  Because of these misleading messages pumped by certain groups on the internet and picked up for a controversy-hungry media, we started to receive many emails from very angry people (most of whom claimed to be Pro-Life and very religious) who threatened to kill us or which were extremely abusive.  Prof Savulescu said these responses were out of place, and he himself was attacked because, after all, “we deserve it.”

We do not think anyone should be abused for writing an academic paper on a controversial topic.

However, we also received many emails from people thanking us for raising this debate which is stimulating in an academic sense.  These people understood there was no legal implication in the paper.  We did not recommend or suggest anything in the paper about what people should do (or about what policies should allow).

We apologise for offence caused by our paper, and we hope this letter helps people to understand the essential distinction between academic language and the misleading media presentation, and between what could be discussed in an academic paper and what could be legally permissible.

Alberto Giubilini and Francesca Minerva

Guest Post by James Wilson

The controversy over the Giubilini and Minerva article has highlighted an important disconnect between the way that academic bioethicists think about their role, and what ordinary people think should be the role of bioethics.  The style of this dispute – its acrimony and apparent incomprehension on both sides – are a sure sign that we as bioethicists need to think harder about what we are doing, and who we are doing it for.

At the heart of tempest has been the authors’ claim that abortion and infanticide are morally equivalent. Nearly everyone will agree that the authors are wrong about this, and that infanticide is and should always remain beyond the pale.

The US Born-Alive Infants Protection Act 2002 stipulates that the category of person – and the full protection due to persons – must be extended to “every infant member of the species homo sapiens who is born alive at any stage of development“.  The deep question – from the perspective of academic ethics – is why every human being that is born alive should count as a person.

Often in bioethics the most difficult task is to articulate just what it is that lies behind the sorts of intuitive moral certainties that we all have: that is, to make clear to ourselves, and to those who are inclined to hold opposing views, just what our confidence in our own intuitive moral judgments is based on.  This is often extremely difficult to do.

Why Some Bioethicists Think that Birth does not Matter

At the heart of Giubilini and Minerva’s claim that infanticide is morally on a par with abortion is the premise birth by itself does nothing to change the moral status of a developing human.

According to them (and like minded philosophers such as John Harris, Peter Singer and Michael Tooley) what makes the difference between a person and something that isn’t a person must be something to do with the capacities and abilities that a person has.  On such views, if we want to say that all human beings should count as persons then we need to provide some account of what feature or features it is that all human beings have that renders it appropriate to treat them as persons.  The feature of being born alive to a human mother does not – according to them – fit the bill.

According to these philosophers, this definition of “person” is both too narrow, and too broad.  It’s too narrow, because it’s clear that there could be intelligent alien species who had the ability to engage in moral thinking; but yet who clearly would not be born to a human mother.  They need not be born at all: perhaps the aliens from the planet Zog assemble themselves out of flatpacks from an interplanetary Ikea.  But so long as they are able to live and to value things as we do, why should we deny them the status of persons?  To do so looks like a human-centred chauvinism, no more than speciesism.

But the feature of being born alive to a human also looks too broad: what if the brain of the infant has been irreparably damaged, so that it will remain in its intellectual functioning at a level far below that of a chimpanzee and will never be able to love, to form plans or even to recognize itself in the mirror?  Why (and in what sense) does an infant like this count as an equal of a fully functional adult?

John Harris has argued that we should strike down the thought that it is being born that makes the difference.  As he once put it, “the geographical location of the developing human, whether it is inside the womb or not, is not the sort of thing that can make a moral difference”.  (Even here, he was careful to clarify – as he has on this blog, that he was neither advocating infanticide, nor arguing for a change in the law.)

A Poor Reply: Banging the Table

The cheapest and easiest response to this challenge is to merely bang the table and assert the sheer obviousness of the difference that birth makes.  As an example of this approach, Richard Nicholson once accused John Harris of indulging in “a philosopher’s mind game”.  He continued, “He is wrong in saying there is no moral change that occurs in the process of birth.  That is a change that is recognised in the law.  Most parents would recognise their views about their newborn baby are considerably different than their views about the foetus in the mother a day earlier.”

All this, one feels, may be true; but it is hardly intellectually satisfying.  Just because most parents would feel differently, it doesn’t in itself follow that they are justified in changing their feelings this way.  It’s weak to counter an argument that puts forward reasons by merely appealing to force of numbers – pointing out that most people judge the same way you do.

Explaining the Significance of Birth

If we want to defend the moral significance of birth, then we need to provide some positive account of why birth matters.  I want to outline very briefly three possible positive accounts.

(1) The infant now counts as a person because he or she is now a separate living entity: he or she is viable and is not dependent on anyone else for existence.

Some worries: it seems that this explanation misfires, because ‘being a separate living entity’ is both too broad, and too narrow, to serve as the feature that makes the difference between a person and a non-person.  It’s too broad because dogs and cats are separate entities in their own right, but this does not make them persons.  But it’s too narrow, because there can be persons who are not viable separate living entities: both of a pair of conjoined twins can count as separate persons, but in a severe case it might be quite impossible for both to be able to survive separation.

(2) The infant was already a person, previously it was lodged in the mother’s body like a guest lodged in a house owned by someone else.

On this view, there were conditions under which it would have been legitimate to expel the foetus despite the fact that it was a person (in circumstances such as those that Judith Jarvis Thomson considers in her famous defence of abortion, for instance). The significance of birth is that all these reasons that the mother may have to abort the foetus are then defeated.

Some Worries: This approach seems initially promising, but it may only push the problem further back: (a) we now need to give some non-arbitrary account of why the foetus was already a person, and how it became a person. (b) On this view it turns out that it isn’t birth that is actually doing the work here in making an entity a person.

(3) Ethical vision beyond explicit arguments

Charles Taylor makes a useful distinction between two different modes of ethical argumentation, which he calls offering basic reasons and articulating a vision of the good.  As he says in Sources of the Self, “It is one thing to say that I ought to refrain from manipulating your emotions or threatening you because that is what respecting your rights as a human being requires.  It is quite another to set out just what makes human beings worthy of commanding our respect, and to describe the higher mode of life and feeling which is involved in recognising this.”

Ethicists often place a very high degree of value on explicitness and arguments from consistency, invoking basic reasons in Taylor’s sense.  A key part of Giubilini and Minerva’s argument has the following structure, for instance:

1. Persons are creatures with feature F.

2. The newborn does not have feature F.

3. Therefore the newborn is not a person.

A large part of the acrimony of the dispute seems to arise from the fact that many feel that to adopt this kind of schema fundamentally misunderstands the foundations of ethical consciousness.  For them, what is foundational is the fragility of the life of the infant, and that once that has been appropriately noticed or articulated, one should be called upon to respond.  So on this view, the answer may not be to describe those valuable features of human beings in terms that are applicable to any potential being at all, but rather to draw attention to just what it is about human being that we mean when we talk about the intrinsic dignity and value of human life.

This is something that is extremely difficult to do within the confines of analytic philosophy.  For such articulation of the phenomenology of our fundamental moral commitments, literature is far more powerful.  I’ll conclude this post with a bit from Tolstoy’s Anna Karenin, which perhaps provides some of this vision.  Levin is struck by wonder at the birth of his son:

Meanwhile, at the foot of the bed, in Lizaveta Petrovna’s skilful hands flickered the life of a human being, like the small uncertain flame of a night-light – a human being who had not existed a moment ago but who, with the same rights and importance to itself as the rest of humanity, would live and create others in its own image… Whence, wherefore had it come, and who was it? He could not understand at all, nor accustom himself to the idea. It seemed to him too much, a superabundance, to which he was unable to get used for a long time.