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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…

The Legal and Moral Significance of Implantation

23 Jun, 15 | by BMJ

Guest post by Sally Sheldon

We tend to talk about contraception and abortion as if they were two separate and readily distinguishable practices, the former preventing pregnancy and the latter ending it. This understanding has a very important effect in current British law, where a relatively permissive approach to the availability of contraception stands in stark contrast to the morally grounded, onerous criminal sanctions against abortion. Yet is the distinction between abortion and contraception really so clear cut?  How and why do we make it? And is the line that we have drawn between the two morally defensible?

As a matter of biological fact, the development of human life is not characterised by bright lines. As the eminent lawyer Glanville Williams once put it, “abstract human life does not ‘begin’; it just keeps going.” A seamless biological continuum exists through the production of sperm and egg, their joining together in a process of fertilisation, the gradual development of the new entity thus created throughout pregnancy, birth, subsequent growth, eventual death and ensuing decay of the body. Defining what happens along the way as an ‘embryo’, ‘fetus’, ‘person’, ‘adult’, or ‘corpse’ requires an attempt to draw lines on the basis of criteria selected as holding significance for legal or other purposes. How and where we draw such lines is a tricky business, involving careful moral reflection informed by medical fact.

The “regulatory cliff edge” between the relatively permissive regulation of contraception and the criminal prohibition of abortion relies on a line drawn on the basis of the biological event of implantation, where the fertilised egg physically attaches itself to the wall of the womb some six to twelve days after ovulation. Yet while enormous legal weight has been placed upon it, little consideration seems to have been given as to why implantation matters morally. The voluminous philosophical literature on the ethical status of the human embryo and foetus offers little support for the view that implantation is an important marker.

Further, while it might once have been suggested that implantation offers a conveniently timed moment for a necessary gear change between the appropriate regulation of contraception and abortion, this argument is difficult to sustain in the light of modern medical science. 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…

Athletic Sex

11 May, 14 | by Iain Brassington

There was an interesting article published in the BMJ a few days ago on the subject of athletes and their sex.  Here’s the opening gambit:

The International Olympic Committee (IOC) and international sports federations have recently introduced policies requiring medical investigation of women athletes known or suspected to have hyperandrogenism. Women who are found to have naturally high testosterone levels and tissue sensitivity are banned from competition unless they have surgical or pharmaceutical interventions to lower their testosterone levels.

The primary justification offered seems to be one of reducing unfair advantage, with a secondary justification that investigations of this sort might be to the medical advantage of the athletes themselves. Rebecca Jordan-Young and her colleagues aren’t impressed, and think that the policy is ethically suspect: not the least of their worries is that the policy effectively medicalises an unusual but benign characteristic of some people.  This could lead to medically useless surgery.  However, the potential problems are wider than that:

When pharmacological intervention or gonadectomy is a precondition for eligibility to compete, an athlete has to make a profound life and health altering decision for non-medical reasons. These are not merely individual decisions: athletes are embedded in families, teams, organisations, and even nations that depend on them to compete. Athletes can be “regarded as vulnerable to undue, even extreme situational pressures arising from the decision-making environment,” especially when a competitive career is also a path to economic mobility and stability.

I have to admit that I’m fairly relaxed about surgical interventions being undergone for non-medical reasons; more…

Rescuing the Duty to Rescue

1 May, 14 | by BMJ

Guest post by Tina Rulli and Joseph Millum

It is commonly thought that individuals have a moral duty to rescue others in peril. Bioethicists have leveraged this duty to rescue for a variety of purposes—including to criticize the use of placebo controls in trials in developing countries; to defend duties of researchers to return urgent incidental findings and provide ancillary care; to argue for a duty to become an organ donor; to defend allocating resources to develop drugs for rare diseases and to fund costly end of life care.

Despite their widespread use, there are serious problems with the two most cited duties to rescue: the individual duty of easy rescue and the institutional rule of rescue. The latter—the psychological tendency to support allocation of large amounts of money to rescuing identifiable victims at the opportunity cost of helping anonymous others—is indefensible.  (See Peter Singer’s opinion piece in the Washington Post criticizing donations to Make-a-Wish). The former can be defended, but has its own problems. One concerns its force: does it really apply only to very low-cost rescues? Consideration of physicians’ duties to warn suggests otherwise. Another problem concerns its scope: whom do I have to rescue? If it applies to everyone who needs rescue, even low-cost rescues may place enormous demands on individuals (cf Peter Singer’s famous essay: “Famine, Affluence, and Morality”).

We identify two further conceptions of the duty to rescue that have received less attention. An institutional duty of easy rescue would justify spending institutional dollars on rescue cases that are not too costly, while leaving room for institutions to fulfill lesser, but still important needs of others. A professional duty to rescue recognizes the more demanding duties certain medical professionals have. Both provide traction in answering some outstanding rescue dilemmas. We conclude our paper by proposing research priorities for bioethicists to help researchers and doctors sort through the obligations they have to people in need of medical rescue.

Read the full paper in the JME here.

An Attack of the What-Ifs

25 Oct, 13 | by Iain Brassington

Among the comments to the last post, there’s this from Parmenion59:

So…if a cure for lung cancer is found, and the study has been funded through money from a tobacco company…the BMJ won’t publish said study?
Way to go BMJ.

Hmmm.  At least on the face of it, this looks like an important point – one that deserves a bit of unpacking.  We can begin by distinguishing between responses to this particular point, and responses to the general idea behind it.  First things first.

I’m willing to bite the bullet and admit without worrying too much that the policy of not accepting papers funded by the tobacco industry may mean that some research is not publicised.  There’s a small handful of reasons why I’m willing to do that.  One of them – admittedly the weakest of the lot – is based on the idea that it’s not wholly clear that much tobacco money really is directed at finding a cure for lung cancer, rather than firefighting other research about the detrimental properties of tobacco.  But that, as I say, is weak, based on suspicion rather than anything enormously substantial; and even if the hunch is correct, it’s merely empirical rather than anything conceptual.  Still, even if the hunch is wrong, it shouldn’t matter, because there’re stronger reasons.

One is based around the idea that there’s a special providence in the fall of a pipette – or, put another way, you can’t keep a good truth down.  If something is there to be discovered and is worth the effort, then it’ll be discovered sooner or later; if not by Smith, then by Jones.  And, because scientific progress is invariably a matter of the accretion of the work of several teams, all working independently and making minor discoveries, rather than one heroic person who would be solely responsible for The Cure For Cancer ™, the loss of one paper here and there probably won’t make all that much of a difference in the grand scheme of things. If that’s correct, then the idea that we might lose the cure for cancer is not all that compelling – not one about which we should worry too much.

A final reason is that, as I’ve said before elsewhere, I’m not persuaded that research is obligatory: it’s admirable, but not required by duty.  There’s a range of second-order arguments one might present here, but most relevant has to do with the benefits that research might generate.   more…

Smoking out Tobacco Industry-Supported Research

18 Oct, 13 | by Iain Brassington

BMJ Open, along with a couple of other journals, published a statement a couple of days ago saying that they’d no longer accept papers based on research wholly or partially funded by the tobacco industry.  The gloss on the statement is damning:

The tobacco industry, far from advancing knowledge, has used research to deliberately produce ignorance and to advance its ultimate goal of selling its deadly products while shoring up its damaged legitimacy.  We now know, from extensive research drawing on the tobacco industry’s own internal documents, that for decades the industry sought to create both scientific and popular ignorance or “doubt.”  At first this doubt related to the fact that smoking caused lung cancer; later, it related to the harmful effects of secondhand smoke on non-smokers and the true effects of using so called light or reduced tar cigarettes on smokers’ health.  Journals unwittingly played a role in producing and sustaining this ignorance.

Some who work within public health and who buy the notion of “harm reduction” argue that the companies that now produce modified cigarette products and non-cigarette tobacco products, including electronic nicotine delivery devices (e-cigarettes), are different from the tobacco industry of old, or that the tobacco industry has changed. For “hardened” cigarette smokers who can’t or won’t quit cigarettes, the argument goes, new tobacco products could represent potential public health gains, and company sponsored research may be the first to identify those gains.

But one fact remains unassailably true: the same few multinational tobacco companies continue to dominate the market globally and, as smaller companies develop promising products, they are quickly acquired by the larger ones. However promising any other products might be, tobacco companies are still in the business of marketing cigarettes. As US federal court judge Gladys Kessler pointed out in her judgment in the case of US Department of Justice versus Philip Morris et al, the egregious behaviour of these companies is continuing and is likely to continue into the future.  And just this summer documents leaked from one company showed a concerted campaign to “ensure that PP [plain packaging of tobacco products, bearing health warnings but only minimal branding] is not adopted in the UK.”  The tobacco industry has not changed in any fundamental way, and the cigarette—the single most deadly consumer product ever made—remains widely available and aggressively marketed.

What should we make of the policy?

A bad argument against the ban – yeah, I know that that misses some linguistic subtlety, but it’s close enough – is that it’s a violation of free speech: it really is no such thing, for the simple reason that noone is trying to stop the tobacco industry making its case – a right to free speech doesn’t imply a right to a platform.  Of course, if every reputable publisher denies the industry a platform, than this might be a de facto rather than de jure curb on free speech – but that’s just the way it goes: just as noone gets to insist that a particular person gives them a platform, they don’t get to insist that they be provided with one at all.  (Also – though it doesn’t apply in this case – merely to splutter “B…b.. but free speech!” isn’t an argument anyway.)

Still, I guess I am uneasy about a ban. more…

Fitness to Practise Revisited

26 Jul, 13 | by Iain Brassington

***UPDATE: Important codicil at the end***

Back in March, I posted something about what I took to be a slightly odd Fitness to Practise decision by the GMC in respect of one Mohammed Al-Byati.  Via the BMJ, here’s another case that seems a bit strange:

A doctor who abducted her six year old daughter from her estranged husband nearly two years ago and took her to Pakistan has been struck off by a panel of the Medical Practitioners Tribunal Service (MPTS).


The MPTS panel, sitting in Manchester, acknowledged that Dar’s conduct did not relate to her medical practice.  But panel chairman Michael Whitehouse said that misconduct could also involve conduct “of a morally culpable or otherwise disgraceful kind,” which could prejudice the reputation of the profession.

The emphasis is mine, though it’s the stuff about the “reputation of the profession” that intrigues me.  If Dar has breached a court order, or is a kidnapping suspect, then fine – but that’s a matter for the courts.  She perhaps wouldn’t be able to practice if found guilty and imprisoned, but that’s a different matter.  It’s not obviously the GMC’s business.

Now, sometimes a profession might have an interest in disciplining people who misuse their association with it.  more…

Torture and Fitness to Practise

12 Mar, 13 | by Iain Brassington

I’m running a bit late with this, but the BMJ reported last week that Mohammed Al-Byati had been suspended from the medical register for 12 months for complicity in torture.  So far, the decision hasn’t been uploaded to the list of Fitness to Practise decisions, but the outline of the case is available here, on the “upcoming hearings” calendar:

The Panel will inquire into the allegation that between December 1992 and March 1994, Dr Al-Byati visited camps and prisons in his capacity as a doctor in Iraq.  It is alleged that during these visits and whilst administering treatment, Dr Al-Byati knew that some prisoners he treated had sustained injuries as a result of torture, and it was likely that the prisoners would be tortured again.  It is also alleged that as a consequence of Dr Al-Byati’s engagement in these events, he was complicit in acts of torture.

The BMJ report relates that

the panel decided not to end his career by erasing him from the medical register, after accepting that he played no part in the torture and had effectively no choice but to carry out orders.  He told the panel that he had been “terrified” of what would happen to him and his family if he did not do as he was told.   The panel’s chairman, Michael Whitehouse, said, “He was a junior doctor whose behaviour was being controlled by a dictatorial, totalitarian regime which used systematic, widespread, and extremely grave violations of human rights to control the population.  Dissent from orders was not tolerated.

There’s a couple of things that’re perplexing about this.

The first is that it’s not clear how close to the torture process Al-Byati actually was.  The FtP outline simply alleges that he knew the people he was treating had been tortured, and that they probably would be again.  The BMJ repeats this.  Al-Byati appears to have denied knowing it, but it’s not clear to me that it’d’ve mattered if he had known: treating someone in those circumstances doesn’t amount to endorsement of the torture.

I mean: imagine that you’re working in A&E and someone is admitted whom you suspect strongly (strongly enough for it to count as knowledge in the common-or-garden sense) to have been injured as a result of domestic violence.  You patch up the patient, who then goes home – to face, you suspect almost as strongly, more violence.  It’d be nuts to suppose that you could be criticised as complicit in or even supportive of that violence, though, or that there might be something problematic about treating the patient in the knowledge of what had happened and may happen again.  At most, you might be criticised for not contacting the police or social servives; but that’s a question of confidentiality, and of a totally different stripe – and, anyway, to whom would Al-Byati have reported his concerns?

The other thing that’s perplexing is that noone claims that Al-Byati had any real choice in the matter.  It doesn’t seem unreasonable for a twentysomething medic to agree to provide medical treatment to those who need it, especially when it’s at the request of the state and that state is Ba’athist Iraq.  Maybe he could have refused in principle – but in practice, that kind of refusal may well have been heroic, and it’s odd to criticise someone for not being sufficiently heroic.

In both cases, consider the alternative.  The alternative for the patient is not being treated.  The alternative for the doctor is… well, who can say?  I doubt that there was much scope for conscientious objection.  And remember that the complaint is not that he assisted in the torture, but that he knew about it.

So why apply sanction?  Here’s Michael Whitehouse, the panel chairman, quoted in the BMJ:

He said that the suspension, for the maximum period allowed, was necessary “to demonstrate clearly to him, the profession, and the public that even though his involvement as an accessory to torture was outside his control, such conduct is unacceptable.”

Ummm… Really?  The emphasis is mine, because this is a very, very odd thing to say.  Treating people for the effects of torture is not to be an accessory in any meaningful sense – especially if you didn’t have a realistic choice.  And the pour encourager les autres claim in this context stinks.  I mean, as a principle of justice, my inclination is to think that it’s iffy at best in any circumstance.  But it’s not really as if anyone needs to have it demonstrated that state-sponsored torture is a bad thing to begin with.  And if, mirabile dictu, someone does need to be reminded of that, it’s not clear that they’re going to be swayed by demonstrations of foot-stamping like this.

Note that this case seems to raise questions similar to those raised in respect of medical involvement in capital or corporal punishment.  However, it’s also significantly different from what I can tell.  For one thing, in regimes in which capital or corporal punishment is used and the presence of a medic is mandated as an integral part of that process (for example, if the law demands that a lethal injection be administered by a medical professional), it seems to me that it’d be conceivable that minimally decent doctors would refuse participation, thereby bringing the whole process to a halt.  One might even imagine doctors refusing to be involved as a means of bringing the process to a halt – though you could, alternatively, make a rule-of-law case to insist that medics ought not to aim to undermine valid laws from valid sources, and draw a distinction between conscientious objection that makes the execution of a sentence (and a prisoner) impossible as a side-effect, and more activistic attempts to exert moral pressure on a notionally unjust law.

Whatever.  There’s a debate to be had there, but it doesn’t really speak to this case, because Ba’athist Iraq was not a rule-of-law regime, and (perhaps more importantly) non-participation wouldn’t – on the face of it – have made any real difference, because from the way the story is reported, the presence of a medic like Al-Byati wasn’t a part of the process.  That is: even if Iraq had been a rule-of-law regime, there’s a difference between treating someone who has been tortured and may be tortured again, and treating that person as a part of the torture framework.  There’s no reason to believe that the law required that the torture be overseen by a medic: only that he happened to be the guy closest to hand when the prisoners needed patching up.  Had he not been there, it’s all-too-easy to believe that the torture would’ve happened anyway.

Maybe I’ve missed something about the case.  But from the way it’s reported, it seems possible that the decision has been at least partially determined by the idea that Al-Byati is contaminated by association with bad people.  Either that, or because of PR concerns about the public perception of the matter should the “news”paper to which I do not link get wind of it.

I think that there’s more to be said.  There must be, mustn’t there?

Neonatal Withdrawal of Treatment: A Doctor Writes…

6 Nov, 12 | by Iain Brassington

There’s a great little article recently published in the BMJ about what it’s like to be the medic considering withdrawal of feeding from a neonate.

Survival is often much longer than most physicians think; reflecting on my previous patients, the median time from withdrawal of hydration to death was 10 days.

I had no idea it’d be that long.  I had no idea it’d be that long even for healthy adults who stopped drinking, let alone already-ill neonates.  (My scientifically-naïve intuition would have been that an adult body could stand up to more than an infant one.)

The fact is ethically neutral; and we need to be careful about skipping over the fact/ value boundary too easily.  But value claims bounce off, and are informed by, factual claims, and this is the sort of thing that might well be important when considering questions about withholding and withdrawing treatment, and about killing and letting die, and all the rest of it.

And, of course, the infant isn’t the only morally relevant actor in all this:

It is draining to be the most responsible physician. Everyone is looking to me to preside over and support this process. I am honest with the nurse when I say that it is getting more and more difficult to make my legs walk me on to this unit as the days elapse, that examining the baby is an indescribable mixture of compassion, revulsion, and pain.

I can see how that’d be.

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