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In the Journals

The Ebola Outbreak in Western Africa: Ethical Obligations for Care

11 Sep, 14 | by BMJ

Guest post by Aminu Yakubu, Morenike Oluwatoyin FolayanNasir Sani-Gwarzo, Patrick Nguku, Kristin Peterson, and Brandon Brown

In our article “The Ebola Outbreak in Western Africa: Ethical Obligations for Care” we focus on the health care system’s ability to combat the recent epidemic of Ebola in Western Africa.  This is a timely and urgent issue.  Many medical ethicists – including those called upon by the WHO – are focusing on availability of experimental drugs, but little is being discussed about on-the-ground care and human rights.  By the time this article was written, in August 2014, there were 1145 deaths from Ebola.  In the news, Ebola treatment facilities were being taken over by armed civilians who stole medicines to protect themselves, resulting in Ebola patients fleeing for their lives and further spreading the virus.  This action has taken a toll on an already limited infrastructure.

The unspoken heroes of the Ebola epidemic are the healthcare workers who brave potential infection to save the lives of those infected.   In Nigeria, nine health care workers were infected, and three health care workers had already died by the time this blog was written.  With this news, willingness of medical staff to provide care for patients with Ebola virus is limited, as the danger to their own life is great.  Moral obligations of healthcare staff to provide care should have limited sanctions for non-compliance so as not to infringe on the healthcare workers right to life.  Workers who do care for Ebola patients must be provided with adequate protective equipment and a safe working environment, as well as compensated if they become infected in the course of duty.  Traditional public health ethics has paid little attention to the protection of the rights of healthcare workers, but the Ebola epidemic has brought this issue to the forefront.  Its time those who are responsible for saving our lives have a voice.

 

Read the full paper here.

UPDATE:  Brandon Brown emails:
I just received a nice on the ground photo (Ebola decontamination) from my collaborators in Nigeria if we can attach to the blog entry.  [Click image for bigger.]

IMG_20140728_182522

 

 

 

On Conflicts of Interest

28 Jul, 14 | by Iain Brassington

It’s only a few days since Richie’s paper on providing IVF in the context of global warming was published, but already there’s been a couple of lines of objection to it that have been fairly widespread; I thought it might be worth nodding to one, and perhaps offering an attempt of a defence against the other.

The first objection is that there’s no justification for the claim about same-sex couples in Richie’s paper – that she shouldn’t have treated homosexuality as a lifestyle choice and as “non-biological” infertility.  I think that there’s significant merit to this objection to the paper; and though neither Dominic nor I mentioned the objection explicitly, I think that it’s there between the lines of each of our commentaries.  (It’s certainly an aspect of the paper that’s picked up by the Telegraph‘s coverage of the paper, and it’s been mentioned a couple of times on Twitter and Facebook by people I know and follow.  (I note that the Telegraph also gave a highly bastardised version of my post here.  Ho hum.))  I think that Richie’s argument would have been at least as strong if she’d talked about providing IVF to anyone whatsoever – the qualifications about different “sorts” of infertility and lifestyle, I suspect, weakened the paper, inasmuch as that a paper with unnecessary and argumentatively weak aspects is more vulnerable to objections generally than one in which those aspects have been left out.  So, yeah: I think that that might count as having been – at best – a strategic error on Richie’s part.

Here’s the other claim that I’ve seen a few times about the paper: that it’s weakened by a conflict of interest because of the author’s affiliation.  This isn’t directly a claim about the quality of the argument in the same way that the previous objection is.  Rather, it’s a claim that there’s something unreliable about the very fact of the argument’s having been put.  (I’m not articulating the distinction very well, but I think you can see what I mean.)  In essence, the worry is this: Richie works for a Jesuit Institution; this isn’t clear from her affiliation in the paper; there’s something iffy about this; this iffiness is some form of conflict of interest and her argument is likely to be biased.

I’m not sure what to make of this. more…

Resurrectionism at Easter

23 Apr, 14 | by Iain Brassington

There’s a provocative piece in a recent New Scientist about what happens to unclaimed bodies after death – about, specifically, the practice of coopting them for research purposes.

Gareth Jones, who wrote it, points out that the practice has been going on for centuries – but that a consequence of the way it’s done is that it tends to be the poor and disenfranchised whose corpses are used:

[T]he probably unintended and unforeseen result [of most policies] was to make poverty the sole criterion for dissection. [... U]nclaimed bodies are still used in countries including South Africa, Nigeria, Bangladesh, Brazil and India. While their use is far less in North America, they continue to constitute the source of cadavers in around 20 per cent of medical schools in the US and Canada. In some states in the US, unclaimed bodies are passed to state anatomy boards.

For Jones, the practice of cooption ought to be stopped.  His main bone of contention is the lack of consent – it’s a problem that’s made more acute by the fact that the bodies of the disenfranchised are more likely to be unclaimed, but I take it that the basic concern would be there for all.

One question that we might want to ask right from the off is why informed consent is important. more…

From the File Marked “This Can’t End Well”

25 Nov, 13 | by Iain Brassington

… and cross-referenced with the file marked “You Wouldn’t Let It Lie”.

Francesca Minerva has a paper in Bioethics in which she refers – none-too-obliquely – to the furore surrounding The Paper Of Which We Do Not Speak.  Her central claim is that there is a threat to academic freedom posed by modern communications, inasmuch as that a paper in a journal can now attract to the author intimidation and threats.  A case in point would be The Paper.  But, she claims, it’s vital to the academic exercise that people be able to knock ideas around.  This ability is limited by things such as the response to The Paper; academic freedom is therefore threatened.

Yeah, but no.  I think it’s reasonable enough to say that academic progress depends on the free exchange of ideas, and that there should be no sacred cows.  Sometimes conventional ideas turn out to be untenable or flat-out wrong; and we tend to take it as axiomatic that it’s desirable to have fewer wrong ideas.  (I suppose we could imagine a culture that is satisfied with its opinions as they are, and is not bothered by their truth so much as by some other value they might have, such as their ability to promote social cohesion; but I’ll leave such cultures aside for the moment.)  I’d go along with the idea that we shouldn’t back away from controversial claims, on the basis that repugnance is no objection to the truth of a claim; that if a claim’s true, we should accept it as best we can, like it or not; and that if a claim is false, we shouldn’t have cause to fear its articulation, because we can take it that it won’t survive scrutiny.

And I’d agree that some of the responses to the paper – and to Julian’s defence of publication – were indefensible, and that this is so irrespective of the merits or demerits of the paper or the defence.  But not all of them were.  While some were from obvious dingbats and keyboard warriors (Jonolan remains even now the sole occupant of the banned commenters list here – and I rather suspect that he rather enjoys that honour), other responses were from people whom one might think wrong, but whose response was nonetheless worth taking seriously because it was much more considered and at least on the face of it amenable to argument – which is what academic discourse is all about.

Does any of this tell us about threats to academic freedom, though?  I don’t think so. 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…

Under-Treatment, Treated.

29 Aug, 13 | by Iain Brassington

Right: file this paper from the JAMA under “Properly Odd”.  It’s a proposal that nonadherence to a treatment regime be classed as a treatable medical condition in its own right.

No, really.  Look at the title: “Medication Nonadherence: A Diagnosable and Treatable Medical Condition”.

Starting from the fairly straightforward premise that non-adherence to treatment regimes is “a common and costly problem”, Marcum et al move at the end of their opening paragraph to have medication nonadherence recognised “as a diagnosable and treatable medical condition”.  The authors allow that, as a precursor to treatment, there must be an accurate diagnosis.  However,

for undetected and under-treated conditions such as medication nonadherence, one way to identify the population of interest is to conduct screening. The 1968 World Health Organization principles on screening tests have clear application to medication non-adherence. For example, the condition is an important problem, there are suitable tests available, and there are acceptable treatments for those with this problem.

Well, OK; but it hasn’t yet been shown that nonadherence is a condition, and so it’s too early to say that it’s a condition for which tests and treatments are available.  It shouldn’t be hard to see what’s gone wrong here: the fact that treatable medical conditions are serious problems that are (or could in principle be) reversible doesn’t entitle us to say that any serious problem that is (or could be) reversible is a treatable medical condition.  The authors appear to have got things – to use the vernacular – arse about tit.

So is there any evidence offered in the paper for non-adherence being a medical condition in its own right?  The paper is short, but even so, it’s not something I want to reproduce here; all the same, there’s nothing that leaps out.  The main planks of the argument are simply that it’s a problem, that it’s a problem that has something to do with health, and that it’s therefore a health problem properly understood.

The authors continue:

Using previously established methods and instruments, screening to diagnose medication nonadherence among adults across care settings should be routine. A number of screening tools or instruments are currently available to determine the underlying behavior(s) of interest.  This approach illustrates how clinicians and researchers can begin conceptualizing the diagnosis and treatment of medication nonadherence.  [...] Also, given the proposal to routinely screen for medication non-adherence in adults, the next step is to match the identified barriers to a proven treatment for the condition.

Well – if I can interrupt for a moment – they can begin diagnosis and treatment of the condition so long as the condition is actually a thing.  Which it isn’t.

I have a horrible feeling that I know what’s going on here; there’s a couple of telltale signs:

Inclusion of medication adherence data in the electronic health record will allow for sharing among health care professionals and insurers, establishing trends over time as well as benchmarking for quality improvement purposes. Moreover, it is paramount that patient-reported medication adherence information (eg, medication beliefs and values) is incorporated into such documentation.

And this makes me think that it’s got something to do with the role of private insurance in the US medical system.  If you can get non-aherence accepted as a condition, then it’s something that insurers’d have to cover, which would mean…

Eh?

… Actually, no.  I’ve no idea.  I mean, it wouldn’t actually make it a condition.  You can’t just define a condition into existence because it’d suit some purpose.

In the current health care climate, there is a strong demand for improving the quality of care delivered, including medication adherence.

Hmm.  That’s not really helping.

 

Are Biomedical Ethics Journals Institutionally Racist?

25 Mar, 13 | by Iain Brassington

So there’s this letter published in the Journal of Bioethical Inquiry that moots the idea that the top biomedical ethics journals might be institutionally racist.  In it, Subrata Chattopadhyay, Catherine Myser and Raymond De Vries point out that the editorial boards of a good number of journals are dominated by members who are located in the global North – countries officially listed as being high or very high on the development index, with only 1.3% drawn from countries classed as least developed.

Developing World Bioethics has the highest proportion of its editorial board located in the least-developed nations; but even there, the figure is only just over 11%.  On the face of it, this doesn’t look too good, especially given the proportion of the world’s population in general that lives in the poorest countries.  The JME, by comparison, draws 100% of its editorial board members from people located in highly and very-highly developed nations.

Still: this isn’t likely to be the whole story.  Udo Schucklenk – a founding editor of DWB, of course – takes issue with the letter on a number of grounds.  For one thing, he he suggests that Chattopadhyay et al might be performing a sleight of hand with their metrics; by lumping together countries ranked as high and very high on the development index, they’re lumping together the UK, Germany, and the US with Iran, Malaysia, and Jamaica.  Neither Iran nor Jamaica is a classic basket-case economy; but, still, “high” and “very high” development covers a vast range of income levels.  Treating all these countries in the same way obscures that there’s a huge range of locations from which editorial staff may be drawn.

I’ll come back to this in a moment. more…

Kelly Hills, Data Miner

7 Nov, 12 | by Iain Brassington

Kelly Hills has been data-mining – collecting and collating information about the frequency with which certain terms appear in paper titles in three journals: the JME, Bioethics, and the AJoB.

I was going to say that the charts are not much use, but that they are pretty and quite cool; and I was going to add that their lack of utility doesn’t matter at all because prettiness and coolness is sufficient to make them worth looking at.  Not everything worthwhile is worthwhile because it’s useful, after all.  Being a philosopher, I have to believe that.

But then it occurred to me that there probably is some utility to them.  Taken with some care, they help us to see what is held to be important by people publishing work – and, I suppose, they might also help decide which journals are more receptive to certain topics (or, conversely, which journals are saturated with them).

Here’s what the JME‘s chart looks like:

The image isn’t perfect, of course: because size is a mark of brute numbers and the algorithm that generates the image isn’t sensitive to context, “ethics”, and “ethical” get separated, when the reality might not indicate that they merit separate consideration.  “Euthanasia” gets only a small amount of attention – which tells us something about the heat-to-light ratios in debates on the topic.  It also gives some support to John Coggon’s idea that it’s getting hard to find anything new worth saying in that particular field – though I’d’ve thought the same, and more, would apply in respect of consent, and that seems to generate a heck of a lot of attention.

198!

23 Oct, 12 | by Iain Brassington

Seriously!  Theoretical Medicine and Bioethics has published a paper with a hundred and ninety-eight listed authors!

I’ve always been slightly puzzled by multi-authored papers – by just how many people get to add their names to a piece of work.  A friend of mine who is a proper scientist once tried to explain how it works in the sciences to me – about how you need to give credit to the people who ran the experiment, but also to those who did the titration and general donkey-work.  That seems fair enough.  Having said that, I suspect that there’s often a bunch of people who get credits that shouldn’t be there.  (I remember once seeing a CV from a guy that had 45 pages’ worth of publications listed.  Granted, it was double-spaced… but, still: there must have been the thick end of a thousand papers listed; there’s no way on God’s good Earth that he could have played a significant role in all of them.  So why was he entitled to claim them?  Why did he take the credit?  Apparently, it was because, although not all of the papers referred to work he’d done, they did all refer to work done by other people in a lab he ran.)  Anyway… the Steinhauser et al ad infinitum paper, with its 198 authors, isn’t lab-based, so the credit-where-it’s-due argument wouldn’t work.

(Jozsef Kovacs, writing in a paper currently available as a pre-pub in the JME, is also concerned about authorial inflation, and who should get the credit for a given paper, and how to improve things.  It’s definitely worth a look.)

The author list for the Steinhauser paper seems to have been generated at least in part via the membership of a Facebook group (and one that no longer exists, or at least one that is so private that it doesn’t show up on a search).  That’s just silly, and there’s no way that anyone can successfully marshall so many contributors.  That turns a paper into an open letter.  Indeed: the “authors” seem to think that their paper could be treated as such without loss: more…

Jon Cogburn’s Plea to Grad Students (and Others)

24 Sep, 12 | by Iain Brassington

[IB: I'm taking the liberty of copying in its entirety Jon Cogburn's post on NewAPPS about submitting papers to journals, because it's worth reading.  He directs it to graduate students - but I think that the same point applies to anyone, especially if they're new to the field in which they're writing.  Since a lot of people writing for journals like the JME - especially on topics in clinical ethics - are medics before they're ethicists, or are coming at ethics from a non-standard direction, I think that the advice is particularly pertinent.]

A Plea to Graduate Students Submitting Papers

Three times this year a bad thing has happened after I’ve encouraged editors to give a paper “revise and resubmit.”

Note that whenever I review a paper and don’t recommend immediate acceptance I work really hard trying to help the writer so that their rewrite will to be up to the quality of the journal.  Even when I counsel “rejection” I still try to give detailed constructive advice about how the paper could be recast, even suggesting places the author should send the rewritten paper.

So three times this year instead of making the changes I recommended the author resubmitted substantially the same paper and argued with some vehemence that they should not have to change their paper in the ways I suggested.  In all three cases the journal editor had given the paper “revise and resubmit,” but then rejected the insufficiently rewritten paper.  In two of these cases I googled the paper title after this was over and found out that the submitters were graduate students.  This is so bad on so many levels.

First, it’s clear to me that some graduate students have no idea that “revise and resubmit” is a very, very good thing, that if you just rewrite the paper up to the reviewer and editor’s standards that at most journals it is almost certain to get accepted.  All three of the people viewed “revise and resubmit” as if it were a kind of rejection, and not a kind of conditional acceptance, as it usually amounts to (de facto if not de jure).  Second, it’s clear to me that some graduate students have no idea what “idiot-proofing” a paper amounts to.  Let me explain.  Suppose that your reviewer is an uncharitable idiot.  Suppose I was when reviewing the papers.  It doesn’t matter!  My comments are still invaluable because you still need to rewrite the thing so that the next uncharitable idiot reviewing it doesn’t make the same mistakes.  Third, it’s clear to me that some graduate students have no idea how high the burden of proof is if you want to convince an editor that the reviewer who has published extensively in the topic in question is making elementary mistakes about the paper.So please communicate this to all and sundry: (1) Revise and resubmit is something to be celebrated, (2) always take into account criticism and suggestions, even if only to idiot-proof for the next reviewer, (3) have some humility.I”m not trying to be censorious here.  If I was I wouldn’t spend so much time giving detailed advice about how to get papers up to publishable standards.  In addition, I know first-hand how stressful this process is for writers and first-hand how stress can produce weird and suboptimal behavior.  I’m trying to help.

I’d very be interested to hear if other reviewers have faced this kind of self-destructive behavior, and if so if there’s anything more we should be doing to stop it.  But if I’m being a jerk here, I trust that someone will point that out too.

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