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Rights, Duties, and Species

19 Dec, 14 | by Iain Brassington

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

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

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

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

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

This could get Personal

5 Dec, 14 | by Iain Brassington

And so 23andMe has launched in the UK.

For those not familiar with it, 23andMe allows individuals to swab themselves and have their genome analysed, at a cost of £125. The company is offering to generate a report covering about a hundred traits, giving information on a range of potentially important to fun things: the list includes tests for the presence or absence of inherited conditions such as Tay-Sachs and Beta Thalassemia; risk factors relating to things like Alzheimer’s; how much DNA you have in common with Neanderthals; and earwax type.

To be honest, I’d’ve thought that by the time you’ve got £125 to spend on a test like this, you’d probably know all you’d ever want to know about your earwax, but… well, apparently there’s more.  Joy.

Anyway: BBC Breakfast invited me to witter on about it the other day.  I only got a couple of minutes, and so didn’t get to say much; shamelessly, I’m going to think aloud a little bit here.  My basic starting point is that it’s hard to see why the test per se is too big a problem: all else being equal, who would begrudge a person information about himself?  All the same, I think that there are questions that are probably worth asking.  (NB: in what follows, whenever I mention 23andMe, the point should be taken to cover any company offering a similar service.)  So, in no particular order… more…

Would Aristotle Vape?

13 Nov, 14 | by Iain Brassington

As I surfaced the other day, there was a discussion on Today about the marketing of e-cigarattes between Deborah Arnott, chief executive of ASH, and Lorien Jollye of the New Nicotine Alliance (now there‘s an organisation that wears its heart on its sleeve!).  It’s available from about the 1:22 mark here.  Having re-listened, it appears to me that they’re talking past each other for a significant amount of time; but the points around which they’re at least orbiting has to do with the safety of e-cigarettes and the permissibility of advertising for them.  Arnott’s concern is not so much about whether using e-cigs – which I believe the well-informed call “vaping” – can be shown in adverts, but how.  Jollye’s claim is that all that matters is whether and that the devices reduce levels of smoking across the board.  The subtext here is that the tone of the advertising possibly doesn’t matter – but if it does matter, and making the devices more attractive gets smokers to make the switch, then so much the better.

Arnott’s response here is that if e-cigs can lure smokers, they can presumably lure non-smokers, too.  And it does seem initially plausible that if the point is to coax smokers rather than non-smokers, it could be done in a non-glamorous way. emphasising the grimness of smoking-related illness and the relative benefits of vaping.  Glamour seems to be an attempt to be appealing to non-smokers as well.

Does that matter, though? more…

Once More unto the Breach of Covenant?

31 Oct, 14 | by Iain Brassington

The “Military Covenant” is in the news again:

The government is failing to abide by its military covenant, medical experts who treat injured soldiers have said.

Leading professors in psychology and orthopaedics say the healthcare system is not providing veterans with the service they have been promised. […]

The moral obligation to treat veterans should not stop when service ends, the covenant states, saying veterans should receive priority healthcare from the NHS when they are being treated for a condition dating from their time in the armed forces.

The Covenant is set out here; most of it is pretty vague, and what isn’t vague is largely predictable in its tone.  In respect of healthcare, the relevant part is on p 6:

The Armed Forces Community should enjoy the same standard of, and access to, healthcare as that received by any other UK citizen in the area they live. […]  Veterans receive their healthcare from the NHS, and should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need.

This, at first glance, seems to be saying that members of the forces, and ex-members, should be treated in the same way as everyone else, except that they shouldn’t.  (There’s a fuller version of the statement here.)  The Government repeats this confusing attitude elsewhere: its own website explains that

[i]t’s not about getting special treatment that ordinary citizens wouldn’t receive, or getting a better result. For those that have given the most, such as the injured and the bereaved, we do make an exception

But maybe that’s just a terminological infelicity.

The Covenant itself does not have the status of law (and even if it did, that wouldn’t make any moral difference, unless you happen to think that all law is de facto good law).  However, the Armed Forces Act (2011) does state that the Secretary of State must prepare and present before Parliament every year a report on the covenant; and, according to §343A(3), more…

Saatchi Bill – Update

28 Oct, 14 | by Iain Brassington

Damn. Damn, damn, damn.

It turns out that the version of the Medical Innovation Bill about which I wrote this morning isn’t the most recent: the most recent version is available here.  Naïvely, I’d assumed that the government would make sure the latest version was the easiest to find.  Silly me.

Here’s the updated version of §1(3): it says that the process of deciding whether to use an unorthodox treatment

must include—

(a) consultation with appropriately qualified colleagues, including any relevant multi-disciplinary team;

(b) notification in advance to the doctor’s responsible officer;

(c) consideration of any opinions or requests expressed by or on behalf of the patient;

(d) obtaining any consents required by law; and

(e) consideration of all matters that appear to the doctor to be reasonably necessary to be considered in order to reach a clinical judgment, including assessment and comparison of the actual or probable risks and consequences of different treatments.

So it is a bit better – it seems to take out the explicit “ask your mates” line.

However, it still doesn’t say how medics ought to weigh these criteria, or what counts as an appropriately qualified colleague.  So, on the face of it, our homeopath-oncologist could go to a “qualified” homeopath.  Or he could go to an oncologist, get told he’s a nutter, make a mental note of that, and decide that that’s quite enough consultation and that he’s still happy to try homeopathy anyway.

So it’s still a crappy piece of legislation.  And it still enjoys government support.  Which does, I suppose, give me an excuse to post this:

Many thanks to Sofia for the gentle correction about the law.

An Innovation Too Far?

28 Oct, 14 | by Iain Brassington

NB – Update/ erratum here.  Ooops.

One of the things I’ve been doing since I last posted here has involved me looking at the Medical Innovation Bill – the so-called “Saatchi Bill”, after its titular sponsor.  Partly, I got interested out of necessity – Radio 4 invited me to go on to the Sunday programme to talk about it, and so I had to do some reading up pretty quickly.  (It wasn’t a classic performance, I admit; I wasn’t on top form, and it was live.  Noone swore, and noone died, but that’s about the best that can be said.)

It’s easy to see the appeal of the Bill: drugs can take ages to come to market, and off-label use can take a hell of a long time to get approval, and all the rest of it – and all the while, people are suffering and/ or dying.  It’s reasonable enough to want to do something to ameliorate the situation; and if there’s anecdotal evidence that something might work, or if a medic has a brainwave suggesting that drug D might prove useful for condition C – well, given all that, it’s perfectly understandable why we might want the law to provide some protection to said medic.  The sum of human knowledge will grow, people will get better, and it’s raindrops on roses and whiskers on kittens all the way; the Government seems satisfied that all’s well.  Accordingly, the Bill sets out to “encourage responsible innovation in medical treatment (and accordingly to deter innovation which is not responsible)” – that’s from §1(1) – and it’s main point is, according to §1(2), to ensure that

It is not negligent for a doctor to depart from the existing range of accepted medical treatments for a condition, in the circumstances set out in subsection (3), if the decision to do so is taken responsibly.

Accordingly, §1(3) outlines that

[t]hose circumstances are where, in the doctor’s opinion—

(a) it is unclear whether the medical treatment that the doctor proposes to carry out has or would have the support of a responsible body of medical opinion, or

(b) the proposed treatment does not or would not have such support.

So far so good.  Time to break out the bright copper kettles and warm woollen mittens*, then?  Not so fast. more…

Ebola in the US: Privacy, public interest and the ethics of media reporting

3 Oct, 14 | by David Hunter

The first confirmed case of ebola has been found in the US, in Texas – unsurprisingly someone who had recently been to Africa. This has prompted an outbreak… of unethical media reporting about the case, with several breaches of privacy which seem unlikely to be in the public interest. Specifically the media has disclosed the victim’s full name, then to add insult to injury they published both his address and then a map of where he lives.

The media frenzy around this case is as unwarranted as it is unsurprising – scarily reminiscient of the painfully telling Onion piece – which claimed just 50 more white people needed to die of Ebola before a vaccine would be developed…

But even if we accept that the public is interested in the case (which no doubt they are) and that this interest warrants reporting on it does that give the media the right to release this person’s personal details and movements?

The main argument that can be offered for breaching typical standards of confidentiality is that the breach is in the public’s interest – this is the defense typically usually used in whistle blowing cases and in cases where medical professionals break confidentiality to prevent harm to others.

So isn’t this justification enough? Aren’t all Americans now at risk of ebola, amd hence have a right to know about who has it and where it is so they can choose to minimise their own risk?

It is worth noting that whilst Ebola is to be frank a terrifying disease it is relatively easily containable by the use of routine public health measures such as surveilance, isolation, contact tracing and modern hygiene standards and practices as it is spread through fairly obvious contact with bodily fluids, rather than airborne. And these fluids are only generated once someone is obviously symptomatic. As such there is little chance of a significant outbreak in countries like America or Australia because the number of contacts likely to be exposed to bodily fluids are usually minimal.

So this information is unlikely to help anyone protect themselves from being exposed to ebola – those who were already exposed (if any) have been exposed and are being contacted, and no one will now be exposed to this particular victim, so having their details in the public domain does no good, and has a potential to do harm in three ways:

1. It can reinforce false beliefs – “why would they tell us this if we weren’t at a significantly increased risk?”

2. It creates the potential for witch hunting – where the victim is blamed and potentially harmed – “civic-minded” citizens might take it upon themselves to “minimise” the risk of infection by burning down the apartment building he lives in for example.

3. It may perversely discourage other exposed travellers from seeking medical treatment and attention – it is worth noting that the victim took himself to hospital to seek treatment. If there is considerable public outcry, stigmatisation, distaste and displeasure the next victim may feel their details will be exposed in a similar fashion and avoid medical attention with predictably disasterous effects both for them, and for those potentially exposed to them.

Could spreading this information be helpful for contact tracing? Contact tracing is a public health practice where all those who might have been exposed are identified and contacted – both to see if they have symptoms and in some cases to isolate them until they are cleared. Reporting these details might enable a few people who haven’t been identified as being in contact to self identify, but practices of contact tracing are well established and this is a relatively easy case since his movements are well known and the victim has been able to communicate with public health officials about those he has been in contact with, so it is likely to be of minimal benefit, if anything it might well create more false positives than anything else – with worried people who think they were exposed using up valuable time and resources.

In a deeply misleadingly titled piece: “With Ebola, the public’s right to know trumps patient privacy” Art Caplan an American bioethicist argues that rebuilding and maintaining trust requires the public be given some normally confidential information. He argues there is a public interest in knowing the process of how this case was handled, and his movements so that the public can be reassured about the system and that they were not exposed. It is fair to note that mistakes were made in this case – he then went to hospital and was discharged despite having disclosed that he had recently travelled from Africa. However there is as Art acknowledges a significant difference between releasing this information, and the victims personal private details. It is hard to see how releasing that information really would provide public reassurance? I’d suggest it doesn’t really, instead it feeds fear and distrust which are the greatest killers in epidemics.

Highly dangerous infectious diseases create unique ethical challenges because by their very nature those who suffer them are as Battin et al put it “both victims and vectors of disease“. But whether someone is a victim or a vector of a disease, we ought to remember that they are still a person and as such deserve to have their private information protected, especially if disclosure is unlikely to benefit and may well harm the public’s interests, no matter how interested they are in knowing it.

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

 

 

 

Adrenaline, Information Provision and the Benefits of a Non-Randomised Methodology

17 Aug, 14 | by Iain Brassington

Guest Post by Ruth Stirton and Lindsay Stirton, University of Sheffield

One of us – Ruth – was on Newsnight on Wednesday the 13th August talking about the PARAMEDIC2 trial.  The trial is a double blind, individually randomised, placebo controlled trial of adrenaline v. normal saline injections in cardiac arrest patients treated outside hospital.  In simpler terms, if a person were to have a cardiac arrest and was treated by paramedics, they would usually get an injection of adrenaline prior to shocks to start the heart.  If that same person was enrolled in this study they would still receive an injection but neither the person nor the paramedic giving the injection would know whether it was adrenaline or normal saline.  The research team is proposing to consent only the survivors for the collection of additional information after recovery from the cardiac arrest.  This study is responding to evidence coming from other jurisdictions that indicates that there might be some significant long term damage caused by adrenaline – specifically that adrenaline saves the heart at the expense of the brain.  It is seeking to challenge the accepted practice of giving adrenaline to cardiac arrest patients.

Our starting position is that we do not disagree with the research team.  These sorts of questions need to be asked and investigated.  The development of healthcare depends on building an evidence base for accepted interventions, and where that evidence base is not forthcoming from the research, the treatment protocols need changing.  This going to be tricky in the context of emergency healthcare, but that must not be a barrier to research.

There are two major ethical concerns that could bring this project to a grinding halt.  One is the opt-out consent arrangements, and the other is the choice of methodology.

Consent, then. more…

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…

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