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Drug Legalisation in Uruguay: Opening up Pandora’s Box

8 Aug, 13 | by BMJ

Guest post by Melissa Bone, University of Manchester

Uruguay is poised to become the first country in the world to legalise and regulate the sale of cannabis for recreational use.  On the 31st July 2013 a draft bill legalising cannabis was passed by members of Uruguay’s lower house of congress, where 50 out of a possible 96 MPs voted in its favour.  If approved by the senate as is expected then the government will legally control the production, distribution and sale of cannabis.  The bill allows for each Uruguayan household to cultivate up to 6 cannabis plants.  Alternatively, residents could join a co-operative which would be licensed to grow up to 99 plants.  Private firms will be able to produce cannabis as well, but they will be required to sell it to the government, who will in turn sell it to consumers through pharmacies.  Only Uruguayan citizens will be able to purchase cannabis; they can purchase up to 40g per month (minors will be excluded).  Driving while under the influence will remain a crime.

Many commentators recognise that Uruguay has taken this bold step due to the devastation that’s wreaked by the so-called “war on drugs”.  This phrase was first coined by President Nixon in1971, and it is widely employed on both sides of the drug legalisation debate to describe a global position that prohibits the possession, production, and sale of certain psychoactives, all of which are listed in the UN drug conventions.  Advocates of drug reform often use the phrase to expose the aggressive and militant tactics which are used in producer countries especially, in an attempt to restrict the production and trade of illicit substances.  For instance, the Latin American region has the highest murder and drug-related violence rates in the world, drug cartels have infiltrated and corroded various positions of power, infamous aerial fumigation operations have destroyed farmer’s livelihoods, and this along with numerous other human rights abuses provides the backdrop for Uruguay’s brave decision.

Predictably, the International Narcotics Control Board (INCB), a committee tasked with ensuring compliance to the UN drug conventions, doesn’t quite see it this way. more…

Emmerich on Fitness to Practise

30 Jul, 13 | by Iain Brassington

Having asked out loud whether anyone could explain a couple of odd FtP decisions, I got this from Nathan Emmerich, offering sociological pop at an answer… 

Iain wondered if anyone could explain the morality that underlies a couple of recent Fitness to Practise decisions made by the GMC.  Well, more accurately he wondered if anyone could explain the “public perception” or “public confidence” aspect of the GMC’s Fitness to Practice guidelines.  Never one to shirk a challenge, I thought I would give it a go…

The first thing to note is that one has to change, or perhaps expand, the terms of the debate.  As a discipline applied philosophical bioethics tends to focus on “ethics”, “ethical reasoning” and codified rules over what I (and some others) would call “morality”.  For our present purposes the starkest way to express the idea is by appeal to the historical morality of the UK medical profession, which used to be based on the idea of the British gentleman of a certain class and standing (and, obviously, race and gender).

This morality was uncodified – it had no explicit ethics.  Indeed, more than this, it was held to be uncodifiable both in principle and as a matter of morality.  It was thought it would be wrong to codify gentlemanly (medical) morality as to do so would open the way to, first, individuals who merely followed rules rather than being the correct sort of persons or having the right character.  Second, it would lead to people who did not have the right character or standing attempting to second-guess the decisions of medical professionals or gentlemen.  Such a thing was, of course, intolerable.

There is no denying that there was a lot wrong with this ‘moral culture’, and a range of factors has been influential in the modification of medical morality from this historical position to the one we have today.  However, “medical morality” has vanished completely, indeed, it is impossible for it to do so: the medical profession (indeed any profession or cultural group) has some underlying moral ethos.  Some cultures, like modern medicine, may also have explicitly stated ethical codes and guidelines that may be more or less in line with the underlying moral culture.  Nevertheless the moral culture itself is not obviated by these codes.  Indeed it underpins the existence and application of any such formally stated ethics.

The problem here is that no rule contains the principles of for its own application.   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…

Not in any Way Topical.

22 Jul, 13 | by Iain Brassington

I know, I know.  I keep banging on about the irrelevance of genetics when it comes to families – about why parenthood isn’t a genetic thing.  But, actually, now I think about it – Duchess of Cambridge blah blah baby blah… I wonder what, if any, constitutional implications there’d be if the heir to the throne were infertile and adopted?

Yeah, I know that it’s doubtless happened before without anyone knowing – but just suppose that the new third in line to the throne were, say, an adopted Cambodian orphan instead of a (close) genetic relation to William and Kate.  I can’t think of any moral objection to that being a barrier to succession.  A child raised in those circumstances would, I think, have just as much right to ascend as would a child related by blood; there’s no reason to suppose that he or she wouldn’t be a part of the family in the fullest sense.

Unless, of course, we think that the word “family” in “Royal family” doesn’t mean quite the same as the word “family” in other contexts.  But then, what would it mean?  Why would genes be important in this circumstance?

And just suppose that the people of late mediaeval and early modern England had had the same obsessions about genes.  That’s something that’s been keeping the Abstruse Goose awake.

AG

Readably big version here.

UPDATE: OK, that’s odd.  The site on which the cartoon appears is currently listed as a virus threat.  I have no idea why.

UPDATE 2: Hmmm.  Seems to work on my home computer.  It might just be the UoM servers being twitchy, then.  Oh, I don’t know.

News from Wisconsin: It’s not OK if your Child Dies, even if you’re Praying

17 Jul, 13 | by Iain Brassington

(Note: I wrote this a couple of weeks ago, but didn’t actually post it for some reason.  I’ve no idea why it’s taken me so long.  But it’s here now…)

Via Facebook a couple of weeks ago, I came across this story, about a couple whose conviction over the death of their child has been upheld:

A mother and father who prayed instead of seeking medical help as their daughter died were properly convicted of homicide, the Wisconsin Supreme Court ruled Wednesday in a decision that dramatically limits legal immunity for parents who turn to God rather than science to heal their children.

[...]

Most states, including Wisconsin, created exemptions from child abuse charges for prayer-healing parents in the 1970s to meet federal requirements.

That last sentence is one I find pretty astonishing; and I thought it worth having a dig around to see what I could learn about Wisconsin’s laws in particular.

This one sets the scene:

Practice of Christian Science. No law of this state regulating the practice of medicine and surgery may be construed to interfere with the practice of Christian Science. A person who elects Christian Science treatment in lieu of medical or surgical treatment for the cure of disease may not be compelled to submit to medical or surgical treatment.

I’m puzzled by the particular emphasis here.  Does Christian Science have a big following in Wisconsin?  Why does it get special mention?  Still: I guess that the gist of the law is unobjectionable – it says, in effect, that a person with capacity mayn’t have treatment forced on them, which is fair enough.  We might even infer that the person who drafted the law thought Christian Science so daft that it needed to be spelled out explicitly that people invoking it have capacity, whatever the appearance.

Still: electing to refuse treatment is one thing; refusing it on behalf of another is another.  It’s at this point that things get a bit weird.  This law, for example, states that

[a] determination that abuse or neglect has occurred may not be based solely on the fact that the child’s parent, guardian, or legal custodian in good faith selects and relies on prayer or other religious means for treatment of disease or for remedial care of the child.

And this feeds into the statute that is, as far as I can see, most relevant to the Neumanns’ case, with §6 being particularly noteworthy:

Treatment through prayer. A person is not guilty of an offense under this section solely because he or she provides a child with treatment by spiritual means through prayer alone for healing in accordance with the religious method of healing permitted under s. 48.981 (3) (c) 4. or 448.03 (6) in lieu of medical or surgical treatment.

Crikey.  I don’t know how that’s justifiable.  I mean, it’s one thing to say that families have the right to function as they will, and that parents have the right to raise their children as they see fit.  I’m not sure that they do (morally, I mean, not legally) – but even if they do have such a right, one would have thought that it has limits.  It’s not hard to think of lurid examples of where the “right” might run out.  But it’s tempting to think that praying instead of seeking treatment that, y’know, has a good evidential basis, might be a straightforward and non-lurid instance of the right petering out.  “Treatment by spiritual means” is a bit rum, too.

If you’ve got certain convictions, you shouldn’t be surprised if you end up with a second conviction of  a quite different sort.

Charles Foster ponders the case here.

Bye-bye, rhino…

25 Jun, 13 | by Iain Brassington

It would appear that the western black rhino has bitten the dust.  Not a western black rhino, but the western black rhino.  There’s no more of them.

It’s sometimes hard to say exactly what causes an extinction – something like predation might be the effective cause, but if the population of a species is not under pressure from other directions, it might not in itself be enough: over-predation of a prey species causes a population crash in the predator, which allows the prey to recover, which allows the predator to recover, and so on.  For this reason, it’d be hard to say with absolute certainty that this species has been extinguished because of human activity.  All the same, whatever humanity’s precise role in the extiction of this rhino, it’s overwhelmingly likely that human activity has contributed in some significant way; and it’s highly likely that one of the main factors is the continuing demand for rhino horn as an ingredient in medicine.  (That’s certainly what PZ Myers infers, and it’s hard to deny the plausibility of the idea.)

What comes next is straightforward enough: a lament that this species of rhino has vanished, and all rhinos (and goodness knows what else as well) might go the same way, for the sake of supplying medicines that don’t work.  And it’s true that the sacrifice of a species on the altar of useless folk-remedies is a particular waste.  Not only have we lost something magnificent: we’ve lost it for absolutley no good reason at all.

But let’s imagine for a moment that rhino horn actually did have some medicinal property.  Would that mitigate the loss? more…

Say twenty hail Autonomy’s and reflect on what you have done – bioethicists as having some, but not priestly authority.

17 May, 13 | by David Hunter

Nathan Emmerich, occasional commentator here at the JME blog has recently published an interesting piece in the Guardian which argues against us taking bioethicists as having a particular type of expertise. While I enjoyed and agree with much of what he argues I do have a couple of quibbles – in particular I worry that the emphasis on inclusiveness and democracy could in effect lead to the exclusion of the bioethicist, which I think would be a mistake.

The type of expertise he argues against bioethicists having is basically what I will refer to as authoritative expertise – someone who has authoritative expertise in a particular field ought to be deferred to when there is a disagreement – their opinion is “better” than ours as lay decision makers. So for example when deciding how long an object is, and whether it will fit in the boot of our car, we ought to defer to the chap with the tape measure, since their measured judgement is better than ours.

I use this example for a reason – Emmerich focuses on knowledge based expertise (no doubt because it is easier to explain to the lay public…) but this isn’t the only form of expertise that warrants some deference there is also expertise which is performative (in this case the act of measuring well). I’m inclined to think that if bioethicists deserve any deference it will be due to their performative expertise, rather than their knowledge.

Emmerich suggests however that bioethicists should not be taken as having authoratative expertise because he thinks knowledge about morality is more like knowledge about aesthetics than knowledge about facts. Hence we ought to give no more weight to the bioethicists opinion about an ethical issue, than we do someone heavily steeped in the Art’s worlds opinion about a piece of modern art – they have a “sophisticated” view but that doesn’t tell me what I should think about the piece.

He thinks bioethicists should conceive of themselves as thinking alongside, working with people to work out what to do rather than telling them what to do. He argues that commenting on the biosciences is particularly dangerous for bioethicists because it is different from medical practice in that its practice isn’t inherently involving ethical decisions – hence he claims bioethicists are tempted to make pronouncements and decide about ethical issues in the biosciences rather than work with bioscientists. As an aside I think this is exactly wrong – I doubt the empirical claim is true (ie that bioethicists proclaim and make decisions more about issues in bioscience than medicine) and I think the process of conducting bioscience does involve constant ongoing ethical decision making – it’s just a different sort of decision making, about the responsible conduct of science and dissemination rather than the treatment of patients. Nonetheless lets leave that aside.

So far so good – I don’t think bioethicists ought to be taken as overwhelmingly authoritative – the most uncomfortable experience I’ve had sitting on an ethics committee was when the committee treated me as a moral expert and simply deferred to my opinion in each case – it took awhile to break them of that. But I disagree with Emmerich about why this is the case. This is in part because I object to the metaethics he is assuming – the reason we find the expert in Art uncompelling is that the general opinion is that there is no truth of the matter when it comes to aesthetic judgements. And presumably Emmerich thinks the same about morality.

I broadly take the same view as Hobbes does here:

Of Man, Being the First Part of Leviathan. The Harvard Classics. 1909–14. Chapter V.

Of Reason and Science
And, as in arithmetic, unpractised men must, and professors themselves may often, err, and cast up false; so also in any other subject of reasoning the ablest, most attentive, and most practised men may deceive themselves, and infer false conclusions; not but that reason itself is always right reason, as well as arithmetic is a certain and infallible art; but no one man’s reason, nor the reason of any one number of men, makes the certainty; no more than an account is therefore well cast up, because a great many men have unanimously approved it. And therefore, as when there is a controversy in an account the parties must by their own accord set up for right reason the reason of some arbitrator, or judge, to whose sentence they will both stand, or their controversy must either come to blows, or be undecided, for want of a right reason constituted by Nature; so is it also in all debates of what kind soever. And when men that think themselves wiser than all others clamour and demand right reason for judge, yet seek no more but that things should be determined by no other men’s reason but their own, it is as intolerable in the society of men as it is in play after trump is turned, to use for trump on every occasion that suit whereof they have most in their hand. For they do nothing else that will have every of their passions, as it comes to bear sway in them, to be taken for right reason, and that in their own controversies, bewraying their want of right reason, by the claim they lay to it.

The point here is that when there is moral disagreement claiming to have the right judgement – the right reason – is like cheating at cards by claiming whenever it is your turn that the trump suit is whichever suit you have the most of in your hand. In other words the dispute is about which reason is right, hence simply saying “mine” does nothing to resolve this. But this view of morality is a bit more complex – I’m inclined to think there is a truth of the matter, it just isn’t easy to access, nor is it easy to show to others. Hobbes solution to the problem of irresolvable disputes is to establish an absolute sovereign who we both agree to defer to, and then we go with whatever they say. I roughly think that is right, with the conditional (that I suspect Hobbes would agree with) that we try to ensure that our absolute sovereign comes out with an answer that is as close to being right as possible. And given the complexity and the difficulty of divining moral truths that deliberation, debate and argument has a better chance of getting the “right” answer than having someone sit by themselves in a room and ponder it.

I think the bioethicist is in a position to contribute something useful to such deliberation, debate and discussion in two ways, both of which require some expertise – even if it is not totally authorative expertise. The first way is this, the bioethicist I assume will have access to more knowledge both about what has been argued in regards to ethical theory and in regards to moves in applied ethics. Knowing these moves can short-cut some discussion and debate by showing paths that will lead nowhere – the implications and consequences of particular arguments. This I think is as useful an input as that of someone who – trained in an empirical discipline – contributes their knowledge of their discipline and its findings to the debate about a particular issue. Secondly, and perhaps more importantly, a bioethicist ought I think to have a certain sort of performative expertise. This is an expertise at argument and debate, at critical thinking, questioning assumptions and being aware just how arguments go wrong, in effect this is philosophical expertise.* Is this authoritative? I think at best only partially – largely it gives the bioethicist the authority to suggest that particular lines of pursuit won’t be fruitful. In any case I think philosophical reasoning is inherently democraticising – because of its origins and use in debate and discussion it ought to aim to up skill and inform everyone in the discussion, rather than claim special status – to go back to my man with a measuring tape analogy the good bioethicist tries to provide everyone in the discussion of whether object x will fit in the car boot with a tape measure for themselves.

There is a more general line of argument which can be drawn from Emmerich’s argument against expertise in regards to bioethicists which is an argument against involving “experts” in making bioethical decisions – in effect Emmerich implies that these being decisions by experts, even committees of multiple types of experts is anti-democratic – because it involves having others making moral decisions for “us” when that is actually our responsibility. Now of course a good bioethicist would question the assumption that being anti-democratic is bad, but I’m going instead to suggest that having others decide for you can be, and in this case is, perfectly democratic. Direct democracy is well known to have certain limitations, not the least that the electorate often wants contradictory things for example that given the option people will opt for lower taxes and higher social spending… I suspect that bioethical issues are an area where direct democracy will be unsatisfying – either because of intractable disagreements within the population (think abortion) or because the technical nature of the decision means that predictably decisions will be made that lead to outcomes that few in the population would endorse. In these cases it would seem sensible to agree to establish a group of decision makers (in Hobbesian terms a sovereign) to delegate this decision to. We do this in regards to most political decisions and hence it seems that establishing a public decision making body such as the HFEA can be a perfectly democratic response, as long as it is established in the right way (in this case in a process where it occurs as a result of legislation passed by a duly elected government). Such a body may not have the moral authority of the expertise of knowing the right answer but they are our best bet at getting somewhere close to it, and hence we ought to accept their decision making. Of course Emmerich is right to think that this needs to be a public facing process which should take into consideration public opinion and input from individual members of the public, but these should be taken as no more authoritative than individual expert’s opinions. Otherwise we are in effect allowing the public (or more accurately a tiny unrepresentative vocal bit of the public) claim “right reason”, when this isn’t warranted.

Emmerich identifies a real temptation and danger for bioethicists, it is tempting to act as moral authorities, and broadly speaking illegitimate to do so. But there are dangers in the other direction as well which we need to be wary of as well I’m inclined to think direct democracy worship is no better than the autonomy worship than many current bioethicists practice.

* I am in this piece using a less than inclusive definition of bioethicist – meaning someone who has at least some training in thinking philosophically about ethical issues – this doesn’t have to be formal education of course,and could be self taught,  but the argument I am making depends on bioethicists as having this – those who work simply empirically on issues in bioethics but have no normative engagement (if such a person actually exists) would at least by the standards of this piece not count as a bioethicist. Sorry.

Conference: Compassion Fatigue: Changing Culture in the NHS

18 Apr, 13 | by Iain Brassington

26-28 June, Woodbrooke Quaker Study Centre, Birmingham

(via Andrew Edgar)

Can the language of compassion capture the moral problems confronted by the NHS, or might it obfuscate and distract us from more subtle and demanding issues?

Through a series of plenary addresses, workshops, panels and shared opportunities for discussion, “Compassion Fatigue” will provide an opportunity to explore the language of compassion, and the impact that it has on the practice of health care provision.

More details below the fold. more…

Cigarettes and Plain Packs: The Ad Campaign

16 Apr, 13 | by Iain Brassington

Blogging here has been light for a little while, and probably will be for a little while longer because of Stuff and Things – but something caught my eye in Sunday’s Indy* that struck me as worth comment.  It was a full-page advert placed by JTI, which describes itself in the small print as “a leading international tobacco company” (and it is).

Anyhoo… the main bit of the ad is a copy of an email, obtained by an FoI request, apparently from the UK Department of Health to the Australian Department of Health and Ageing; it reads as follows (with the highlighting copied from the ad here as closely as I can manage):

Dear [redacted]

I work on the UK government’s tobacco policy team, with [redacted] and you will be aware that the UK government is considering the introduction of plain packaging of tobacco products.

As I’m sure you’re aware, one of the difficulties regarding this is that nobody has done this and therefore, there isn’t any hard evidence to show that it works.   Therefore, I am wondering whether the Australian government drafted any type of impact assessment or cost analysis in which the likely benefits and costs are measured, and if so, whether you would be willing to hare the information with us.

Many thanks,

And then in bold underneath, JTI’s copywriters have added:

WE COULDN’T HAVE PUT IT BETTER OURSELVES

Now, the email is dated the 10th of May 2011.  Australia’s plain-packaging law came into effect on the 1st December 2012; as far as I’m aware, Australia was the first country to pass such a law.  So, at the time of writing, there could not have been any hard data about its impact.  There could not possibly be any hard evidence to show that plain packaging works to reduce smoking rates.

The argument of the advert – actually, no: the subtext, since it’s not really an argument – is that the UK government should not introduce plain packaging because of the lack of hard data.  This seems to amount to a claim that governments should not introduce policies without hard data concerning their efficacy.  And there’s something correct about that for the most part.  But hard data are only available in the wake of the introduction of a policy.  If the policy is novel – as it is – then JTI would seem to be committed to the claim that no government should be the first to introduce a policy; which is as much as to say that no government should introduce it at all.

It’s understandable that that’s what they think.  But why not just say so?  Isn’t this ad just rather disingenuously dressing up opposition as something else?

Or have I missed something?

 

*Saturday’s Indy, with its column-inches devoted to Andrew Wakefield, is worth rather a lot of comment: more than I can offer at the moment.  I’ll point you in the direction of Martin Robbins in the Staggers instead.

Cutting Class: Thinking about Self-Harm without Disgust

29 Mar, 13 | by BMJ

Guest Post by Kerry Gutridge* and A.M. Calladine

Imagine you are a doctor, nurse or teacher and someone in your care asks for a razor.  The person you look after wants to slice into their own skin and draw blood. They are compelled to hurt themselves.  They have an overwhelming urge to feel a momentary visceral sense of pain.  Would you provide them with a blade?  Is it ever right to enable people in your care to harm themselves?

At first glance such questions may appear shocking and seem likely to elicit a strong gut reaction. Surely it can’t be right for people in a position of authority, with a duty of care to be seen to apparently condone or provide a means for vulnerable people to engage in such self-destructive behaviour?

Yet recent media reports (such as this and this) suggest that such a choice has already been made.  Teachers at Unsted Park gave a “special needs” pupil sterile Bic safety blades so they could injure themselves in the privacy of the school bathroom.  According to reports, staff checked in on the pupil every two minutes.  After the pupil had finished cutting teachers cleaned and dressed their wounds.

The news story attracted a predictable sense of outrage.  Readers commenting on newspaper message boards found the school’s decision at best incomprehensible and often disgusting and immoral.  According to the top-rated comments on the Daily Mail website:

That’s Nuts!  What’s wrong with these people??!!!

And

Absolutely shocking, I am by far an expert in the field but that sounds ridiculous to me

Unfortunately such feelings of revulsion and disgust are not limited to the comment boards of the Mail.  One of the authors of this blog was told by another academic that their doctoral abstract on the subject of self-harm made them feel physically sick.

The news reports on the case at Unsted School are vague.  The nature and severity of the pupil’s injuries are unclear and the age of the pupil is put between seven and nineteen.  Without more detailed information it would be disingenuous to comment at length on this specific case.  The Unsted Park School policy of allowing the pupil to self-harm has since been abandoned after some of the teachers complained to the local authority.

It is not the first time that the issue of institutional enablement or allowance of self-harm has been subject to scrutiny. more…

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