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JME

Controversial Views on “FGM”

2 Feb, 16 | by bearp

by Brian D. Earp / (@briandavidearp), with a separate guest post by Matthew Johnson

Even the term is controversial. Female genital mutilation/FGM? Many women from societies that practice such traditional initiation rites find the term offensive. Female genital alteration? But that could refer to a wide range of procedures, including some that might be medically advised. Female circumcision? That’s the term used by many practicing communities—but others think it trivializes harm. Whatever the term, the set of practices called “FGM” by the World Health Organization has been in the media of late.

According to the Guardian, “The number of women and girls in the United States at risk of female genital mutilation has tripled over the last 25 years, according to a government study released on Thursday.” However, “the increase in women at risk in the US [is] wholly a result of rapid growth in the number immigrants” from countries that practice FGM.

In other words, there are apparently no firm data on how many (female) individuals have actually been affected by non-therapeutic genital altering procedures in the United States in recent years: “being at risk” seems to have been defined as “coming from a country where such procedures are known to be performed in some communities.”

But the type and prevalence of “FGM” procedures can vary widely within countries—i.e., they can occur in some communities and/or families but not others—and as Sara Johnsdotter and Birgitta Essén have recently argued, the practice is often relinquished as immigrants begin to acculturate to the so-called West.

So the headline claim that “Genital mutilation risk triples for girls and women in US” should be treated as controversial, in my view—not to mention ripe for being widely misunderstood—pending further, more finely-grained research.

Another controversial view I should highlight comes from a forthcoming paper in the Journal of Medical Ethics, where Kavita S. Arora and Allen J. Jacobs are set to propose that certain “minor” forms of FGM should be tolerated in Western societies. The paper has not yet been published, but my response to it—a piece entitled, “In Defence of Genital Autonomy for Children—is, for some reason, already available online-first. You can read the unabridged version of my paper (with a detailed appendix) by clicking here.

Keep your eyes open for an official announcement from the journal regarding the paper by Arora and Jacobs; I understand that it will be published alongside a commentary from the editors and at least two other dissenting views besides by own.

Finally, let me turn to an essay by Dr. Matthew Johnson of Lancaster University, which will certainly be regarded as controversial by some, but which I think expresses a valuable perspective worth taking seriously (even if one ultimately disagrees with certain aspects of Dr. Johnson’s argument). The essay is published below as a “guest post” on this blog. Please keep in mind that its contents reflect the views of Dr. Johnson, and not necessarily those of the Journal of Medical Ethics, its editors, or anyone else.

Cameron, FGM and Boarding Schools: Empathy and Punishing Parents

by Dr. Matthew Johnson

David Cameron’s declaration that there will be ‘no more’ passive tolerance of Female Genital Mutilation (FGM) comes against the backdrop of the revelation that 1,000 cases of FGM had been recorded in three months this year as part of NHS data collection on the practice. This data collection commenced in April as part of the Government’s eradication drive, and its findings demonstrate the seriousness of the practice. One natural response to the problem is, as Cameron suggests, to call for sterner punishments for practitioners and, indeed, parents who inflict the practice. However, if our concern is to prevent harm, there are many reasons to reject that route and indeed precedents in our treatment of other (different) harmful practices which highlight the deficits in the approach.

more…

Should Junior Doctors Strike?

25 Jan, 16 | by Iain Brassington

Guest Post by Mark Toynbee, Adam Al-Diwani, Joe Clacey and Matthew Broome

[Editor’s note: Events in the real world have moved more quickly than David or I have; the facts of the junior doctors’ strike have moved on since the paper was published and this post submitted.  Still, the matters of principle remain. – IB]

A strike by junior doctors is planned for January 2016 following failure of the last-ditch ACAS (Advisory, Conciliation and Arbitration Service) mediated talks between the BMA and the Department of Health (via NHS Employers) – see media reports here, here, and here.  Industrial Action had previously been planned for December last year but was suspended at the last minute when both sides agreed to the now failed mediation.  The current regrettable position has resulted from over two years of formal negotiations between the BMA and NHS Employers regarding a new junior doctor contract.  The BMA went to its junior doctor members for a mandate for industrial action last autumn as the talks stalled and received an almost unprecedented mandate with 98% indicating they would be prepared to strike.

Subsequently, many well-known figures voiced their concerns about the ethical and practical implications of industrial action (here and here).  Strikes by doctors are not common, with only one example in the UK in the last generation, but far from unprecedented.  The overwhelming recent ballot result raises many interesting issues, foremost among them the ethical legitimacy of industrial action by doctors, specifically junior doctors.

The term ‘junior doctor’ is often misunderstood.  It applies to all doctors from graduation until completion of specialist training – over 50,000 individuals.  Their roles and responsibilities have evolved significantly over many years; their pay and hours have reduced whilst their debts, costs and responsibilities have increased.  The patient-doctor relationship has also changed with increased emphasis on patient involvement and the promotion of autonomy.

We have looked at arguments proposed during previous instances of doctor industrial action, often from this journal (see this, this, and this) and considered them in the current context.  Absolute ethical objections to doctor industrial action appear old-fashioned, especially when applied to junior doctors.  Concerns about harms caused by doctors withdrawing their labour also seem less sustainable in the light of recent evidence than perhaps would be expected.  Indeed, the ethical responsibilities of doctors may require them to take action if they believe patient care, or the well-being of their colleagues’, is being compromised.

So far there has been strong support for the junior doctors from the Consultant bodies of many Trusts, and the Royal Colleges.  The modern NHS asks more of its junior doctors than ever before, placing ever increasing responsibilities on their shoulders, with ever more challenging working conditions.  With industrial action by junior doctors now likely to go ahead, claims that it would be unethical appear to us to be increasingly hard to justify.

Read the paper here.

*Reboot*

25 Jan, 16 | by Iain Brassington

It’s been a while, what with marking and supervising and writing new courses and general faff, but with luck the blog’ll be getting updated a bit more frequently; there’s a couple of guest posts in the queue, the first of which I’ll post later today.  And I’m hoping to restart semi-regular moans of my own ASAP, too.

In the meantime, I’m just going to draw your attention to this paper in the latest issue of the JME, in which Montgomery and Montgomery write about Montgomery.  If that doesn’t give you a deep sense that all is well with the world, you’re dead inside.

Should Doctors Strike?

9 Nov, 15 | by bearp

 

Should doctors strike?

Is it ethical for doctors to go on strike, potentially putting their patients at risk of getting inadequate treatment?

As the BBC reports, ministers and junior doctors are currently “locked in a dispute.” One possible outcome of this disagreement is a physicians’ strike, which raises a number of tricky ethical questions. But before we get into those questions, it might be helpful to take a look at a quick sketch of what the problem is all about (from the BBC article):

Junior doctors’ leaders are objecting to the prospect of a new contract. The government has described the current arrangements as ‘outdated’ and ‘unfair,’ pointing out they were introduced in the 1990s. Ministers drew up plans to change the contract in 2012, but talks broke down last year. The government has indicated it will impose the new contract next year in England. The BMA has responded by initiating the industrial action process. …

The latest information provided by the government, which is the most detailed so far, includes an 11% rise in basic pay for doctors. But that comes at a price. Other elements of the pay package are being curbed.

The prospect of a strike appears to be firmly on the table: “Doctors can take strike action but only if it affects non-emergency care. The last time this happened was during [a] pensions dispute in 2012, but that was the first time such action had been taken for almost 40 years. Doctors still attend work – so they are ready for urgent and emergency cases.”

The Journal of Medical Ethics has tackled this issue before. Writing for the journal in 2013, John Park and Scott Murray gave an analysis of the 2012 “pensions dispute” just mentioned.

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. Almost all doctors will agree that we should always follow the law, but often the law is unclear or does not cover a particular case. Here we must appeal to ethical discussion.

The General Medical Council, in its key guidance document for practising doctors … claims that ‘Good doctors make the care of their patients their first concern.’ Is this true? And if so, how is this relevant to the issue of striking? One year on since the events, we carefully reflect and argue whether it was right for doctors to pursue strike action, and call for greater discussion of ethical issues such as the recent strikes, particularly among younger members of the profession.

In light of the current turmoil, the Journal of Medical Ethics welcomes submissions on the ethics of physicians striking, including papers which build on, critique, or respond to the work of Park and Murray. Their 2013 paper can be accessed here. As Associate Editor Dominic Wilkinson stated in an interview:

In their submissions, authors should focus on ethical questions and put their discussion in the context of ongoing international debate and existing literature. Possible questions include, for example: what is a fair level of remuneration for public sector healthcare workers, including doctors? Should all doctors be paid equally? Should antisocial hours be rewarded financially? In a financially constrained environment, should doctors’ pay go down in order to protect funding for health care provision?

Papers can be submitted to the Journal of Medical Ethics here. Author instructions are here.

The Journal of Medical Ethics remains the top-ranked journal in bioethics for 2015 according to Google Scholar Metrics, with an impact factor of 1.511 and an h5-index of 28. We look forward to seeing your submissions.

Check out the current issue by clicking here.

Flibanserin and Regulatory Failure

25 Sep, 15 | by Iain Brassington

Guest Post by Adriane Fugh-Berman

On August 18th, 2015, the FDA approved flibanserin (brand name Addyi), a purported aphrodisiac that can drop blood pressure so precipitously that users sometimes pass out and require medical intervention to regain consciousness.  The labelling for flibanserin indicates that it is for:

the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD), as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is NOT due to:

• A co-existing medical or psychiatric condition,

• Problems within the relationship, or

• The effects of a medication or other drug substance.

Focus for a moment on “Low sexual desire that causes marked distress or interpersonal difficulty”.  So a woman upset by a belittling spouse who wants sex more often than she does is eligible for a prescription drug?  It gives a whole new meaning to the term “drugs of abuse.”  Note that even if the putative patient isn’t distressed, she is still eligible for being drugged if her partner is creating interpersonal difficulty.  Here’s a thought – why not sedate him instead?

Not every partner is a jerk, and there are certainly women distressed by loss of libido, but flibanserin isn’t the answer for these women either.  As an aphrodisiac, it’s no great shakes; its predominant mechanism may simply be sedation.  Flibanserin increased “sexually satisfying events” by less than one event a month (the event, by the way, need include neither an orgasm nor a partner).

The labeling of flibanserin reveals the absurdity of this “disease” and its treatment. more…

Putting a Price on Empathy

12 Aug, 15 | by BMJ

Guest Post by Sarah Carter

My paper is another to add to the ever-increasing number of articles about moral (bio)enhancement – but why is this issue so important?  To take a cynical view: if we had a pill or injection that could make people more moral, less prone to harming others, and so on, it would likely be very attractive to governments (perhaps because of real concerns that we’re headed for disaster unless such steps are taken, or simply because it would save on policing and military bills).  So it’s very important to try to get our heads around this subject while it’s still something that’s merely an idea, rather than waiting until it’s something in our medicine cabinets.  This means thinking about and discussing everything from what moral enhancement would actually involve, right through to questioning how it should be distributed, regulated, and even – as my paper addresses – promoted to the public.

Writers such as Persson and Savulescu argue that there is a need to undertake moral bioenhancement as a means to avoid mankind wandering down the path of ultimate harm, but they concede that many people (especially those we might say to be most in need of moral bioenhancement) would be unlikely to undergo it willingly.  In 2014, Vojin Rakic suggested that incentives such as tax breaks, retirement benefits, schooling allowances, and affirmative action policies, should be used as a way to encourage people to undergo moral bioenhancement.  I think that Rakic’s idea, while prima facie sensible and reasonable, simply will not work. This is not due to issues of coercion or social justice that we would normally associate with the use of incentives, but rather because likely public perceptions of moral bioenhancement mean that the use of incentives for this purpose may present a taboo trade-off. more…

How do Medical Students Learn Ethics?

3 Aug, 15 | by Iain Brassington

Guest Post by Carolyn Johnston

How interested are medical students in learning ethics and law? I have met students who have a genuine interest in the issues, who are engaged in teaching sessions and may go on to intercalate in ethics and law. On the other hand some consider that ethics is “just common sense”. They want to know only the legal parameters within which they will go on to practice and do not want to be troubled with a discussion of ethical issues for which there may not be a “correct” answer.

Ethics and law is a core part of the undergraduate medical curriculum and so in order to engage students successfully I need to know whether my teaching materials are relevant, useful and interesting. In 2010 I ran a student selected component in which MBBS Year 2 students created materials for medical ethics and law topics for pre-clinical students which they considered were engaging and relevant, so that students might go further than learning merely to pass exams. One student, Marcus Sorensen, who had managed a design consultancy focusing on web design and development before starting his medical studies, came up with the idea of a website as a platform for ethics materials for King’s students and he created the website http://get-ethical.co.uk.

It was through our ongoing discussions that we identified a lack of information about students’ experiences of learning medical ethics and law, especially outside the classroom environment. more…

How to be a good (consequentialist) bioethicist…

6 Jul, 15 | by David Hunter

There has recently been a pattern of papers (and I am not going to identify which ones) which I take as being slightly embarrassing to academic bioethicists because they portray us in a less than flattering light because of the naive mistakes they seem to make, or the outlandish poorly argued claims they make. I have noted a trend for these to have come from relatively new, consequentialist bioethicists and being the helpful sort that I am, the aim of this blog post therefore is to help consequentialist bioethicists from falling into these pitfalls.

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…

What should Investigators be Doing with Unexpected Findings in Brain Imaging Research?

22 Jun, 15 | by BMJ

Guest Post by Caitlin Cole

Incidental findings in brain imaging research are common. Investigators can discover these unexpected findings of potential medical significance in up to 70% of their research scans. However, there are no standards to guide investigators as to whether they should actively search for these findings or which, if any, they should return to research participants.

This complex ethical issue impacts many groups in brain imaging: participants and parents of child participants who may desire relevant health information, but alternatively may suffer from anxiety and financial burden; investigators who must ethically grant their participants autonomy, but who also may suffer from budget and personnel restrictions to manage the review and report of these findings; Institutional Review Board (IRB) members who must provide ethical oversight to imaging research and help mandate institutional standards; and health providers who must interface with their patients and assist with follow up care when necessary.

Our research study shows these groups share some ideas on the ethics of returning incidental findings – the researcher has an ethical responsibility or obligation to tell a subject that there’s something there, however they do it, but just inform the subject, even though it’s not part of the research” – yet also acknowledge the inherent risk in reporting medical research information. As one of our IRB members commented, I mean [in regards to withholding findings] one reason would be to protect the patient from doing something stupid about them.

When participants are asked about incidental findings, they consistently state that they want to receive all information pertinent to their health. Research participants want to make their own medical decisions and feel investigators have a responsibility to keep them informed.

However, it is clear from our research that participants do not always understand the difference between a brain scan for research purposes and a clinical scan. The incidental finding reports that they receive include personal health information, written in medical jargon, discovered during a clinical procedure that may have immediate or long term medical significance. Because of this crossover between conducting research and sharing health information, participants may overestimate the clinical utility of the reported research information. This is a challenge for investigators whose role is to conduct research, not to diagnose participants or offer findings with clinical certainty. Participant assumptions otherwise have the potential to cause downstream legal complications for the research institution.

It is necessary to understand the impact on all parties involved in the process of disclosing incidental findings to determine appropriate management policy. This challenging task should not be underestimated as these groups think differently about the balance between risk and benefit based on their role in this process, whether they be a research participant, a research investigator, an IRB member or a health provider. Overall there is an ethical demand to manage and report unexpected findings discovered in brain imaging research; finding a way to do this while minimizing negative impact for all involved is important.

Read the full paper here.

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