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JME

Gaia Doesn’t Care where your Baby Comes From

25 Jul, 14 | by Iain Brassington

Guest Post by Dominic Wilkinson, Associate Editor, Journal of Medical Ethics

In a provocative paper published today in the Journal of Medical Ethics, US theologian Cristina Richie argues that the carbon cost and environmental impact of population growth in the West should lead to restrictions on artificial reproduction.  She points to the substantial carbon emissions that result from birth in developed countries like North America.  Seven percent of the world’s population contribute fifty percent of the world’s CO2 emissions, and children born by in vitro fertilization are likely to be in this seven percent.  Richie argues in favour of a carbon cap on artificial reproduction and argues that IVF should not be funded for women who are “biologically fertile”.

Richie is correct to point to the enormous carbon cost of additional human population. One of the most significant ways that individuals in Western countries can reduce global carbon emissions is by having fewer children. However, her focus on artificial reproduction and on the “biologically fertile” is not justified.

Richie ignores questions about the moral implications of climate change and climate cost for natural reproduction.  She sets to one side “the larger realm of sexual ethics and procreation”.  Yet there are two reasons for thinking that this is a mistake.  First, as Richie notes, “Reproduction-related CO2 is primarily due to choices of those who have children naturally: a huge majority of all births.”  Only 2% of all children born in the UK are conceived by IVF.[1]  Therefore interventions to reduce the number of children naturally conceived will potentially have a fifty fold higher impact on carbon emissions.  Secondly, it is profoundly unjust to apply restrictions to reproduction only on those who are unable to conceive by natural means.  It could be justified to limit the reproductive choices of women because of concern for the environment.  However, if this were justified, it would be equally justified to try to limit the reproduction of the naturally fertile and the naturally infertile.  It is ad hoc and unfair to confine our attention to those who must reproduce artificially.

Second, Richie proposes that public funding for IVF be confined to those who are “biologically infertile”, excluding same sex couples and single women.  However, she provides no reason at all for restricting the availability of IVF for these women.  Put simply, the carbon cost of artificial reproduction is exactly the same for a woman who is infertile because of endometriosis or polycystic ovary syndrome or because she does not have a male partner.  The only possible reason for making a distinction between biologically infertile and biologically fertile women is because Richie believes that lesbian and single women are less deserving of public funding because of their lifestyle choices.  However, that argument, as problematic and contentious as it is, is completely independent of the question of environmental impact.  The carbon cost of children born to gay couples is likely to be exactly the same as the carbon cost of children born to women with endometriosis.

The carbon cost of additional births might well be sufficiently important for the state to justify limiting reproductive freedom.  However, if the state is going to interfere in couples’ decisions about whether to have children or the number of children that they have, it should do so fairly and equally.  Carbon caps should be applied equally to those who conceive naturally and those who require artificial reproductive treatment.  They should not be used as a way to discriminate against those who are single or gay, or have some other ‘undesirable’ characteristic.

 

[1] http://www.hfea.gov.uk/ivf-figures-2006.html#1284

ARTs in a Warming World

25 Jul, 14 | by Iain Brassington

There are some people who disagree, but we can take some things as read: there is such a thing as global climate change, it is at least substantially anthropogenic, and there are moral reasons to try to minimise it.

With that in mind, how should we think about reproductive technologies?  These are techniques whose intent is to create humans, and – presumably – those humans will have an environmental impact.  This is a question that Christina Richie confronts in her paper in the JME:

The use of ART to produce more human-consumers in a time of climate change needs to be addressed.  Policymakers should ask carbon-emitting countries to change their habits to align with conservation.  And though all areas of life – from transportation, to food, to planned technological obsolescence – must be analysed for ecological impact, the offerings of the medical industry, especially reproductive technologies, must be considered as well.

One of her suggestions is of carbon-capping for the fertility industry; she’s more reluctant to suggest a moratorium on the use of ARTs.  But she does suggest thinking quite seriously about who should get access to fertility treatment.  After all, she points out, fertility treatment is unlike other medical treatments in a number of ways.  Not the least of these is that someone whose life is saved by medicine will go on to have a carbon footprint bigger than it might have been – but that’s not the intention.  The whole point of fertility treatment is to create new humans, though – and therefore the treatment has not just a footprint, but a long-lasting carbon legacy.

I wonder, actually, whether the argument could be radicalised. more…

Are FIGO’s Regulations Risking the Lives of Pregnant Women?

10 Jul, 14 | by Iain Brassington

Guest post by Douwe Verkuyl

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women’s Health believes that there is never an indication for a tubal occlusion (TO) to be performed at the time of caesarean section or following a vaginal delivery in cases where this sterilisation has not been discussed with the woman in an earlier phase of her pregnancy.  This applies even if there is a uterus rupture.

But what if a mother of 5 children, living in rural Africa near a Catholic clinic, unexpectedly needs referral to a government hospital because of arrested labour, and faces a journey of at least 4 hours over a dirt road?  Does the Committee’s recommendation against belated TO counselling still apply if referring establishments have deliberately ignored its advice to counsel pregnant women early in pregnancy about the option of a concurrent sterilisation in the event that a caesarean section is needed?  Catholic institutions – which are often the only health facility for miles around – not only ignore this advice, but also fail to assist a woman with “sinful” modern contraception after she has returned with a scarred uterus.  In many Western, developed countries, Catholic contraception doctrines are mostly inconvenient, guilt-provoking and expensive.  In rural Africa, Latin America and the Philippines, they often kill.

Imagine a 37-year-old woman in labour in a well-equipped and staffed Doctors Without Borders (DWB) emergency hospital which happened to be located near her home.  She has previously given birth, with some difficulty, six times at home, and now there is a full civil war.  The doctors detect foetal distress.  They think there might be a 10%-30% chance her child will be damaged or die before it is born.  On the other hand, with the uncertain political situation – consider that on 17 June a DWB hospital was bombed in Sudan – and poor infrastructure, it might be the case that her chance of dying from a uterine scar during a subsequent labour is around 30%, and the probability that she has continuous access to reliable reversible contraception for the next 13 years is zero.  If she would choose to have a TO with a caesarean section that would solve the quandary.  Is it really unethical to ask her, or unethical not to give her that choice?

Read the full paper in the latest edition of the JME here.

Intentionally Exposing Patients to HIV: When Might it be Ethical?

7 Jun, 14 | by BMJ

Guest Post by Bram Wispelwey, Ari Zivotofsky, and Alan Jotkowitz

Much has been made of the fact that over the last two decades HIV has transformed from an inevitable, agonising killer into a controllable chronic disease.  But have we reached a point where infecting someone with HIV in order to avoid other, potentially worse health outcomes might be justified?  In the realm of organ transplantation we found that if we are not yet there, perhaps we should be.

Our paper was in part inspired by what many considered a shocking ruling by former Israeli Chief Rabbi Eliyahu Bakshi-Doron, who decreed that it was consistent with Jewish religious law for HIV-negative individuals to receive HIV-positive organ transplants, even if the evidence indicates a possibility for the recipient to contract the disease.  Many considered this opinion premature because only recently had HIV-positive individuals been found to be good candidates for solid organ transplantation, and doctors in South Africa were still in the early research stages of examining kidney transplantation between HIV-positive individuals.  But in examining the ethical considerations of autonomy, beneficence, non-maleficence, and justice, we argue in our paper that Rabbi Bakshi-Doron’s opinion is ethically sound.

Focusing on the history of HIV in transplantation and using a comparison to current practice with regard to another infectious disease, cytomegalovirus, we demonstrate that disallowing HIV-negative candidates from receiving HIV-positive organs would be a significant limit on patient autonomy.  The elimination of the ban on this type of potentially life-saving (and improving) donation may also represent a more socially just option, as it would expand the donor pool and engender cost savings. HIV-positive to HIV-positive donation will soon be a reality in several countries; it’s time to think about going one step further.

 

Read the full paper here.

Rescuing the Duty to Rescue

1 May, 14 | by BMJ

Guest post by Tina Rulli and Joseph Millum

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

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

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

Read the full paper in the JME here.

Multiplex Parenting: in vitro Gametogenesis and the Generations to Come

24 Mar, 14 | by BMJ

Guest Post by César Palacios-González, John Harris and Giuseppe Testa; for the full paper, click here.

Recent biotechnology breakthroughs suggest that functional human gametes could soon be created in vitro.  While the ethical debate on the uses of in vitro generated gametes (IVG) was originally constrained by the fact that they could be derived only from embryonic stem cell lines, the advent of induced Pluripotent Stem Cells (hiPSC) creates the possibility that somatic cells may be used to generate gametes.  This means that in the future it might be possible to generate human sperm and oocytes from male cells, and oocytes from female cells.  (So far it has not been possible to derive sperm from female cells.)

Among the different applications that have been explored in the academic literature, like the creation of embryos for genetic research and what has been called “in vitro eugenics”, we think that the most dramatic application of IVG will be in the field of human reproduction.  In a recent article in the Journal of Medical Ethics, Robert Sparrow rightly notices that IVG could allow post-puberty males who are unable to produce viable sperm, women who have undergone premature menopause, and those who have lost their gonads due to injury or had them removed in the course of cancer treatment to have genetically related kin.  To this list we add (and explore in our paper) a fourth use that has been overlooked until now: that IVG would allow the reparation of some of the harms done to people by means of biological involuntary sterilization. more…

The Definition of Mental Disorder: Evolving but Dysfunctional?

12 Feb, 14 | by Iain Brassington

Guest post by Rachel Bingham

In 1973 the American Psychiatric Association removed homosexuality from the official classification of ‘mental disorders’.  This was the result of a successful public campaign and changing political views.  Yet, if homosexuality could be (wrongly) diagnosed as a mental disorder – using an official classification – what does this say about the other states that remain in the classification?  How can we be sure that other states are not being labeled as mental disorders solely due to discrimination and stigma?

One way to respond to these concerns is to offer a definition of mental disorder, aiming to capture all and only genuine mental illness.  Unfortunately, this has proved exceptionally difficult to do.  Definitions that rely only on ‘facts’ – information about the brain, the genes, and so on – do not tell us whether or not a condition is really an illness.  They simply tell us about the underlying biology once we already recognize an illness to be present.  For example, finding differences in the brains of people who are criminals or of people who have recently fallen in love would not prove these states to be “illnesses”; it would only show that different states of being are reflected differently in the brain.  It is widely acknowledged that defining mental disorder requires some sort of value judgment – that is, recognition that the state in question is undesirable or harmful.  But once we bring value judgments into play concerns about social discrimination are amplified.  Might other states be wrongfully diagnosed solely because of social or political dimensions that have not yet been recognized for what they are?  If value judgments are permitted to define disorder, do we risk repeating a history of wrongful psychiatric diagnosis?  These questions are explored at greater length in the full paper in the JME, available here.

An Attack of the What-Ifs

25 Oct, 13 | by Iain Brassington

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

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

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

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

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

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

Biases in Clinical Ethics Consultation

19 Sep, 13 | by Iain Brassington

Guest post by Morten Magelssen, Reidar Pedersen, and Reidun Førde

Read the full paper here.

A difficult case involving a patient in an intensive care unit is brought to a clinical ethics consultant.  The ethics consultant argues that intensive care is futile and should be withdrawn.  The clinicians are grateful for the advice, and, with the assent of the patient’s relatives, decide to withdraw intensive care accordingly.

Clinical ethics consultation – by committees or individual consultants – involves reflection upon ethically and medically challenging cases.  When reflection is carried out in a systematic manner, then ideally the ethically salient points are brought out and discussed in a comprehensive and unbiased way.

But what if the consultation itself introduces new biases and implicit value judgments?  We won’t take a stand on how often this in fact happens, but rather draw attention to how easily it may occur and the dangers involved.  In our JME article we identify six sources of bias – or conflicts of interest – in clinical ethics consultation. For instance, in the case above, the ethics consultant could be biased towards the interests of health-care professions, or towards the hospital’s interests in keeping costs down and maintaining an unblemished public image.  In general, we argue, the potential for harmful biases is greater when the consultation is performed by an individual consultant rather than by a committee.

The introduction of new, harmful biases through ethics consultation, a process intended to reduce biases, would be problematic (and somewhat ironic).  Especially considering that, in the eyes of clinicians, the conclusion and advice of ethics consultation may appear to bear a stamp of ”ethically approved”.

We are fundamentally optimistic about the positive role clinical ethics consultation can play in aiding clinicians in the management of ethically complex cases.  However, ensuring the quality of clinical ethics case deliberations is vital.  Although biases can never be completely eradicated, the identification of potentially significant biases is an important part of quality improvement.

Safety First? How the Current Drug Approval System Lets Some Patients Down

15 Aug, 13 | by BMJ

Post by Julian Savulescu

Cross-posted from the Practical Ethics blog, and relating to this paper in the JME.

Andrew Culliford, whose story is featured in the Daily Mail, is one of the estimated 7 in 100,000 people living with Motor Neuron disease, a progressive degenerative disease which attacks muscles, leaving those affected eventually unable even to breathe unassisted. For Andrew, a young father who has a severe form of the disease, it means a two to five year life expectancy.

Like Les Halpin and Jenn McNary, the mother of twins afflicted with a similar rare disease, he has a simple request: earlier access to medicines that might help improve or extend his life.

The US introduced a mandatory pre-approval process for pharmaceutical drugs after over 100 people were killed by an untested drug formulation. Today, each drug must go through a series of strictly controlled trials, including Phase 1 tests on healthy volunteers, followed by Phases 2 and 3 which test the drug and dosages on smaller and then larger patient groups. The process is estimated to cost $500 million per drug and to take 8 – 12 years.

The process is designed to ensure the efficacy of drugs has been scientifically demonstrated to a very degree of confidence, and to ensure that patient safety is sufficiently protected. In many ways it has been a triumph of science and regulation.

But it has been a failure for one small group of patients: those with rare, imminently lethal diseases, for whom there are no existing good treatments. more…

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