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Should Junior Doctors Still Strike?

20 Sep, 16 | by bearp

Guest Post by Adam James Roberts

In early July, the British Medical Association’s junior members voted by a 16-point margin to reject a new employment contract negotiated between the BMA’s leadership and the Government. The chair of the BMA’s junior doctors committee, Johann Malawana, stood down following the result, noting the “considerable anger and mistrust” doctors felt towards the Government and their concerns about what the contract would mean “for their working lives, their patients and the future delivery of care” in the National Health Service (the NHS).

The BMA pressed the Government to reopen negotiations and to reverse its decision to impose the contract unilaterally. Those appeals having been rebuffed, the BMA announced two months later a new programme of strikes, citing concerns about the impacts on part-time workers, “a majority of whom are women”; on those doctors who already work the greatest number of weekends, “typically in specialties where there is already a shortage” of staff; the contract’s implications for the ability of the NHS to “attract and keep enough doctors” into the future; and the lack of an answer as to how the Government would manage to staff and fund the extra weekend care which was so often drawn on to justify pushing that new contract through.

Earlier this year, Mark Toynbee and colleagues argued in the JME that the earlier rounds of strikes by British juniors were probably ethically permissible, noting that emergency care would continue to be available, that the maintenance of patient well-being was apparently a goal, and that the strikers felt they were treating industrial action as a last resort. In a later paper, I attempted to outline and apply an ethical framework drawing on Thomist ‘just war’ theories, reaching the same conclusion about the strikes as Toynbee did.

In this guest post, I attempt to update or supplement that literature, considering some of the more recent and popular arguments against the current rounds of strikes and whether any of them might be morally compelling. In particular, I look at the fact that the BMA’s junior leadership had described the rejected offer as “a good deal”; the argument that strikes are a disproportionate response to the remaining issues; the concerns voiced about the strikes by Britain’s General Medical Council; and the allegation that striking doctors are “playing politics”.

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Is it Ethical to Pay Adolescents to Take HIV Treatment?

20 Sep, 16 | by miriamwood

Guest Post by Rebecca Hope, Nir Eyal, Justin Healy & Jacqueline Bhabha

Article: Paying for antiretroviral adherence: is it unethical when the patient is an adolescent?

With treatment, a child with HIV in sub-Saharan Africa can expect to live a healthy life. Better access to HIV treatment is contributing to a global decline in HIV deaths and new infections. Yet in adolescents, the mortality rate is rising – it increased by 30% between 2005-2012 – and HIV is now the leading cause of death among African adolescents. Globally, one in three adolescents with HIV do not take adequate therapy to suppress the HIV virus.

When antiretroviral treatment is life-saving and free, why is adherence so hard for infected adolescents? YLabs, a non-profit that designs and tests solutions to improve the health of disadvantaged youth, began working with adolescents living with HIV in Rwanda and South Africa to understand what prevents them from taking their treatment. Some of our team were involved in that work. Adolescents with HIV are navigating important transitions in their relationships, sexuality, and socio-economic roles, whilst living with a highly stigmatised condition. Lack of social support, isolation, and low mood made it hard for teens to motivate themselves to take medicines regularly. Poverty also stood in the way of regular clinic attendance. Many interviewees were more concerned about their finances than their health: one sixteen year old Rwandan girl living with HIV said: “When I’m in class thinking about how to pay school fees, I think about stopping taking my medicine and starting to try to find money.”

In addition, adolescence is often a time of risk-taking and short-term thinking, contributing to unhealthy habits. Neurodevelopmental research suggests that areas of the brain stimulated by rewards reach peak activation in adolescence, and adolescents prefer immediate, small rewards over larger gains that come later. At the same time, the development of ‘self-control’ regions, which help us make wise, considered decisions, lags far behind–a perfect neurodevelopmental storm. For many adolescents, skipping tablet-taking today, when they feel well, might be favoured over staying healthy in five years’ time. We asked, could adolescents’ increased susceptibility to rewards make short-term financial rewards a useful tool to improve long-term healthy adherence habits?

Copyright: YLabs. Photographer: Majdi Osman.

The YBank membership card for adolescents participating in a pilot study of financial incentives

With Rwandan adolescents, YLabs designed YBank, a new approach to improve antiretroviral treatment adherence, currently being piloted in Rwanda with the Rwanda Biomedical Centre. The YBank program combines short and long-term financial incentives with peer support, access to banking and financial literacy training. But is it ethical to pay adolescents to take their medications?
Researchers from YLabs and from the Harvard TH Chan School of Public Health’s Department of Global Health and Population investigated whether it is ethical to incentivize teens to take antiretroviral therapy. Payment for antiretroviral and other medication adherence is an accepted practice for adults. Our JME paper examines three ethical concerns about incentivizing adolescents with HIV to take antiretrovirals that might be more serious for adolescents than for adults.

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Making Humans Morally Better Won’t Fix the Problems of Climate Change

25 Aug, 16 | by miriamwood

Guest Post: Bob Simpson, Monash University

Re: Climate change, cooperation and moral bioenhancement

The Intergovernmental Panel on Climate Change has repeatedly said that greenhouse gas emissions increase the likelihood of severe and irreversible harm for people and ecosystems. And in his State of the Union address in 2015, Barack Obama emphasised these problems, saying that climate change poses the greatest threat to humanity’s future. We’ve come to expect pronouncements like these. Political leaders and transnational policy institutions both have an important role to play in implementing the measures needed to address threats from climate change – measures like international economic agreements, energy sector reform, and technological research.

By contrast, we wouldn’t expect advocates of biotechnological human enhancement to be proposing solutions to climate change. What does human enhancement have to do with oceanic warming or greenhouse gas emissions? According to people like Ingmar Persson and Julian Savulescu, who advocate “moral bio-enhancement”, these things are in fact related. They say that we should be finding ways to use biotechnological interventions to make people more trusting and altruistic towards strangers, and hence more willing to make personal sacrifices – like, say, dramatically reducing their carbon footprint – in order to cooperate in global policies aimed at mitigating the impact of climate change.

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What is a Moral Epigenetic Responsibility?

23 Aug, 16 | by miriamwood

Guest Post: Charles Dupras & Vardit Ravitsky

Re: The ambiguous nature of epigenetic responsibility

Epigenetics is a recent yet promising field of scientific research. It explores the influence of the biochemical environment (food, toxic pollutants) and the social environment (stress, child abuse, socio-economic status) on the expression of genes, i.e. on whether and how they will switch ‘on’ or ‘off’. Epigenetic modifications can have a significant impact on health and disease later in life. Most surprisingly, it was suggested that some epigenetic variants (or ‘epi-mutations’) acquired during one’s life could be transmitted to offspring, thus having long-term effects on the health of future generations.

Epigenetics is increasingly capturing the attention of social scientists and ethicists, because it brings attention to the importance of environmental exposure for the developing foetus and child as a risk factor for common diseases such as cardiovascular, diabetes, obesity, allergies and cancers. Scholars such as Hannah Landecker, Mark Rothstein and Maurizio Meloni have argued that epigenetics may be used to promote various arguments in ongoing debates on environmental and social justice, as well as intergenerational equity. Some even suggested that epigenetics could lead to novel ways of thinking about moral responsibilities for health.

Is it fair that disadvantaged populations are exposed to an inequitable share of harmful environments – such as polluted areas – that are epigenetically-detrimental to their health? Who should be held responsible for protecting children and future generations from epigenetic harm induced by their environments? Should we hold the parents accountable for detrimental epigenetic impact of their behavior on their children? And how should we manage the possible risks of stigmatization and discrimination of people that we consider blameworthy of inflicting epigenetic harm on others? These sensitive questions call for a nuanced investigation of the impact epigenetics can have on our understanding of moral responsibility.

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Are Doctors Who Know the Law More Likely to Follow it?

17 Aug, 16 | by miriamwood

Guest Post: Ben White and Lindy Willmott, Australian Centre for Health Law Research

This was the question we considered in a recent JME article about the role of law in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. The short answer is ‘yes’. The longer answer is also ‘yes’ – although our results suggest that doctors may be acting in a way that complies with the law but not doing so because of the law.

Our article, which is part of a wider project, reports on survey results from 649 doctors from New South Wales and Victoria (Australia’s two most populous States). The doctors surveyed were from the seven specialties most likely to be making end-of-life decisions: emergency, geriatric, palliative, renal and respiratory medicine, medical oncology, and intensive care. We asked these doctors questions to determine their legal knowledge and we also asked them to respond to a scenario where following the law (by respecting an advance directive) conflicted with a more clinically oriented approach.

Compliance with the law was low with only 32% of doctors following the advance directive. Of interest was that doctors who knew the relevant law were more likely to comply with it and follow the advance directive than those doctors who did not know the law. Initially we thought that this could indicate that legal knowledge might lead to legal compliance. However, we then examined the reasons doctors gave for decision-making and also the factors they relied on to understand whether law was seen as important or not by doctors in their deliberations.

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An Accidental Expert

9 Aug, 16 | by miriamwood

 

Guest Post: Derick Wade

Back to the Beside: Making Clinical Decisions in Patients with Prolongued Unconsciousness

In 1994, not long after the Bland judgement, I was telephoned one day by the office of the Official Solicitor. “Was I familiar with the vegetative state, and if so would I be prepared to see two people for them?”  I could reasonably honestly answer that I was familiar with it – one sees people left unconscious long after brain injury in my line of work.  I did not claim expertise, and nor was I asked.  I said “yes, to both questions.” and was sent relevant guidelines, and instructions.  With practice I improved, and I wrote my first article on the matter with one of the Official Solicitors, published in the BMJ.  I also saw one case who was definitely not vegetative (and two very well know experts had said that she was); the case has been written up with a ten year follow-up (not by me).

In about 2000, having seen about fifteen or more cases for the Official Solicitor and various NHS hospitals, the next chance event occurred.  Talking one evening with my family about my work, my elder daughter asked me what I thought about the ethics of withdrawing food and fluid.  I replied something like “Well, I have never really thought about it.” which horrified her, and surprised me (though research suggests that actually I am quite normal in that regard, as doctors usually consider matters clinically, not ethically).  Anyway, I decided to research the issue and wrote another article, which was also published in the BMJ.  Interestingly despite making several provocative statements, I only received one letter about it.

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The Challenge of Futile Treatment

29 Jul, 16 | by Iain Brassington

Guest Post by Lindy Willmott and Ben White

For decades, researchers from around the world have found evidence that doctors provide futile treatment to adult patients who are dying.  Some discussion of this topic has turned on matters of definition (see our recent contribution to this debate), with a broader concept of “perceived inappropriate treatment” being favoured by commentators more recently.  However, this debate skirts the fundamental issue: how can treatment that may prolong or increase patient suffering, waste scarce health care resources, and cause distress to health care workers still occur in hospitals around the world?  In other words, in these days of overworked doctors and underfunded healthcare systems, how is this still an issue?

Some research has tackled this although it has tended to focus on doctors operating in intensive care units and there has been very little research which looks at the reasons given by doctors from a range of specialties about why futile treatment is provided at the end of life.

Our study, undertaken by a team of interdisciplinary researchers, explored the perceptions on this topic of doctors, from a range of specialities, who are commonly involved with treatment at the end of life.  We interviewed 96 doctors at three hospitals in Queensland, Australia, from a range of specialities including intensive care, oncology, internal medicine, cardiology, geriatrics, surgery, and emergency.  Doctors reported that doctor-related and patient-related factors were the main drivers of futile treatment, although reasons relating to the institutional nature of hospitals were also important.

We found that doctor-related reasons were important in the provision of futile end-of-life care.  Many doctors reported attitudes of their colleagues that reflect a cultural aversion to death.  Doctors saw themselves as trained healers who viewed every death as a failure, and pursued a cure rather than appropriate palliative treatment for dying patients.  Doctors described wanting to help the patient and not give up hope that a treatment might provide some benefit.  They also said they wanted to satisfy patients, families, and medical professionals themselves that everything possible had been done, due to both emotional attachment to the patient and fear of the legal consequences of refusing demands for treatment.  They also admitted to providing families and patients with a smorgasbord of treatment options as a means of avoiding uncomfortable conversations about dying.  Doctors’ personalities, religious backgrounds, and their own experiences with death and dying were also said to contribute to the giving of futile treatment. more…

Individualised and Personalised QALYs in Exceptional Treatment Decisions

28 Jul, 16 | by BMJ

Guest Post by Warwick Heale

When NICE decides whether to make a treatment available on the NHS it considers both clinical effectiveness and cost effectiveness.  Cost effectiveness is based on population-level QALY data, as is appropriate for a population-level policy.  However, this can cause problems for exceptional individual patients.

When a doctor wants to offer an individual patient a treatment that has been deemed by NICE not to be cost-effective, the doctor can make an Individual Funding Request (IFR) to NHS England or a Clinical Commissioning Group.  The doctor must convince the IFR Panel that the patient is exceptional and that it is worth spending the money on this patient, leaving less to be spent on others.  The Panel’s presumption, based on the population-level data, is that the treatment will not be cost effective, and this stacks the cards against the individual patient, however extreme the patient or their condition may be compared to the population average.

One solution to this might be to consider individualised cost or response (individualised QALYs) or personalised valuations of health states (personalised QALYs).  Applying these concepts might protect the patient from a treatment being refused even if he or she is markedly different from the population average.  In doing this, we would actually promote utility and effective use of resources which is one aim of the IFR process, but one which I think it fails to achieve as effectively as it might.

Consideration of personalised QALYs also offers a justification for offering a Jehovah’s Witness a more costly alternative to blood transfusion, on the basis that this would actually maximise the utility we gain from our limited resources – in contradiction to the more obvious view that this would compromise utility.  Furthermore, in doing this we don’t need to give any special status to religious considerations – the Jehovah’s Witness, the patient of a different faith and the atheist should all be subject to the same principles of personalised QALYs.  Personalised QALYs also allow us to think about patient choice alongside utility rather than as independent principles.

Read the full paper here.

IAB 2016: Graeme Didn’t Say “None”…

21 Jun, 16 | by Iain Brassington

Every two years, I write a little post-mortem of the IAB conference, mentioning particular high and low points.  But since I’ve heard near-blanket praise for this year’s Edinburgh fandango, there won’t be too many of the latter.  And everyone with whom I’ve been in contact since has been highly impressed; we’re all still on a bit of a high.

So what was particularly good?  Well, in general, I thought that the standard of argument in most of the papers was high: it’s nice to see really big ideas being grappled with.  Matthias Risse’s paper on IP, particularly in the context of making drugs available to the least well-off, was the keynote on Thursday morning, and was notable in this regard.  Risse was arguing that the current IP regime owes too much to Locke, and not enough to Grotius.  In other words, he made no bones about an appeal to 17th-century political philosophy.  A simple and undemanding rehearsal of principlism this was not.  I’d perhaps have liked to hear more about rights to the medicines in question, as a complement to the point about IP rights – after all, unless there’s a right to the medicines, many of the arguments about IP may be moot; but I’m sure that is, or at least could be, done elsewhere.

Similarly, Gillian Brock’s paper about the medical brain-drain left a few questions unanswered – the proposal that there be some kind of mandatory service for professionals from low-to-middle-income countries arguably places a burden on some people for the misfortune of not having been born in a wealthy part of the world, and leaves open questions about what the point of eduction is to begin with (national needs or personal flourishing?) – but was very good all the same.  I missed Catherine Belling’s “Going Under and Coming Round”, but everyone to whom I spoke was mightily impressed – Stephen Latham seemed genuinely lost for words about how good it was; and I also missed Alondra Nelson’s keynote on the social life of DNA, which seems also to have been warmly received.

Of the parallel sessions, one that particularly stands out is Tamara Kayali Browne’s paper on sex-selection; there’s a different-but-related paper by her currently available as a preview in the JME.

On the Arts and Bioethics theme, Adura Onashile’s HeLa was a thoughtful take on a familiar story, and generated a really interesting Q&A; Vishal Shah’s Vellum was a strange and wonderful thing.

The Early Career Researcher emphasis seems to have been a great success, too.

So were there any down points?

  • Well, there were fewer parallel sessions than there have been in previous iterations of the conference (or at least, so it felt); and that did give the thing a slightly different dynamic.  However, I can’t put my finger on exactly what the difference was, qualitatively speaking; and the fact that there’s a difference doesn’t mean that things should have been done otherwise.  With a lot of people having been offered posters rather than oral sessions (one of my submissions being among them), I think that it’s simply a different way of going about things, and I suspect that any quibbles will boil down to taste.  I don’t think that there’re real grounds for complaint.
  • I was a little saddened that I didn’t get to play my normal game of spot-the-bizarre-paper-that-somehow-got-accepted-with-hilarious-consequences, because there was no bizarre paper, as far as I could see.  (Hmmm.  Maybe that means that my symposium paper was the bizarre one.  Eeeep.)  So that’s a minor disappointment, I guess.  But being denied the opportunity of a good facepalm in the pub afterwards isn’t all that much of a hardship.
  • At the ceilidh, a frightening number of people seemed to be unable to count to eight.
  • I was in Edinburgh a fortnight ago, and it was gloriously sunny and warm.  During the IAB, it was cold and wet.  The word “dreich” shouldn’t be usable in June, but it was this time.  Yet it’d hardly be fair to complain about the IAB on that basis.  Besides, nasty weather reduces the incentive to skive and go for a walk up Arthur’s Seat.  Besides besides… it would have been a shame to miss any of the conference.  So who cares about the rain?

Which is as much as to say: no down points really.  Well – except for that one paper talking about assisted dying that relied on a picture of a child next to a headstone where an argument should have been.  You know who you are.

That aside, though, it was all preternaturally good stuff.

After the closing ceremony, I asked Graeme Laurie how many virgins he’d had to sacrifice in order to make sure that things went as well as they did.  He did not say “none”.  Make of that what you will.

Writers Whose Expertise is Deplorably Low

4 Jun, 16 | by Iain Brassington

Something popped up on my twitter feed the other day: this document from Oxford’s philosophy department.  (I’m not sure quite what it is.  Brochure?  In-house magazine?  Dunno.  It doesn’t really matter, though.)  In it, there’s a striking passage from Jeff McMahan’s piece on practical ethics:

Even though what is variously referred to as ‘practical ethics’ or ‘applied ethics’ is now universally recognized as a legitimate area of philosophy, it is still regarded by some philosophers as a ghetto within the broader 
area of moral philosophy.  This view is in one way warranted, as there is much work in such sub-domains of practical ethics as bioethics and business ethics that is done by writers whose expertise is in medicine, health policy, business, or some area other than moral philosophy, and whose standards of rigour in moral argument
are deplorably low.  These writers also tend
 to have only a superficial understanding of normative ethics.  Yet reasoning in practical ethics cannot be competently done without sustained engagement with theoretical issues
in normative ethics.  Indeed, Derek Parfit believes that normative and practical ethics are so closely interconnected that it is potentially misleading even to distinguish between them.  In his view, the only significant distinction is between ethics and metaethics, and even that distinction is not sharp.  [emphasis mine]

It’s a common complaint among medical ethicists who come from a philosophical background that non-philosophers are (a) not as good at philosophy, (b) doing medical ethics wrong, (c) taking over.  All right: there’s an element of hyperbole in my description of that complaint, but the general picture is probably recognisable.  And I don’t doubt that there’ll be philosophers grumbling along those lines at the IAB in Edinburgh in a couple of weeks.  There’s a good chance that I’ll be among them.

There’s a lot going on in McMahan’s piece, and his basic claim is, I suppose, open to a claim that, being a philosopher, he would say that, wouldn’t he?  But even if that claim is warranted, it doesn’t follow that it’s false.  And it probably isn’t false.  There is some very low-quality argument throughout bioethics (and, from what I remember from my time teaching it, business ethics) – more particularly, in the medical ethics branch of bioethics, and more particularly still, in the clinical ethics sub-branch.  Obviously, I’m not going to pick out any examples here, but many of us could point to papers that have been simply not very good, because the standard of philosophy was low, without too much difficulty.  Often, these are papers we’ve peer-reviewed, and that haven’t seen the light of day.  But sometimes they do get published, and sometimes they get given at conferences.  I’ve known people who make a point of trying to find the worst papers on offer at a given conference, just for the devilry.

It doesn’t take too much work to come up with the common problems: a tendency to leap to normative conclusions based on the findings of surveys, or empirical or sociological work; value-laden language allowing conclusions to be smuggled into the premises of arguments; appeals to vague and – at best – contentious terms like dignity or professionalism; appeals to nostrums about informed consent; cultural difference used as an ill-fitting mask for special pleading; moral theories being chosen according to whether they generate the desired conclusion; and so on.  Within our field, my guess is that appeals to professional or legal guidelines as the solutions to moral problems is a common fallacy.  Not so long ago, Julian noted that

[t]he moralists appear to be winning.  They slavishly appeal to codes, such as the Declaration of Helsinki.  Such documents are useful and represent the distillation of the views of reasonable people.  Still, they do not represent the final word and in many cases are philosophically naïve.

Bluntly: yes, the WMA or the BMA or the law or whatever might say that you ought to do x; and that gives a reason to to x inasmuch as that one has a reason to obey the law and so on.  But it’s unlikely that it’s a sufficient reason; it remains open to us always to ask what those institutions should say.  Suppose they changed their minds and insisted tomorrow that we should do the opposite of x: would we just shrug and get on with the business of undoing what we did today?

And yet…  The complaint about poor argument is not straightforward, for a couple of reasons. more…

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