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Autonomy and the Circumcision Wars

27 Feb, 15 | by Iain Brassington

Guest Post by Akim McMath

In December of last year, the Centers for Disease Control and Prevention (CDC) released its proposed new recommendations on male circumcision.  The verdict?  Circumcision provides major benefits with minimal risks.  These benefits accrue whether circumcision is performed in infancy or later on in life.  Circumcision may even help to stem the HIV epidemic in the United States.  Perhaps you should do something about that foreskin.

The resulting firestorm was swift, fierce, and predictable.  Critics of infant circumcision blasted the CDC, accusing it of trampling the child’s right to bodily integrity.  Defenders of circumcision fired back, extolling the prophylactic virtues of the procedure.  Subtle questions about autonomy were lost in the maelstrom.  Yet these questions lie at the heart of the conflict, as I suggest in a new article.

Let’s look more closely at the debate over circumcision and HIV.  Defenders of circumcision tout studies showing that circumcision reduces female-to-male sexual transmission of HIV.  Critics retort that there exists a more effective and less drastic means of achieving the same end – namely, condoms.  Perhaps, concede the defenders, but many men don’t use condoms consistently and effectively – hence the enduring problem of STIs.  That’s their choice! say the critics.  So? say the defenders.  And so on, ad infinitum.

The foregoing squabble is essentially a disagreement about autonomy.  Critics of infant circumcision are idealists about the child’s future autonomous choices.  They assume that the child will make prudent choices in future, even when he may not.  Assuming prudent condom use, circumcision is unlikely to provide much additional protection against HIV.  Defenders of circumcision, on the other hand, are realists about the child’s future choices.  They account for the fact that the child may not make the best choices in future.  On more realistic assumptions about the child’s future condom use – or lack thereof – circumcision may provide significant additional protection.

So who is right: the realists or the idealists?  Is infant circumcision an acceptable precaution against harms that may result from irresponsible choices in future?  Or should we give the kid the benefit of the doubt and assume he will make prudent choices when he is older?

Consider the ethics of coercion more generally.  Typically, coercively protecting people from their own autonomous choices – or strong paternalism – is deeply problematic.  Respect for autonomy requires that we allow people to make foolish choices.  On the other hand, there is nothing paternalistic about coercively preventing people from harming others.  As some clever person once put it, “My right to swing my fist ends where your nose begins.”

We can look at the ethics of circumcision from two angles: from the perspective of the child’s own interests, and from a wider public health perspective.  When we are just considering the child’s own interests, we should be idealists about his future autonomous choices.  To circumcise him now in order to protect him from imprudent choices in future would be strongly paternalistic, and would therefore be objectionable.  But there are other interests at stake.  Since HIV is an infectious disease, reducing one person’s risk of HIV infection reduces the risk to many others.  When we consider this wider public health perspective, we should be realists about the child’s future choices.  Public health policy should be based on the choices people actually make, not on the choices they might make in an ideal world.

What does all this mean for the CDC recommendations?  It suggests that the CDC relies far too heavily on HIV prevention as a justification for infant circumcision.  In the United States, the adult prevalence of HIV is 0.6 percent – not very high by global standards.  Furthermore, as the CDC itself admits, only 10 percent of new infections are transmitted sexually from a female to a male.  And, as I have argued, most of these initial infections cannot justify infant circumcision; it is the extent to which these infections increase risks to others that is ethically relevant.  All of this suggests it would take very many (perhaps thousands) of circumcisions to prevent one new ethically relevant HIV infection in the United States.  The public health justification for infant circumcision, at least in terms of HIV prevention, seems much weaker than the CDC’s enthusiasm would suggest.

In any case, the circumcision wars will go on – and there is no end to the conflict in sight.

Read the full paper here.


Does religion deserve a place in secular medicine?

26 Feb, 15 | by bearp

By Brian D. Earp

The latest issue of the Journal of Medical Ethics is out, and in it, Professor Nigel Biggar—an Oxford theologian—argues that “religion” should have a place in secular medicine (click here for a link to the article).

Some people will feel a shiver go down their spines—and not only the non-religious. After all, different religions require different things, and sometimes they come to opposite conclusions. So whose religion, exactly, does Professor Biggar have in mind, and what kind of “place” is he trying to make a case for?


Physicians and Euthanasia: What about Psychiatric Illness, Dementia and Weltschmerz?

18 Feb, 15 | by BMJ

Guest Post by Eva Bolt

In the Netherlands, requests for euthanasia are not uncommon. A physician who grants a request for euthanasia in the Netherlands is not prosecuted if the criteria for due care (described in the Euthanasia Act) are met. An example of one of these criteria is the presence of unbearable suffering without prospect of improvement. Almost all physicians in the Netherlands can conceive of situations in which they would perform euthanasia. However, each request for euthanasia calls for careful deliberation. When confronted with a request, a physician needs to judge the situation from two perspectives. The first is the legal perspective; would this case meet the criteria for due care? To judge this, a physician can fall back on the description of the Euthanasia Act and receives help from a consulting physician. The second perspective is personal; how does the physician feel about performing euthanasia in this situation? Is it in line with his personal values?

Our study shows that cause of the patient’s suffering is one of the aspects that influence the physician’s decision on euthanasia. This is interesting, because the Dutch euthanasia act does not make a distinction between different diseases. In case of suffering with a clear physical cause like cancer, most physicians can conceive of performing euthanasia. However, there are also people who request for euthanasia without suffering from a severe physical cause. In these cases, there are not many physicians who would consider complying with this request. As a consequence, people suffering from a psychiatric disease and early stage dementia with a euthanasia wish will rarely find a physician who would grant their euthanasia request. The same is true for people who are tired of living but who do not suffer from a severe physical disease. Also, most physicians will not consider following advanced euthanasia directives asking for euthanasia in case of advanced dementia.

Concluding, while most Dutch physicians can conceive of granting requests for euthanasia from patients suffering from cancer or other severe physical diseases, this is not the case in patients suffering from psychiatric disease, dementia or being tired of living. This distinction is partly related to the criteria for due care. For instance, some physicians describe that it is impossible to determine the presence of unbearable suffering in a patient with advanced dementia. Other explanations for the distinction are not related to the criteria for due care. For instance, it is understandable that physicians do not agree with performing euthanasia in a patient with advanced dementia who does not fully understand what is happening, even if the patient has a clear advanced euthanasia directive.

Each physician needs to form his or her own standpoint on euthanasia, based on legal boundaries and personal values. We would advise people with a future wish for euthanasia to discuss this wish with their physician in time, and we would advise physicians to be clear about their standpoint on the matter. This can help to prevent disagreement and disappointment.

Read the full paper here.


In the Journal: The Ethics of Molecular Memory Modification

8 Jan, 15 | by BMJ

Guest post by Katrina Hui

What if memories could be enhanced or erased, not through traditional pharmaceuticals, but directly, through manipulation of the molecular processes that govern memory?

Several years ago, scientists thought they had found a single molecule believed to be the key to memory editing. This molecule, called protein kinase Mζ (PKMζ), appeared to play a crucial role in the preservation of specific long-term memories. Though its actual molecular mechanism remains unclear, the discovery demonstrates that memory is governed by molecular processes and can possibly be manipulated through such means. Though research is still in its early stages, the example of molecular memory modification raises some interesting questions about the ethics of memory that merit consideration.

According to current frameworks of memory, memories are made temporarily unstable after recall and are “rewritten” each time they are summoned before being stored again. Early research seemed to indicate that specific memories could be enhanced by increasing levels of PKMζ, then recalling the target memories. On the flip side, memories could be “erased” by interfering with the expression of the molecule at a similar point in time in the recall process, thus destabilizing and preventing the re-storage of previously held memories. To add to the excitement, modifying specific memories with PKMζ seemed to have few side effects on other memories or processes.

However, more recent research has called into question PKMζ’s involvement in long-term memory storage and maintenance, and it remains unclear if PKMζ really is as powerful as it was once thought to be.

Nonetheless, the possibility of manipulating memory through molecular means will continue to be investigated. Molecular memory modification (MMM) provides a new perspective on some unresolved ethical questions regarding memory. For instance, is there a “the duty to remember” certain valuable memories? This duty could have a place in the courtroom, for example, where eyewitness testimony, while notoriously unreliable, is also frequently used and sometimes essential. On the other hand, while requiring or perhaps even forcing people to remember might appeal to those with an authoritarian bent, in reality, the mechanism of action of MMM in particular requires active recall from the participant, illustrating how subject participation, a previously neglected topic in ethical debates about memory, could be essential.

More broadly, the example of MMM illustrates that the idea of “enhancing” memory, rather than a monolithic process, is multifaceted. The folk intuition of enhancing memory, generally implies remembering more, for a longer time. However, a closer examination of the molecular processes underlying memory functions, the term “enhancement” is shown to be vague, as there are many dimensions along which memory could be enhanced, such as fixing incorrect associations, eliminating temporary memory blocks, or even erasing memories in cases such as Post-Traumatic Stress Disorder. What ethical concerns are relevant and we mean when we use the term “enhancement” ultimately depends on how memories are altered. As research continues, new mechanisms for improving memory will emerge, and more precision about the ethical calculus will be required.


Read the full paper here.

Should Anyone get IVF?

25 Nov, 14 | by Iain Brassington

Cast your mind back to this summer, and Christina Richie’s paper about the provision of ARTs.  It attracted a fair bit of controversy because of the way it talked about gay people’s rights to access ARTs, and their “voluntary” infertility.  For my money, that was the weakest part of the paper, and it should have been left out of the argument; the majority of the paper, and the more ethically interesting part, had to do with the environmental impact of striving to have more and more kids, irrespective of their parentage.  But I can see why the part about gay people struck many people as worth commenting on.

Why mention all that now?  Well, there’s a nice paper by Emily McTernan currently on pre-pub in the Journal of Applied Philosophy asking whether any fertility treatment should be state-funded.  In it, she asks whether IVF should be state-funded at all.  In a nutshell, her claim is that many of the arguments about the good of parenthood are either weak in their own right, or else could apply equally well to any number of other goods that a person might pursue.  Those that are weak are obviously less likely to sustain a claim that iVF should be provided; those that apply equally well to other goods obviously suggest either that governments should fund the pursuit of those other goods as well, or that if pursuit of those other goods is not funded, then neither should IVF be.  Thus

it is unjustifiable for a state to provide fertility treatment more generously than it funds other valuable like projects, both in the quantity of funding and the lack of means testing.

What I really like about the paper is that McTernan sets out the main arguments for funding in a simple but never simplistic manner, and calmly knocks them down one by one.  I’m already inclined to be suspicious of, if not hostile to, public funding of IVF (there being things with a more pressing need for public money, and genetic relatedness being not all that important), but she puts the arguments more neatly than I ever could.  She’s very good at pointing out that a particular argumentative strategy might be tempting, but that we would probably fight shy of adopting it because it would commit us to moral conclusions we wouldn’t normally want to embrace.  So, for example, if you’re inclined to agree with the Daniels line that adverse departures from normal species functioning could count as disease, you might be tempted to say that infertility is a disease – and therefore ought to be treated, or at least ameliorated, by IVF.  But

lack of reproductive success cannot itself suffice to make for an adverse departure [from the norm]: we would not want to conclude that those preferring same-sex partners have a disease, given the reproductive failure resulting from their statistically unusual sexual preference, let alone that it should be treated.


Elsewhere, she attacks the idea of parenting as a unique good as a ground for providing IVF, and the idea that we ought to support and enable reproduction as a social good.  McTernan recognises that there is arguably a social injustice in that a woman’s most fertile years tend to coincide with the years most crucial for her career.  This means that a woman who wants kids is likely to defer pregnancy, thereby reducing her chance of getting pregnant.  IVF might correct for that.  However, McTernan contends, this isn’t compelling, not least because the argument transforms a social phenomenon – which she thinks constitutes an injustice – into a problem with the individual; providing IVF (which isn’t all that reliable anyway) might provide an interim solution to the social problem, but it does nothing to address it fundamentally.  So, she claims, the argument probably isn’t all that strong.

But she then makes a fascinating exception – and this is where her paper is in interesting contrast to Richie’s: it’s that we do have more of a reason to provide IVF to gay couples. more…

Growing a Kidney Inside a Pig Using your own DNA: The Ethics of ‘Chimera Organs’

6 Nov, 14 | by Iain Brassington

Guest post by David Shaw

Imagine that you’re in dire need of a new kidney. You’re near the top of the waiting list, but time is running out and you might not be lucky enough to receive a new organ from a deceased or living donor. But another option is now available: scientists could take some of your skin cells, and from them derive stem cells that can then be added to a pig embryo. Once that embryo is implanted and carried to term, the resulting pig will have a kidney that is a perfect genetic match to you, and the organ can be transplanted into your body within a few months without fear of immune rejection. Would you prefer to take the risk of waiting for an organ donated by a human, which would require you to take immunosuppressant drugs for the rest of your life? Or would you rather receive a “chimera organ”?

This scenario might seem far-fetched, but it is quite likely to be a clinical reality within a decade or so. Scientists have already used the same technique to grow rat organs inside mice, and it has also been shown to work in different types of pig. Although clinical trials in humans have not yet taken place, using these techniques to create human organs inside animals could solve the current organ scarcity problem by increasing supply of organs, saving thousands of lives each year in Europe alone. As illustrated in the example, organs created in this way could be tailored to the individual patient’s DNA, allowing transplantation without the risk of immune rejection. However, the prospect of growing organs of human origin within (non-human) animals raises several ethical issues, which we explore in our paper.

Although chimera organs are ‘personalised’ and unlikely to be rejected, one of the major concerns about using organs transplanted from animals is the risk of ‘zoonosis’ – the possibility that an animal virus might be transmitted along with the organ, resulting in a new disease that could cause a pandemic. more…

Paper Preview: Implementation of a Consent for Chart Review and Contact

23 Sep, 14 | by BMJ

Guest post by Irena Druce
Our article “Implementation of a Consent for Chart Review and Contact and its Impact in one Clinical Centre” focuses on issues regarding patient health information privacy and recruitment for medical research studies.  Research studies are an integral part of the advancement of medical therapies; however, recruitment into research studies can be challenging.  In Canada, the use of health information is governed by Personal Health Information Protection Act and at our institution a policy is in place that allows only those health professionals directly in the circle of care access to patient information to further protect patient’s privacy.  This policy could have a potential negative effect on recruitment rates into research studies.  Physicians and other clinical personnel often do not have the time to discuss ongoing research projects with patients as time is spent focusing on the patient’s medical issues.  In addition, there is concern that if  physicians use the information that they gather in a clinical encounter to recruit for research studies, it is equivalent to that physician sharing medical information  with someone who does not have a right to it.

In light of these challenges, the Division of Metabolism and Endocrinology at the University of Ottawa implemented a consent for chart review and contact (CCRC).  The CCRC is a document presented to a patient on their first meeting a new physician.  The CCRC gives permission for the patient’s medical file to be reviewed by research personnel to determine whether a patient is eligible for a research study.  If the patient meets the study criteria, the CCRC also grants permission for the patient to be contacted by research personnel to be provided with the details of the research study so they can decide if they wish to participate.

It has been proposed that patients may feel pressured to agree if a  CCRC is presented on their first meeting a new health professional.   Patients may feel that refusing the CCRC would affect the future care they receive.  Our  paper discusses how we have addressed this possible pitfalls with our CCRC document.

In addition, we performed an analysis to assess the impact the CCRC was having at our institution.  We compared the basic demographics of the patients who did and did not agree to the CCRC.  Furthermore, we analysed our centre’s recruitment rate into a known, ongoing, multi-centre, international trial.  Of the participating centres, we found that our institution had some of the highest recruitment rates into the trial, and that the majority of our patients were being recruited via our novel approach of the CCRC.  It is not certain that the use of a CCRC would consistently translate into higher recruitment, but certainly our experience has been encouraging.  Data suggest that participation in research trials has been decreasing in recent years.  Any measure to preserve recruitment may be beneficial, especially a measure which allows for the conduction of research, without having to sacrifice any patient rights with regards to privacy and confidentiality.

Read the paper here.


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Posted in clinical ethics, Guest Post, JME

The Ebola Outbreak in Western Africa: Ethical Obligations for Care

11 Sep, 14 | by BMJ

Guest post by Aminu Yakubu, Morenike Oluwatoyin FolayanNasir Sani-Gwarzo, Patrick Nguku, Kristin Peterson, and Brandon Brown

In our article “The Ebola Outbreak in Western Africa: Ethical Obligations for Care” we focus on the health care system’s ability to combat the recent epidemic of Ebola in Western Africa.  This is a timely and urgent issue.  Many medical ethicists – including those called upon by the WHO – are focusing on availability of experimental drugs, but little is being discussed about on-the-ground care and human rights.  By the time this article was written, in August 2014, there were 1145 deaths from Ebola.  In the news, Ebola treatment facilities were being taken over by armed civilians who stole medicines to protect themselves, resulting in Ebola patients fleeing for their lives and further spreading the virus.  This action has taken a toll on an already limited infrastructure.

The unspoken heroes of the Ebola epidemic are the healthcare workers who brave potential infection to save the lives of those infected.   In Nigeria, nine health care workers were infected, and three health care workers had already died by the time this blog was written.  With this news, willingness of medical staff to provide care for patients with Ebola virus is limited, as the danger to their own life is great.  Moral obligations of healthcare staff to provide care should have limited sanctions for non-compliance so as not to infringe on the healthcare workers right to life.  Workers who do care for Ebola patients must be provided with adequate protective equipment and a safe working environment, as well as compensated if they become infected in the course of duty.  Traditional public health ethics has paid little attention to the protection of the rights of healthcare workers, but the Ebola epidemic has brought this issue to the forefront.  Its time those who are responsible for saving our lives have a voice.


Read the full paper here.

UPDATE:  Brandon Brown emails:
I just received a nice on the ground photo (Ebola decontamination) from my collaborators in Nigeria if we can attach to the blog entry.  [Click image for bigger.]





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Advance Directives, Critical Interests, and Dementia Research

14 Aug, 14 | by BMJ

Guest post by Tom Buller, Illinois State University

In my paper, “Advance Directives, Critical Interests, and Dementia Research”, I investigate whether advance directives can be applied in the context of dementia research. Consider, for the sake of argument, the following fictional case. William, a 77-year-old man who has moderate to severe dementia. When he was first diagnosed and while still competent he declared on many occasions that he wished to do all he could to help future sufferers of the disease and find a cure for Alzheimer’s, and he repeatedly said that he very much wanted to participate in any clinical trials, even those that might involve hardship and risk. With the full agreement of his family William was enrolled in a five-year clinical trial testing a new treatment for Alzheimer’s that involves.

I think it can be legitimately argued that William has the right to make a future-binding decision to participate in the above trial, for the reasons that justify the use of a decision in the treatment context also apply in the present research context. First, William’s beneficent desire to help future sufferers of Alzheimer’s is part and parcel of his character and what gives his life value. Second, the principle of precedent autonomy is not invalidated by the fact the person is encouraging, rather than, refusing intervention, and that the chosen course of action requires the assistance of others. Third, William’s decision is not invalidated by the fact that it is motivated by beneficence rather than self-interest.

If this analysis is correct, then it would seem that there are good reasons to think that a competent person has the right to decide to participate in future research once competence has been lost, even research that is (significantly) greater than minimal risk.


Read the full paper online first here.

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On Conflicts of Interest

28 Jul, 14 | by Iain Brassington

It’s only a few days since Richie’s paper on providing IVF in the context of global warming was published, but already there’s been a couple of lines of objection to it that have been fairly widespread; I thought it might be worth nodding to one, and perhaps offering an attempt of a defence against the other.

The first objection is that there’s no justification for the claim about same-sex couples in Richie’s paper – that she shouldn’t have treated homosexuality as a lifestyle choice and as “non-biological” infertility.  I think that there’s significant merit to this objection to the paper; and though neither Dominic nor I mentioned the objection explicitly, I think that it’s there between the lines of each of our commentaries.  (It’s certainly an aspect of the paper that’s picked up by the Telegraph‘s coverage of the paper, and it’s been mentioned a couple of times on Twitter and Facebook by people I know and follow.  (I note that the Telegraph also gave a highly bastardised version of my post here.  Ho hum.))  I think that Richie’s argument would have been at least as strong if she’d talked about providing IVF to anyone whatsoever – the qualifications about different “sorts” of infertility and lifestyle, I suspect, weakened the paper, inasmuch as that a paper with unnecessary and argumentatively weak aspects is more vulnerable to objections generally than one in which those aspects have been left out.  So, yeah: I think that that might count as having been – at best – a strategic error on Richie’s part.

Here’s the other claim that I’ve seen a few times about the paper: that it’s weakened by a conflict of interest because of the author’s affiliation.  This isn’t directly a claim about the quality of the argument in the same way that the previous objection is.  Rather, it’s a claim that there’s something unreliable about the very fact of the argument’s having been put.  (I’m not articulating the distinction very well, but I think you can see what I mean.)  In essence, the worry is this: Richie works for a Jesuit Institution; this isn’t clear from her affiliation in the paper; there’s something iffy about this; this iffiness is some form of conflict of interest and her argument is likely to be biased.

I’m not sure what to make of this. more…

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