You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our Group site.


Enhancement as Nothing More than Advantageous Bodily and Mental States

20 May, 16 | by BMJ

Guest Post by Hazem Zohny

Some bodily and mental states are advantageous: a strong immune system, a sharp mind, strength.  These are advantageous precisely because, in most contexts, they are likely to increase your chances of leading a good life.  In contrast, disadvantageous states – e.g. the loss of a limb, a sense, or the ability to recall things – are likely to diminish those chances.

One way to think about enhancement and disability is in such welfarist terms.  A disability is no more than a disadvantageous bodily or mental state, while to undergo an enhancement is to change that state into a more advantageous one – that is, one that is more conducive to your well-being.  This would hugely expand the scope of what is considered disabling or enhancing.  For instance, there may be all kinds of real and hypothetical things you could change about your body and mind that would (at least potentially) be advantageous: you could mend a broken arm or stop a tumour from spreading, but you could also vastly sharpen your senses, take a drug that makes you more likeable, stop your body from expiring before the age of 100, or even change the scent of your intestinal gases to a rosy fragrance.

Would all such changes be instances of enhancement? more…

Healthcare Ethics Consultants’ Place in the World of Health Care ‘Professionals’

17 May, 16 | by BMJ

Guest Post by Abraham Schwab

During a recent meeting at a local hospital, I was asked what role a good Healthcare Ethics Consultant should play.  I gave a more ambiguous answer than I would like.  I pointed out that Healthcare Ethics Consultants can help patients, providers, and administrators come to a common understanding of the values at play in a particular health care situation.  A Healthcare Ethics Consultant can also help them reach a decision that reflects the medical realities, the patient’s values, and, as appropriate, the families’ values.  But I also pointed out that the role of the Healthcare Ethics Consultant is determined by the particular institution’s needs.  One institution’s Healthcare Ethics Consult can look like another’s Family Care Conference or another’s Palliative Care Consult and so on.  In short, the Healthcare Ethics Consultant’s role and responsibilities is not neatly defined across institutional boundaries.

The American Society of Bioethics and Humanities (ASBH) Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants aims to “set out the core ethical responsibilities of individuals performing healthcare ethics consultation.”  If successful, it would provide guidance as clinical ethicists and others attempt to answer the question, “What is a Healthcare Ethics Consultant responsible for?”.  Looking over the ASBH’s code, however, it’s hard to imagine using it to provide a content-rich and clear answer.   As I argue in my paper, “The ASBH Code of Ethics and the Limits of Professional Healthcare Ethics Consultations”, the code falls short of its goal in two substantive ways.  First, the Code implicitly relies on the category “professional”, despite the fact that this category lacks clear definition.  Second, the code articulates only vaguely defined responsibilities.

The ASBH’s Code of Ethics is a short document – less than five pages – but invokes the word “professional” 14 times.  That the word is not defined in the code is of no surprise: the use of “professional” is common coin in health care fields.  And yet, the category “professional” is poorly defined.  As I argue, the best available definition is a formal one: professionals share a common commitment to something.  But that something remains undefined in general.  The concept of “profession” is a placeholder indicating that practitioners of a particular occupation have taken on certain additional obligations, and those obligations are specific to the profession in question.  When an occupation claims to be a “profession”, a necessary follow-up question is, “But what does that mean for your occupation?”  Ideally, the ASBH’s Code of Ethics would answer this question for Healthcare Ethics Consultants.

In this regard, the ASBH’s code falls far short.  Most of the broadly defined obligations could be the obligations of any occupation.  The obligations also include conceptual confusions, from conflating privacy and confidentiality to invoking the requirement that Healthcare Ethics Consultants should meet professional standards – the very standards that the Code itself should be providing.

Despite these shortcomings, I write to criticise the ASBH code, not to bury it.  Healthcare Ethics Consultants play important roles in the institutions in which they exist.  Help in defining their responsibilities is needed.  And so I also provide a suggestion for moving the ASBH code forward.  Specifically, the relationships between  “professionals” in health care has shifted.  The isolated responsibilities of the isolated physician have gone the way of the country doctor.  The work of health care “professionals” is now the work of a team and a system, and the responsibilities that attach to these “professionals” are team-based responsibilities.  Further defining the responsibilities of Healthcare Ethics Consultants will require a more comprehensive collaboration across disciplinary boundaries.

If the ASBH’s Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants is to help answer the question, “What role does a Healthcare Ethics Consultant play?”, it’s next iteration will have to provide more narrowly and clearly defined responsibilities.

Read the full paper here.

Autism, Mental Illness, Euthanasia and the WaPo

5 Mar, 16 | by Iain Brassington

There was a piece in the Washington Post the other day with a striking headline: Where the Prescription for Autism can be Death.

Normally, if we’re saying that the prescription for x is y, we mean to say that y is being suggested as a treatment for x.  Painkillers are the prescription for a bad back, a steroid cream the prescription for eczema, and so on.  Even if you find that phrasing a bit clunky, “prescription” implies the recommendation of a medical expert.  On that basis, the implication here is that somewhere in the world, doctors are seeing patients, diagnosing autism, and saying, “I wonder if the best thing would be to kill you”.  That would be uiruite a Big Deal.

The place in question is Holland.  But a quick look at the article shows – surprise, surprise – nothing of what’s hinted at in the headline.  Here’s the opening few sentences, edited slightly for formatting:

In early childhood, the Dutch psychiatric patient known as 2014-77 suffered neglect and abuse.  When he was about 10, doctors diagnosed him with autism.  For approximately two decades thereafter, he was in and out of treatment and made repeated suicide attempts.  He suffered terribly, doctors later observed, from his inability to form relationships: “He responded to matters in a spontaneous and intense, sometimes even extreme, way. This led to problems.”

A few years ago, 2014-77 asked a psychiatrist to end his life.  In the Netherlands, doctors may perform euthanasia — not only for terminal physical illness but also upon the “voluntary and well-considered” request of those suffering “unbearably” from incurable mental conditions.
The doctor declined, citing his belief that the case was treatable, as well as his own moral qualms.  But he did transmit the request to colleagues, as Dutch norms require.  They treated 2014-77 for one more year, determined his case was, indeed, hopeless and, in due course, administered a fatal dose of drugs.  Thus did a man in his 30s whose only diagnosis was autism become one of 110 people to be euthanized for mental disorders in the Netherlands between 2011 and 2014.

So, then, it’s a story about a man, who happened to be autistic, and who asked a psychiatrist for euthanasia.  After a little to-ing and fro-ing, that request was granted.  There is no reason to believe that this was a case of death being prescribed for autism.  It’s just that he happened to be autistic and to want to die, and a prescription for assistance was provided.  Phrasing is important.

Dutch law on assisted dying is famously liberal; in considering the permissibility of euthanasia for psychiatric as well as somatic illnesses, it is in the minority of the minority of jurisdictions that consider the permissibility of any euthanasia.  I have addressed the question of psychological suffering in relation to euthanasia elsewhere, and shan’t rehearse the details here; suffice it to say, I don’t see any reason in particular to think that mental illness and physical illness should be treated all that differently in principle: more…


24 Dec, 15 | by Iain Brassington

Here’s an intriguing letter from one John Doherty, published in the BMJ yesterday:

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes, but such constructs are culture bound.

When I worked in outback Australia the patients called me “Mate,” which is what I called them.

They still wanted me to be in charge.

Intriguing enough for me to go and have a look at what this Kennedy person had written.  It’s available here, and the headline goes like this:

The Title “Doctor” in an Anachronism that Disrespects Patients

Oooooo-kay.  A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all.  (Don’t ask me why I detest that so; I don’t know.  It’s just one of those things that I will never be able to tolerate, a bit like quiche.)  But let’s see…  It’s not a long piece, but even so, I’ll settle for the edited highlights: more…

Homeopathy, Blacklisting, and the Misuse of Choice

15 Nov, 15 | by Iain Brassington

It seems that homeopathy might at last be facing some serious opposition from within the NHS, with the prospect of its being blacklisted being considered.

There’s any number of people who’ll be entirely on board with that. Homeopathy doesn’t work.  Of course, a lot of medicines turn out not to work, or not to work well.  But the difference between homeopathy and unsuccessful drugs is that the latter are at least more likely to have a plausible mechanism – roughly, one of throwing molecules at other molecules, or coaxing the body to throw molecules at molecules.  Homeopathy doesn’t even have that.  It relies on water having a memory.

At the very best, it contributes nothing. But it does cost money – not much, but more than none, and in the end, the taxpayer has to pony up for it.  Money is being wasted every time the NHS pays for homeopathic treatment, and that looks to be unjust.  (It’s not the most unjust thing in the world, but that’s neither here nor there.  Wrongs are wrongs, even if harms might vary.)

It might even get in the way of effective treatments, if patients use it rather than them.  That might mean that they’re worse off than they could otherwise be.  At the outside, it might mean that they’re a danger to others – they might be spreading illness by dint of not getting treated properly for it.

To that extent, Simon Singh strikes me as being bang on the money: more…

“Our lives are not actually our own”

23 Jul, 15 | by Iain Brassington

Long-term readers of this blog will know that, every now and then, I have a look at the CMF’s blog.  This is largely because of my interest in the ethics of assisted dying, and the blog is actually a pretty good way into developments on the other side of the lines.  There is rarely, if ever, anything new produced that’d move the argument on – but then, those of us who’re sympathetic to legalisation really aren’t doing any better.  It’s become rather a sterile debate.

I do tend to blank out the apologetics; bet every now and again, something catches my eye: a part of this recent post, about the latest attempt to introduce an assisted dying Bill into Parliament, is one such.  There’s a part where Peter Saunders claims that the Sermon on the Mount moved away from a literal take on the prohibition of murder to something more in keeping with the spirit of the law.  This, though, prompts a question for me: why can’t we accommodate a person’s desire to die within the general law against killing?  Might that desire mean that assistance is properly described as something other than murder?  It is tempting to infer from what Saunders says elsewhere that he is at least not too worried about some forms of intentional killing: writing about the Kermit Gosnell story a couple of years ago, his headline noted that Gosnell may face the death penalty – but the body text did not mention that at all, let alone take a position on it.  Yet if all deliberate killing is so straightforwardly wrong, we might expect that killing at least to be noted.  If deliberate killing by means of the death penalty doesn’t raise a peep of objection, then we might wonder why assisting in someone’s death at that person’s behest is more of a worry.

Saunders does have an answer to this query, though: more…

On the other hand…

20 Jul, 15 | by Iain Brassington

… the phenomenon of apologising for the wrong thing comes alongside people taking umbrage at the wrong thing.  Last week, the BMJ ran a head-to-head feature on the “question” of whether doctors should recommend homeopathy.  This was the latest in a series of articles in which a question is posed, apparently strictly on the understanding that it’ll accommodate a polarised debate, and one person is invited to give a “yea” response, and another to give “nay”.  I won’t bother here with a screed about homeopathy: Edzard Ernst does a good job in the BMJ piece, as have many others across the blogosphere.  (You could do worse, for example, than to have a wander through the Anomalous Distraction blog, which is written by an ex-schoolmate of mine, and which also has lots of pretty pictures of proteins and things.)  Since it’s a nice day, and I’m in a reasonably good mood, I’ll even admit that when Hahnemann was working, something like homeopathy was probably as good a punt as anything else that medicine had to offer.  But… y’know.

Aaaaaanyway…  A rather angry letter appeared.  I think it’s worth examining, because it makes a number of normative and value claims; and if norms and values aren’t the meat and veg of an ethicist’s life, then we might as well go home. more…

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…

While We’re Talking about Ambiguous Sex

16 May, 14 | by Iain Brassington

So: what is one to make of Conchita Wurst?  I’ve not heard the song that won Eurovision this year, but I’m willing to bet that the world would be a better place if every entrant had been thrown into the Køge Bay before a single note was struck.  But that might just be me.


Conchita Wurst. Wurst. Geddit? Wur… Oh, suit yourself

Writing in the TelegraphBrendan O’Neill has other concerns.  Why, oh why, oh why can’t people just use the pronoun “he” when referring to Wurst?  Wurst was born a man; therefore the male pronoun is more appropriate.  (He’s never one to duck the important issues of the day, is Bren.)  “Did everyone overnight transmogrify into a Gender Studies student and imbibe the unhinged idea that gender is nothing more than a ‘playful’ identity?” he asks.  More: the fact that people refer to Wurst with the feminine pronoun is a symptom of what he calls “today’s speedily spreading cult of relativism”, and allowing people to choose their identity is “narcissistic”.

Now, let’s just ignore for the moment that Conchita Wurst is a character, and so it makes perfect sense to call her “her” in just the same way that one might use “her” to refer to Dame Edna Everage.  (Thanks to someone I don’t know on Facebook for making that analogy – it’s a good ‘un.)  O’Neill sort-of-acknowledges that, but he doesn’t let that minor point get in the way of a more general rant against people preferring to be referred to by one pronoun rather than another.  For example, he takes this swipe at Chelsea Manning:


From the File Marked “This Can’t End Well”

25 Nov, 13 | by Iain Brassington

… and cross-referenced with the file marked “You Wouldn’t Let It Lie”.

Francesca Minerva has a paper in Bioethics in which she refers – none-too-obliquely – to the furore surrounding The Paper Of Which We Do Not Speak.  Her central claim is that there is a threat to academic freedom posed by modern communications, inasmuch as that a paper in a journal can now attract to the author intimidation and threats.  A case in point would be The Paper.  But, she claims, it’s vital to the academic exercise that people be able to knock ideas around.  This ability is limited by things such as the response to The Paper; academic freedom is therefore threatened.

Yeah, but no.  I think it’s reasonable enough to say that academic progress depends on the free exchange of ideas, and that there should be no sacred cows.  Sometimes conventional ideas turn out to be untenable or flat-out wrong; and we tend to take it as axiomatic that it’s desirable to have fewer wrong ideas.  (I suppose we could imagine a culture that is satisfied with its opinions as they are, and is not bothered by their truth so much as by some other value they might have, such as their ability to promote social cohesion; but I’ll leave such cultures aside for the moment.)  I’d go along with the idea that we shouldn’t back away from controversial claims, on the basis that repugnance is no objection to the truth of a claim; that if a claim’s true, we should accept it as best we can, like it or not; and that if a claim is false, we shouldn’t have cause to fear its articulation, because we can take it that it won’t survive scrutiny.

And I’d agree that some of the responses to the paper – and to Julian’s defence of publication – were indefensible, and that this is so irrespective of the merits or demerits of the paper or the defence.  But not all of them were.  While some were from obvious dingbats and keyboard warriors (Jonolan remains even now the sole occupant of the banned commenters list here – and I rather suspect that he rather enjoys that honour), other responses were from people whom one might think wrong, but whose response was nonetheless worth taking seriously because it was much more considered and at least on the face of it amenable to argument – which is what academic discourse is all about.

Does any of this tell us about threats to academic freedom, though?  I don’t think so. more…

JME blog homepage

Journal of Medical Ethics

Analysis and discussion of developments in the medical ethics field. Visit site

Creative Comms logo

Latest from JME

Latest from JME

Blogs linking here

Blogs linking here