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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…

The Unbearable Asymmetry of Bullshit

16 Feb, 16 | by bearp

By Brian D. Earp (@briandavidearp)

* Note: this article was first published online at Quillette magazine. The official version is forthcoming in the HealthWatch Newsletter; see


Science and medicine have done a lot for the world. Diseases have been eradicated, rockets have been sent to the moon, and convincing, causal explanations have been given for a whole range of formerly inscrutable phenomena. Notwithstanding recent concerns about sloppy research, small sample sizes, and challenges in replicating major findings—concerns I share and which I have written about at length — I still believe that the scientific method is the best available tool for getting at empirical truth. Or to put it a slightly different way (if I may paraphrase Winston Churchill’s famous remark about democracy): it is perhaps the worst tool, except for all the rest.

Scientists are people too

In other words, science is flawed. And scientists are people too. While it is true that most scientists — at least the ones I know and work with — are hell-bent on getting things right, they are not therefore immune from human foibles. If they want to keep their jobs, at least, they must contend with a perverse “publish or perish” incentive structure that tends to reward flashy findings and high-volume “productivity” over painstaking, reliable research. On top of that, they have reputations to defend, egos to protect, and grants to pursue. They get tired. They get overwhelmed. They don’t always check their references, or even read what they cite. They have cognitive and emotional limitations, not to mention biases, like everyone else.

At the same time, as the psychologist Gary Marcus has recently put it, “it is facile to dismiss science itself. The most careful scientists, and the best science journalists, realize that all science is provisional. There will always be things that we haven’t figured out yet, and even some that we get wrong.” But science is not just about conclusions, he argues, which are occasionally (or even frequently) incorrect. Instead, “It’s about a methodology for investigation, which includes, at its core, a relentless drive towards questioning that which came before.” You can both “love science,” he concludes, “and question it.”

I agree with Marcus. In fact, I agree with him so much that I would like to go a step further: if you love science, you had better question it, and question it well, so it can live up to its potential.

And it is with that in mind that I bring up the subject of bullshit.


Stay Classy, BMJ.

14 Feb, 16 | by Iain Brassington

Lord only knows, it pains me to jump to George Osborne’s defence – more so by resurrecting a meme that was already past it when I was first invited to run this blog in 2008 – but on this one occasion, I’m going to have to do it.

Last week, the BMJ reported about a case in which a psychiatrist was struck off the medical register for having entered into a sexual relationship with a vulnerable client.  That’s dodgy enough in its own right; but he also asked her at the beginning of the affair to promise not to report him to the GMC.  That shifts the whole case from being only (!) deeply dodgy to downright despicable – in effect, he’s admitted in that that there is cause to report him for his behaviour, but then gone ahead with that behaviour anyway.  The vulnerability of the woman with whom he was having the affair adds extra piquancy to the whole sorry tale.

I don’t think that there can be any objection to this sort of thing being reported, though it doesn’t get reported often.  I don’t know how often the GMC hears this kind of case, or whether every hearing attracts coverage.  Maybe cases like this get reported whenever they happen, but that they don’t happen all that often.  Or maybe they’re not infrequent, but the GMC has the consistent bad luck only to hand down its verdicts on days when there are bigger news stories to eclipse them.

Or maybe – and I have a suspicion that this is so – it’s the kind of case that is much more likely to get reported when the perpetrator happens to be the brother of the Chancellor of the Exchequer.  Call me a cynic, but that seems… tolerably likely.

Exhibit A on the evidence table: the opening sentence of the story in the BMJ.

Adam Osborne, the psychiatrist brother of the United Kingdom’s chancellor of the exchequer, George Osborne, has been struck off the UK medical register for “blatant disregard of the fundamental tenets of the medical profession.”

Quite what George has to do with the story, and why the link to him is worth drawing is beyond me.

Ha!  Just kidding.  It’s not beyond me at all.  It’s almost entirely to do with making the story enticing.  Adam’s behaviour is no better or worse by dint of his family connections; they do nothing except to add a detail to something that would otherwise be merely sordid.  And if you can offer a whiff of guilt-by-association by drawing a link between a creepy doctor and a prominent member of a government currently deeply unpopular among medics… well, so much the better, eh?

Now, the BMJ is not the only organisation to make this move: Adam Osborne has been in trouble before, and the BBC, for example, has never been reluctant to point out the family link.  Here’s the thing, though: I don’t think that the Beeb should be doing it either.  For sure, the BBC is at the very least a general-interest news provider, whereas the BMJ could, I think, be expected to concentrate on medicine and medics; yet even that partial mitigation of the BBC is so dismally weak that the only reason to articulate it is to provide a space to air doubts about whether it should have been articulated.

The BBC shouldn’t be doing it; no news organisation should be doing it; the BMJ shouldn’t be doing it.

The same principle applies to other people with embarrassing siblings, of course.  Yes, we know that climate-change “sceptic” Piers Corbyn is Jeremy’s brother.  Unless Jeremy’s policies on CO2 emissions are influenced by Piers, though, that’s neither here nor there; and in the event that Piers does something even dafter than predicting that another ice-age will begin in the middle of next week, there’d almost certainly be no justification for roping in his Jeremy.  The same rules apply.  But since that’s not a medical matter, I’m not going to moan about it here.

I just want to make it clear that I’m not holding a torch for George on this.  I may disagree with him about any number of things, but the conduct of his brother is one thing for which we shouldn’t throw brickbats at him.  Leave George alone.

Zika, Gandhi and the CDC

11 Feb, 16 | by BMJ

Guest Post by Agomoni Ganguli Mitra

Three pieces of news over the last weeks particularly troubled me.  In the first, and perhaps most radical of them all, Latin American governments began to urge women not to become pregnant over the next couple of years, as a public health measure to restrict the number of children born with microcephaly, potentially caused by the Zika virus currently plaguing the region.  The second came from the Indian Minister of Women and Child Development, Maneka Gandhi, one of the highest ranking officials in the current Indian government.  For years, India has struggled with non-medical sex-selective abortion (and female infanticide) in such significant numbers, that the sex-ratio for infants in certain regions has become heavily skewed.  Despite sex-determination being illegal since 1994, the practice has continued with the complicity of physicians and clinics, and in some cases without the consent of the pregnant women themselves.  At a conference in early February, Gandhi suggested that an alternative to the current, ineffective policy of criminalising those who provide ultrasounds and sex-selective abortions, would be to register and monitor every pregnant woman in the country to ensure that female foetuses are brought to term and female infants are not killed shortly after birth.  The last and most recent piece is perhaps the least shocking of them all, if only because we almost take it for granted that women’s health and lifestyles choices are seen to be closely related to their ability and inclination to produce babies.  The US government’s Centre for Disease Control and Prevention (CDC), in a bulletin patronisingly subtitled Why Take the Chance?, has suggested that women should think carefully before mixing sex and alcohol intake, if they are trying to get pregnant, or (and this is what makes it particularly problematic) could unknowingly be pregnant.

On the face of it, these are three very different sets of circumstances, geographical, political and social contexts, and in applied ethics, context is crucial to rigorous analysis.  And yet I am struck by how, ironically, these policies and policy proposal fail to be contextualised within broader considerations of reproductive rights and justice by policy makers. more…

Should Junior Doctors Strike?

25 Jan, 16 | by Iain Brassington

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

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

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

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

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

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

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

Read the paper here.


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…

Pro-Lifers’ Arguments Might be their Greatest Gift to Pro-Choicers

19 Dec, 15 | by Iain Brassington

Abortion is always going to be a controversial topic.  For what it’s worth, I hold that there’s nothing wrong with it.  That’s me speaking from my habitual non-consequentialist position.  From a more utilitarian perspective, I’m willing to concede that, given the choice between world A, in which abortions happen, and world B, in which they don’t because noone gets pregnant without wanting it, and everyone is perfectly happy to continue with her pregnancy, A is worse.  But A is nevertheless a whole lot less bad than world C, in which women are compelled to continue with pregnancies they don’t want.  In other words, there’s no need or desire for abortion in super-happy-fluffy world, and super-happy-fluffy world is better than the real world – but we live in the real world, and having abortions available makes the real world better than it could be.

I’d like to think that I’m doughty enough to have my mind changed on this, though.  Should someone have a really good argument for the wrongness of abortion, or the overwhelming badness, I’d like to think that I could be persuaded – that I’d let the argument go wherever it takes me.  I think that that’s just intellectual honesty.  It’s just that I have yet to come across an argument that I find persuasive, and I don’t even know what such an argument would look like.

What I can say is that, while I find even the best pro-life arguments unpersuasive, some are worse than others, though.  There’s a guy who keeps posting to the Bioethics Facebook group with links to lamentably bad arguments.  And, of course, there’s the CMF.

On their blog, Philippa Taylor has been getting herself into a tizzy about the recent ruling that Northern Ireland’s very restrictive laws contravene human rights legislation, and suggests that there is a whole range of reasons why the law should not be changed there.

Let’s have a look… 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…

Should Doctors Strike?

9 Nov, 15 | by bearp


Should doctors strike?

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

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

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

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

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

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

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

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

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

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

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

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

Check out the current issue by clicking here.

Stop What You’re Doing: This is Important.

14 Oct, 15 | by Iain Brassington

I’d not realised it, but the latest iteration of the erstwhile Medical Innovation Bill – colloquially known as the Saatchi Bill – is up for debate in the Commons on Friday.  This is it in its latest form: to all intents and purposes, though, it’s the same thing about which I’ve blogged before.

In a nutshell, the Bill does nothing except remove protections from patients who would (under the current law) be able to sue for negligence in the event that their doctor’s “innovative” treatment is ill-founded.

Much more articulate summaries of what’s wrong with the Bill can be found here and here, with academic commentary here (mirrored here on SSRN for those without insitutional access).  There have been amendments to the Bill that make the version to be discussed on Friday slightly different from that analysed – but they are only cosmetic; the important parts remain.

Ranged against the Bill are the Medical professional bodies, the personal injuries profession, patient bodies, and research charities.  In favour of the Bill are the Daily Telegraph, a few people in the Lords who should know better (Lord Woolf, Lady Butler-Sloss: this means you), and Commons MPs who – understandably – don’t want to be seen as the one who voted against the cure for cancer.

Gloriously, Christ Heaton-Harris, who introduced the Bill, did so only after winning the ballot for Private Members’ Bills.  In a nutshell, he was allotted Parliamentary time, and then began the process of wondering what to do with it – which suggests that even the Bill’s sponsor doesn’t have a burning commitment to the cause – or, at least, didn’t when he took it on.

Still, the Bill has the support of Government; as it stands, there’s a good chance that it’ll pass.

SO: Take a few minutes to look up your MP’s email address – you can do that by following this link – and drop him/ her a line to encourage them to vote against the Bill.

Do it.

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