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Public Health

Ebola in the US: Privacy, public interest and the ethics of media reporting

3 Oct, 14 | by David Hunter

The first confirmed case of ebola has been found in the US, in Texas – unsurprisingly someone who had recently been to Africa. This has prompted an outbreak… of unethical media reporting about the case, with several breaches of privacy which seem unlikely to be in the public interest. Specifically the media has disclosed the victim’s full name, then to add insult to injury they published both his address and then a map of where he lives.

The media frenzy around this case is as unwarranted as it is unsurprising – scarily reminiscient of the painfully telling Onion piece – which claimed just 50 more white people needed to die of Ebola before a vaccine would be developed…

But even if we accept that the public is interested in the case (which no doubt they are) and that this interest warrants reporting on it does that give the media the right to release this person’s personal details and movements?

The main argument that can be offered for breaching typical standards of confidentiality is that the breach is in the public’s interest – this is the defense typically usually used in whistle blowing cases and in cases where medical professionals break confidentiality to prevent harm to others.

So isn’t this justification enough? Aren’t all Americans now at risk of ebola, amd hence have a right to know about who has it and where it is so they can choose to minimise their own risk?

It is worth noting that whilst Ebola is to be frank a terrifying disease it is relatively easily containable by the use of routine public health measures such as surveilance, isolation, contact tracing and modern hygiene standards and practices as it is spread through fairly obvious contact with bodily fluids, rather than airborne. And these fluids are only generated once someone is obviously symptomatic. As such there is little chance of a significant outbreak in countries like America or Australia because the number of contacts likely to be exposed to bodily fluids are usually minimal.

So this information is unlikely to help anyone protect themselves from being exposed to ebola – those who were already exposed (if any) have been exposed and are being contacted, and no one will now be exposed to this particular victim, so having their details in the public domain does no good, and has a potential to do harm in three ways:

1. It can reinforce false beliefs – “why would they tell us this if we weren’t at a significantly increased risk?”

2. It creates the potential for witch hunting – where the victim is blamed and potentially harmed – “civic-minded” citizens might take it upon themselves to “minimise” the risk of infection by burning down the apartment building he lives in for example.

3. It may perversely discourage other exposed travellers from seeking medical treatment and attention – it is worth noting that the victim took himself to hospital to seek treatment. If there is considerable public outcry, stigmatisation, distaste and displeasure the next victim may feel their details will be exposed in a similar fashion and avoid medical attention with predictably disasterous effects both for them, and for those potentially exposed to them.

Could spreading this information be helpful for contact tracing? Contact tracing is a public health practice where all those who might have been exposed are identified and contacted – both to see if they have symptoms and in some cases to isolate them until they are cleared. Reporting these details might enable a few people who haven’t been identified as being in contact to self identify, but practices of contact tracing are well established and this is a relatively easy case since his movements are well known and the victim has been able to communicate with public health officials about those he has been in contact with, so it is likely to be of minimal benefit, if anything it might well create more false positives than anything else – with worried people who think they were exposed using up valuable time and resources.

In a deeply misleadingly titled piece: “With Ebola, the public’s right to know trumps patient privacy” Art Caplan an American bioethicist argues that rebuilding and maintaining trust requires the public be given some normally confidential information. He argues there is a public interest in knowing the process of how this case was handled, and his movements so that the public can be reassured about the system and that they were not exposed. It is fair to note that mistakes were made in this case – he then went to hospital and was discharged despite having disclosed that he had recently travelled from Africa. However there is as Art acknowledges a significant difference between releasing this information, and the victims personal private details. It is hard to see how releasing that information really would provide public reassurance? I’d suggest it doesn’t really, instead it feeds fear and distrust which are the greatest killers in epidemics.

Highly dangerous infectious diseases create unique ethical challenges because by their very nature those who suffer them are as Battin et al put it “both victims and vectors of disease“. But whether someone is a victim or a vector of a disease, we ought to remember that they are still a person and as such deserve to have their private information protected, especially if disclosure is unlikely to benefit and may well harm the public’s interests, no matter how interested they are in knowing it.

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

10 Jul, 14 | by Iain Brassington

Guest post by Douwe Verkuyl

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

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

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

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

Who’s the SilLIer?

30 Mar, 14 | by Iain Brassington

It’s funny how things come together sometimes.  A few months ago, I mentioned a slightly strange JAMA paper that suggested that non-compliance with treatment regimes should be treated as a treatable condition in its own right.  The subtext there was fairly clear: that there’s potential scope for what we might term “psychiatric mission-creep”, whereby behaviour gets seen as pathological just if it’s undesirable and can be changed with drugs.  I was reminded of this by a couple of things I found last weekend.

I was avoiding work by pootling away on the internet, and stumbled across a couple of things.  This – an article about American politics that notes the use of psychiatry as a means of social control – was one of them:

[In 1980] an increasingly authoritarian American Psychiatric Association added to their diagnostic bible (then the DSM-III) disruptive mental disorders for children and teenagers such as the increasingly popular “oppositional defiant disorder” (ODD). The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules,” “often argues with adults,” and “often deliberately does things to annoy other people.”

Many of America’s greatest activists including Saul Alinsky [...] would today certainly be diagnosed with ODD and other disruptive disorders. Recalling his childhood, Alinsky said, “I never thought of walking on the grass until I saw a sign saying ‘Keep off the grass.’ Then I would stomp all over it.” Heavily tranquilizing antipsychotic drugs (e.g. Zyprexa and Risperdal) are now the highest grossing class of medication in the United States ($16 billion in 2010); a major reason for this, according to the Journal of the American Medical Association in 2010, is that many children receiving antipsychotic drugs have nonpsychotic diagnoses such as ODD or some other disruptive disorder (this especially true of Medicaid-covered pediatric patients).

For some reason, I had foxes on my mind as well, and so I entered the word “Fox” into google; and I should have known that it’d provide lots of hits for the US TV conglomerate.  One story that came up on the search had to do with a twitter account called @LIPartyStories.  This was apparently a feed that would repost pictures sent from its teenage followers of themselves in various states of intoxication and déshabillé.  So far, so straightforward: the day that teenagers stop getting drunk and doing stupid things at parties is the day that the world will stop turning.  Granted, when I was young, we didn’t post stuff online – but if the internet had been around, we probably would have.  Kids do daft stuff; they sometimes regret it; then they grow up, and do daft stuff less.

Keith Albow, a Fox pundit, doesn’t see it quite like that: more…

Welcome to Britain.

30 Dec, 13 | by Iain Brassington

It having been a long time since my last post, and this being the season of good-will, I wasn’t going to comment on the government’s new policy of charging migrants for A&E services.  Noone needs that kind of spleen on a dreich Monday; besides: I’ve got a PhD thesis that needs assessing, and a bathroom floor that I’ve been meaning to re-lay all year – all manner of better uses of my time.

Still, there’s a couple of things that merit comment.  First, there’s this, from the Government’s press-release:

We know that some people are abusing the system by coming into the country early enough to have one or more antenatal appointments before giving birth on the NHS – without the intention to pay.

I love a good vague statistic.  “Some” people.  There’s nothing offered about how many that amounts to.  Presumably, it’s more than one, but fewer than everyone.  Beyond that, though… well…  The phrase “some” just isn’t very useful when it comes to making judgements about anything – as waitresses (and diners) can attest.  But still, I’m willing to concede that “some” indicates a positive integer, and that there is therefore some measurable impact on expenditure arising from such people.  This doesn’t tell us whether it’s expenditure at a level that should bother us.  The DoH press release offers some illumination on this point: more…

Research Ethics and Ethical Problems

16 Aug, 13 | by Iain Brassington

Noted on Ben Goldacre’s twitter feed a couple of weeks ago was this article in Slate about the recruitment of pregnant women into drug trials.

Essentially, there’s a situation in which there’s a dearth of information about the impact of drugs during pregnancy.  According to the article,

[p]harmaceutical companies are not willing to navigate the legal and ethical minefield of testing drugs on pregnant women, especially because pregnancy lasts only nine months, a short window in which the tests could pay off in additional sales.  As a result, drugs are often prescribed to this population off-label, meaning that they haven’t been specifically approved for pregnant women.

Of course, that doesn’t explain why testing is an ethicco-legal “minefield” to begin with.  Still, it’s not all that hard to come up with at least a skeletal explanation: the whole point of trials is that the effect of a drug is unknown, and this might mean that it’s not safe.  When we’re talking about a volunteer, then it’s important that they know the risks before enrolling; but when a woman is pregnant, another dimension is added: she’s effectively volunteering her unborn child as well.  And it might be problematic to expose another human – even a foetus – to an unknown risk.

But this leaves us with a paradox: more…

Drug Legalisation in Uruguay: Opening up Pandora’s Box

8 Aug, 13 | by BMJ

Guest post by Melissa Bone, University of Manchester

Uruguay is poised to become the first country in the world to legalise and regulate the sale of cannabis for recreational use.  On the 31st July 2013 a draft bill legalising cannabis was passed by members of Uruguay’s lower house of congress, where 50 out of a possible 96 MPs voted in its favour.  If approved by the senate as is expected then the government will legally control the production, distribution and sale of cannabis.  The bill allows for each Uruguayan household to cultivate up to 6 cannabis plants.  Alternatively, residents could join a co-operative which would be licensed to grow up to 99 plants.  Private firms will be able to produce cannabis as well, but they will be required to sell it to the government, who will in turn sell it to consumers through pharmacies.  Only Uruguayan citizens will be able to purchase cannabis; they can purchase up to 40g per month (minors will be excluded).  Driving while under the influence will remain a crime.

Many commentators recognise that Uruguay has taken this bold step due to the devastation that’s wreaked by the so-called “war on drugs”.  This phrase was first coined by President Nixon in1971, and it is widely employed on both sides of the drug legalisation debate to describe a global position that prohibits the possession, production, and sale of certain psychoactives, all of which are listed in the UN drug conventions.  Advocates of drug reform often use the phrase to expose the aggressive and militant tactics which are used in producer countries especially, in an attempt to restrict the production and trade of illicit substances.  For instance, the Latin American region has the highest murder and drug-related violence rates in the world, drug cartels have infiltrated and corroded various positions of power, infamous aerial fumigation operations have destroyed farmer’s livelihoods, and this along with numerous other human rights abuses provides the backdrop for Uruguay’s brave decision.

Predictably, the International Narcotics Control Board (INCB), a committee tasked with ensuring compliance to the UN drug conventions, doesn’t quite see it this way. more…

Cigarettes and Plain Packs: The Ad Campaign

16 Apr, 13 | by Iain Brassington

Blogging here has been light for a little while, and probably will be for a little while longer because of Stuff and Things – but something caught my eye in Sunday’s Indy* that struck me as worth comment.  It was a full-page advert placed by JTI, which describes itself in the small print as “a leading international tobacco company” (and it is).

Anyhoo… the main bit of the ad is a copy of an email, obtained by an FoI request, apparently from the UK Department of Health to the Australian Department of Health and Ageing; it reads as follows (with the highlighting copied from the ad here as closely as I can manage):

Dear [redacted]

I work on the UK government’s tobacco policy team, with [redacted] and you will be aware that the UK government is considering the introduction of plain packaging of tobacco products.

As I’m sure you’re aware, one of the difficulties regarding this is that nobody has done this and therefore, there isn’t any hard evidence to show that it works.   Therefore, I am wondering whether the Australian government drafted any type of impact assessment or cost analysis in which the likely benefits and costs are measured, and if so, whether you would be willing to hare the information with us.

Many thanks,

And then in bold underneath, JTI’s copywriters have added:

WE COULDN’T HAVE PUT IT BETTER OURSELVES

Now, the email is dated the 10th of May 2011.  Australia’s plain-packaging law came into effect on the 1st December 2012; as far as I’m aware, Australia was the first country to pass such a law.  So, at the time of writing, there could not have been any hard data about its impact.  There could not possibly be any hard evidence to show that plain packaging works to reduce smoking rates.

The argument of the advert – actually, no: the subtext, since it’s not really an argument – is that the UK government should not introduce plain packaging because of the lack of hard data.  This seems to amount to a claim that governments should not introduce policies without hard data concerning their efficacy.  And there’s something correct about that for the most part.  But hard data are only available in the wake of the introduction of a policy.  If the policy is novel – as it is – then JTI would seem to be committed to the claim that no government should be the first to introduce a policy; which is as much as to say that no government should introduce it at all.

It’s understandable that that’s what they think.  But why not just say so?  Isn’t this ad just rather disingenuously dressing up opposition as something else?

Or have I missed something?

 

*Saturday’s Indy, with its column-inches devoted to Andrew Wakefield, is worth rather a lot of comment: more than I can offer at the moment.  I’ll point you in the direction of Martin Robbins in the Staggers instead.

Crime and the Less-Polluted City Solution

10 Jan, 13 | by Iain Brassington

People who listen to Today may have heard an article in the prime 8:10 slot on the 9th about the correlation between a drop in the use of leaded petrol, and a drop in violent crime rates.  (Mother Jones actually beat the BBC, having published a piece on the same research last week: I meant to post something then, but was buried by other stuff.)

The nub of the story is this: that violent crime has been falling in the past few years, and though this pattern seems to lag about 20 years behind a fall in the use of lead in petrol, the fit is pretty good: a decline in leaded petrol predicts a decline in violent crime by about two decades – which is just about the time that we might expect would elapse between the formation of the brain and the highest likelihood of violent behaviour in humans.  Neat.  The Mother Jones piece provides lots of links to the relevant research – links to this (from 1999), and this (from 2007), and this (from 2012).

If the lead hypothesis is sound, it seems to be ethically interesting in a couple of ways. For one thing, it opens the way to at least some antisocial behaviour to be seen as being symptomatic of a deeper public health problem.  That’s interesting enough as it is, but – admittedly – it might be little more than interesting, on the grounds that leaded petrol is pretty much a thing of the past anyway (Wikipedia says that, as of 2011, leaded petrol was widely available only in 7 countries).

But the other way in which it’s interesting has to do with arguments about so-called “moral enhancement”. more…

Junk food feeders are criminal child abusers? Really?

15 Oct, 12 | by David Hunter

Public Service Announcement: Sensitivity Advisory Sticker – Caution Post contains sarcasm.
In the interests of our more sensitive readers not taking offence I recommend they skip this post on the grounds that it will contain gentle sarcasm, disagreement and a certain amount of me asking “Is that really what they mean to say?”*

Blog Post:
The Oxford Practical Ethics Blog is typically very good, hence when there are posts that seem shall we say not quite as thought through as they might be it seems worth mentioning this and raising some debate. Presently Charles Foster has an interesting post: Should you be prosecuted for feeding junk food to your child?

more…

Mouse Eggs: A Cool Solution to a First-World Problem?

8 Oct, 12 | by Iain Brassington

The news that Japanese researchers have successfully induced skin cells to behave like viable eggs, which have then been fertilised to create a new generation of mice, may well come to be seen as a scientific milestone.  And if it’s not that, it’s definitely very, very cool.  (The original paper is here.)

Though the research does not necessarily translate into humans, it appears to demonstrate that the genetic material found in every cell in the body can be put to use in the creation of offspring. In principle, this offers infertile women the opportunity to have children that are genetically related, even if they do not have viable eggs of their own: cells from another part of the body could be used and “reprogrammed” to behave as eggs would.  (Putting the procedure to use in humans would be illegal under current UK law, since the synthesised eggs would not be what the Human Fertilisation and Embryology Act calls “permitted”.  But the law is, after all, just the law.)

There will probably be concerns raised; but they aren’t obviously any more serious in relation to this technology than they would be in relation to others.

The most obvious concern – and, prima facie, the most powerful – would be about the safety of the procedure were it to be used in humans. more…

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