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Rant

Natal Nativism

12 Oct, 16 | by Iain Brassington

Scene: the boardroom of a large NHS Trust, somewhere in England.

“And so that brings us neatly to the last item on the agenda: passport checks for pregnant women who want a checkup.  The thing is, you see, that it turns out that we’ve been providing obstetric care to some women who aren’t actually UK citizens.  And, clearly, that has to stop.”
“To stop?”
“Well, maybe not stop.  But you know what I mean.  We can’t go providing treatment to anyone who comes knocking at the door!  Why, we’d have a queue from here to Timbuktu, not to mention the cost!”
“Oh, quite.  No, I quite agree that we can’t be the world’s supplier of healthcare.”
“No.  So that’s settled, then.  No more obstetric services to women who can’t demonstrate their eligibility.”
“Hmmmm.”
“You don’t look convinced.  What’s the problem?  These women aren’t eligible.”
“Well, no.  But… well, look.  Remember when Dr Smith retired, and when Dr Jones got that transfer to work in the Inner Hebrides?”
“All too well.  Two great losses to the Trust.  What’s your point?”
“Well, I seem to remember that we pooled together to buy them nice leaving presents.”
“We did.  It was the least we could do.”
“I agree.  But, you see, the thing is, they weren’t actually entitled to them.  If you see what I mean.”
“I’m not sure I follow.”
“No.  Well, you see, the thing is, we bought them those presents, and gave them to them, because it’s the decent thing to do.  There’s no rule that says that we have to buy them.  They wouldn’t have been wronged if we hadn’t.”
“Yeeeeeeessssss…  I mean, no.  But yes.”
“But we gave them the presents anyway.  Because the rules set out what’s minimially decent.  Not an upper limit.”
“Yeeeeeesssss…”
“Well, you see, I was just wondering: might the same apply in other contexts?  Allowing for the obvious differences, of course.”
“You’re losing me again.”
“I thought I might be.  Well, you see, it’s like this.  We’ve been providing treatment to pregnant women without paying attention to whether they’re entitled by the strict letter of the law.  And that law specifies who is entitled to treatment.  But that doesn’t necessarily impose any exclusions.  You see, I wonder if by getting bogged down in the rules, we might… um…”
“Might what?”
“Well, you see, the thing is…”
“Go on…”
“Look: we might end up looking like utter shits.”

Wholly fictional, this, of course.  No such conversation took place.  On the other hand, as reported by the Beeb, here’s a document from St George’s University NHS Trust.  Skip to p80: more…

Gouging

26 Aug, 16 | by Iain Brassington

Jumping to the defence of pharmaceutical companies over their pricing policies isn’t fashionable – and a lot of the time, it’s not going to end prettily.  But it’s perfectly coherent to think that the profit motive is one of the motors of innovation, and that it’s part of the quid pro quo for spending money on drugs that may do nothing; in fine, that the profit motive may actually be a necessary part of getting the good stuff we want.  To an economist, the phrase “normal profit” means the minimum profit necessary to keep a firm going – where average revenue equals average total cost.  But if that was all that was on offer, there’d be no incentive to enter a market in the first place: if you’re (on average) in the same place as you were before entering the market, why bother?  So it’s reasonable to think that there ought to be some level of supernormal profits.  They help ensure we get a world that’s better tomorrow than it was yesterday.

On this account, the problem is not with making a supernormal profit – oh, all right then: what in everyday English we’d simply call a profit – but with gouging and/ or profiteering.  The question that needs to be addressed is one of what level of profit, and what kind of return on investment, is reasonable.  In some sectors of the economy, it may be quite high.  For example, if I can manufacture a luxury good for which people are willing to pay through the nose, and make a stonking great profit from it… well, all hail me.  In other sectors, this will not be the case.

The determinants of the level of acceptability will depend on all kinds of factor.  It’s a complicated question, and it may defy satisfactory answers from time to time.  All the same: one doesn’t have to be able to say that or why x is good in order to be able to say that y stinks.  The story about EpiPen pricing that’s emerged over the last week or so is one such case.

Here’s the story: EpiPens deliver a dose of adrenaline, and are therefore very useful in cases of allergic reaction.  Adrenaline is not expensive, but delivering it via a syringe is cumbersome; EpiPens make it much simpler.  Mylan Pharmaceuticals obtained the rights to the device in 2007; since then, the price has risen by somewhere between 400 and 500% in the US (different sources offer different amounts; but a pack of two EpiPens costs about $415 in the US, and about $85 in France).  That’s bad enough on the face of it, though Mylan CEO Heather Bresch does apparently have a defence, as Fortune explains: more…

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.

Apologising for the Wrong Thing

11 Jul, 15 | by Iain Brassington

A little addendum to yesterday’s monster post.

Ivan Oransky reports that, before deleting her Twitter account, Hope Amantine had apparently also said in a tweet that the story was “not meant to offend”.  I’ve noticed that a lot recently: a person does something wrong, is publicly called out for it, and apologises for any offence caused.  Greenpeace apologised for any offence caused when they trampled over the Nazca lines.  Gary Barlow apologised for any offence caused by the stories about his tax-dodging.  (Not for offence caused by tax dodging, but for offence caused by the world having come to know of it, natch.)

I hate it when people say that.

It reduces moral discourse to one of whether or not Smith was sufficiently courteous.  Moral discourse is richer than that.  Hell, moral discourse has got almost nothing to do with that.

More, I doubt anyone was offended in any of those cases.  That wasn’t the problem.  Lying was; trampling humanity’s patrimony was; dodging tax was.  Apologising for causing offence is a non-apology, and leaves the real moral problem utterly unremarked.

I just wanted to get that off my chest.  As you were.

Oh, dear, Richard…

20 Aug, 14 | by Iain Brassington

Look, I know that Twitter really isn’t the place for nuanced debate.  But, by that token, everyone else should realise that as well – especially intellectual superstars. So how, then, to explain Richard Dawkins’ spectacular foot-in-mouth moment earlier today? It started off reasonably enough, with him tweeting about Catholicism’s stance on abortion and providing a link to this piece by Jerry Coyne in the New Republic; lots of people are going to agree with both Coyne and Dawkins, and lots to disagree, but we should expect that.  The tweet got a couple of replies.  I can’t be bothered transcribing them, but here’s a screenshot; you should be able to click to enbiggen it. Screen shot 2014-08-20 at 19.50.23

So far so good.  Dawkins’ reply is about as good a version of the sentience argument that you could cram into 140 characters; and InYourFaceNewYorker’s point articulates a problem faced by any number of women who are carrying a child with a disability of some kind.  (Well, by any number of parents, I suppose, except that it’s women who hold the moral trump here simply by dint of being the one carrying it.  Fathers could agonise about the best thing to do, too; it’s just that they don’t get to make the final decision.  Oh, you know what I mean.)  Where you stand on abortion doesn’t preclude recognising that it’s a genuine moral dilemma for many people, and a that there are respectable arguments and proponents of those arguments on both sides – by which I mean that people on either side should be able to recognise that their opponents are at the very least worth the effort of an argument. InYourFaceNewYorker goes on to articulate some of the aspects of the debate that make it so emotive and so intellectually rich:

Screen shot 2014-08-20 at 19.58.49

That doesn’t reflect Dawkins’ response to the dilemma, though.  Brace yourselves. 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…

How to write a crap essay/paper in bioethics – or how to write bioethics to be published in medical journals…

7 Oct, 13 | by David Hunter

I’ve been considering writing a reflective piece about the general quality of bioethics papers in medical journals, focusing on how the medium (the audience and the severe word limits) impacts on the message and its quality – possibly as a bit of a moan since I’ve not yet managed to get a medical journal to accept one of my papers (my favourite rejection from an editor yet being “nice try, but too philosophical – maybe try the journal of medical ethics?”). Furthermore publication pressures tend to select for particular styles of pieces – I’ve remarked to people in the past that the way to get published in the BMJ is to write a piece critical of research ethics review – preferably with an anecdote  Then this morning on twitter I saw this lovely funny piece by James Lenman of the University of Sheffield on how to write a crap essay in philosophy which contains gems such as:

 “Whenever in any doubt as to what to say about X, say, apropos of nothing in particular and without explanation, that X is extremely subjective.

When that gets boring, try saying that X is all very relative. Never say what it is relative to.”

And I decided to just borrow and extend the idea in this piece. So take James’ rules as given and add these rules to enable the reader to write a crap piece of work in bioethics:

1. Unreflectively copy a piece of work by a philosopher. If they wasted time qualifying their view or noting it only applies in a limited situation make sure you strip that out.

2. Remember if you are a doctor you don’t need good arguments – you have authority… Remember if you are a philosopher you don’t need to know the context to write authoritatively about it.

3. Never use an argument where an anecdote will do. A homily is worth a thousand arguments.

4. Instead of making an argument, say “I will argue”. Then don’t, an assertion will do. No one will notice.

5. Don’t ever make a modest claim when you can make a bold assertion. Only extremes can be correct.

6. According to the OED it is important to define your terms using the dictionary not how they have been defined in the relevant literature.

7. Please do begin your paper with a vaguely relevant quote from “Literature” this shows that you are well read and thus quite clearly correct. As D’Israeli said: “The wisdom of the wise, and the experience of ages, may be preserved by quotation.”

8. If empirical evidence is relevant to your paper make sure you either don’t find any or you just run a google search and then cherry pick the evidence to support your case without considering its quality.

9. Remember the is/ought problem is a philosophical problem not a bioethical problem so you don’t need to worry about it when making grand assertions from tiny bits of empirical evidence.

10. Ad hominem is a valid argument structure.

11. All slopes are slippery. If its bad and it is remotely possible let us assume that it will happen.

12. There are no principles/theories but the four principles.

13. Obviously the four principles approach is the only one worth considering. Make sure you refer to all four principles (but nothing other than them) especially if several of the principles are irrelevant to the situation you are discussing – before concluding that autonomy trumps the others.

14. Remember the more arguments/assertions you can give the better – why waste time on critical reflection and depth when you can squeeze in more arguments/assertions. Especially ensure that there is no methodological or theoretical consistency about the position you advance.

15. If your argument gets into trouble you can save it by referring to Nazi Germany and implying that your opponents view would have been looked on kindly there.

Please suggest more rules in the comments…  

Gay Conversion “Therapy”: Might the CMF have a point?

5 Feb, 13 | by Iain Brassington

Spoiler alert: Almost certainly not.  But hear me out for a bit.

The Christian Medical Fellowship blog had an article posted yesterday about what it praised as a balanced documentary concerning “sexual orientation change efforts” – gay conversion therapy to you and me – on Radio 4 on Sunday.  Actually, it wasn’t a documentary – it was a short article on Sunday, the station’s religious-affairs-quota-filling hour (go to about 30:50 here), and it’s no more a documentary than is the sports bulletin – and the balance is “BBC balance”, which means giving equal airtime to the fireman and the fire.  But anyway, that’s not what struck me.

Neither am I particularly bothered for the sake of this post about whether or not psychotherapy can make any difference to sexual orientation.  I’ll simply allow, for the sake of the argument, that it can at the very least make a difference to sexual behaviour, and maybe to orientation tout court.

What struck me was a couple of things that Peter Saunders says on his CMF blog post about the use of such “therapies”.  One of the striking things was this: more…

But that’s not what it says, is it?

25 Jan, 13 | by Iain Brassington

Today’s blast of righteous indignation is directed towards New Mexico.  House Bill 206 says, in essence, that… well, it’s short, so here it is in full:

HOUSE BILL 206

51ST LEGISLATURE – STATE OF NEW MEXICO  FIRST SESSION2013

INTRODUCED BY

Cathrynn N. Brown

AN ACT

RELATING TO CRIMINAL LAW; SPECIFYING PROCURING OF AN ABORTION AS TAMPERING WITH EVIDENCE IN CASES OF CRIMINAL SEXUAL PENETRATION OR INCEST.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1.  Section 30-22-5 NMSA 1978 (being Laws 1963, Chapter 303, Section 22-5, as amended) is amended to read:

“30-22-5.  TAMPERING WITH EVIDENCE.–

A.  Tampering with evidence consists of destroying, changing, hiding, placing or fabricating any physical evidence with intent to prevent the apprehension, prosecution or conviction of any person or to throw suspicion of the commission of a crime upon another.

B.  Tampering with evidence shall include procuring or facilitating an abortion, or compelling or coercing another to obtain an abortion, of a fetus that is the result of criminal sexual penetration or incest with the intent to destroy evidence of the crime.

C.  Whoever commits tampering with evidence shall be punished as follows:

(1)  if the highest crime for which tampering with evidence is committed is a capital or first degree felony or a second degree felony, the person committing tampering with evidence is guilty of a third degree felony;

(2)  if the highest crime for which tampering with evidence is committed is a third degree felony or a fourth degree felony, the person committing tampering with evidence is guilty of a fourth degree felony;

(3)  if the highest crime for which tampering with evidence is committed is a misdemeanor or a petty misdemeanor, the person committing tampering with evidence is guilty of a petty misdemeanor; and

(4)  if the highest crime for which tampering with evidence is committed is indeterminate, the person committing tampering with evidence is guilty of a fourth degree felony.”

SECTION 2.  EFFECTIVE DATE.–The effective date of the provisions of this act is July 1, 2013.

The new bit is section B.

In a statement, the congresswoman who introduced the Bill, one Cathrynn Brown, said that her intention was to punish the person who commits incest or rape and then procures or facilitates an abortion to destroy the evidence of the crime.

Hmmm.  Except that that’s not what it says, is it?  Maybe she should read the text of her own Bill.  It talks about procuring an abortion, as well as compelling or coercing another person to have one.

I think that the second bit is actually fairly unobjectionable.  To compel someone to have a medical procedure, whomever that someone is, and whatever the procedure, is to wrong them; and if you compel them to have the procedure in order to remove evidence of another wrong, then the wrongness is multiplied.  But, y’know… that first bit… um… more…

Passive Euthanasia: A Cri de Cœur

5 Oct, 12 | by Iain Brassington

Don’t worry: this isn’t another instance of me yammering on about the right to die or the right to induce death.

I’ve recently received a parcel; it contained a copy of this book by Leanne Bell, which happened to fall open at p 204.  On that page, you’ll find this passage:

Active euthanasia involves a deliberate act intended to kill […].  This is illegal in England and Wales because it satisfies the definition of ‘unlawful killing’ and will therefore either be murder or manslaughter depending on the mens rea (that is, the state of mind) of the doctor at the time.  He is likely to face criminal prosecution, regardless of whether the patient and/or the family requested or consented to it.  By contrast, passive euthanasia involves the withholding or withdrawing of treatment from the patient, i.e. an omission rather than an act, and, in certain circumstances, can be legal. [emphasis mine – IB]

No.  Wrong.  Wrong on two fronts.  Withholding treatment may be an omission, but withdrawing it isn’t.  More importantly, while the active/ passive distinction boils down to one between administration and non-administration, it is simply not true that non-administration is the same as passive euthanasia.

Euthanasia requires the intention to end life based on a motive of beneficence directed at the person who will die.  Neither withdrawing nor withholding treatment indicates the intention to end life.  Only if you’re withdrawing or withholding treatment with the intention that this should end life have you committed passive euthanasia.

There’s a simple test you can run here: When withdrawing or withholding treatment, would it be coherent to hope for the patient’s survival – however miraculous – without further intervention?  It would not be coherent in cases of euthanasia, because you can’t intend that life should end and yet hope that it doesn’t.  It could be coherent otherwise.

Or another version of the same test: If you are considering withholding or withdrawing treatment and the patient does not die, would you see this as contrary to your intention?  If yes, you’re considering passive euthanasia; if no, you aren’t.

Bell is by no means alone in getting PE wrong.  The mistake is all over the place – both in the clinical ethics literature, and in the wider public domain.  I’m not wholly sure where it’s come from, but I suspect it may derive from Rachels having made it in”Active and Passive Euthanasia“, and then a little more explicitly in “Killing and Letting Die“:

Many people believe that “passive euthanasia” – allowing terminal patients to die, rather than pointlessly prolonging their lives – is sometimes permissible; but they also believe that killing patients is always wrong.

I’ve got a lot of time for Rachels, and much of what he says on killing and letting die in these essays is good.  But this is wrong.  Even good essays can have wrinkles in them; and this is a big one.  And if it’s the source of the same mistake being made elsewhere, that’s quite serious. more…

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