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Flibanserin and Regulatory Failure

25 Sep, 15 | by Iain Brassington

Guest Post by Adriane Fugh-Berman

On August 18th, 2015, the FDA approved flibanserin (brand name Addyi), a purported aphrodisiac that can drop blood pressure so precipitously that users sometimes pass out and require medical intervention to regain consciousness.  The labelling for flibanserin indicates that it is for:

the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD), as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is NOT due to:

• A co-existing medical or psychiatric condition,

• Problems within the relationship, or

• The effects of a medication or other drug substance.

Focus for a moment on “Low sexual desire that causes marked distress or interpersonal difficulty”.  So a woman upset by a belittling spouse who wants sex more often than she does is eligible for a prescription drug?  It gives a whole new meaning to the term “drugs of abuse.”  Note that even if the putative patient isn’t distressed, she is still eligible for being drugged if her partner is creating interpersonal difficulty.  Here’s a thought – why not sedate him instead?

Not every partner is a jerk, and there are certainly women distressed by loss of libido, but flibanserin isn’t the answer for these women either.  As an aphrodisiac, it’s no great shakes; its predominant mechanism may simply be sedation.  Flibanserin increased “sexually satisfying events” by less than one event a month (the event, by the way, need include neither an orgasm nor a partner).

The labeling of flibanserin reveals the absurdity of this “disease” and its treatment. more…

The Legal and Moral Significance of Implantation

23 Jun, 15 | by BMJ

Guest post by Sally Sheldon

We tend to talk about contraception and abortion as if they were two separate and readily distinguishable practices, the former preventing pregnancy and the latter ending it. This understanding has a very important effect in current British law, where a relatively permissive approach to the availability of contraception stands in stark contrast to the morally grounded, onerous criminal sanctions against abortion. Yet is the distinction between abortion and contraception really so clear cut?  How and why do we make it? And is the line that we have drawn between the two morally defensible?

As a matter of biological fact, the development of human life is not characterised by bright lines. As the eminent lawyer Glanville Williams once put it, “abstract human life does not ‘begin’; it just keeps going.” A seamless biological continuum exists through the production of sperm and egg, their joining together in a process of fertilisation, the gradual development of the new entity thus created throughout pregnancy, birth, subsequent growth, eventual death and ensuing decay of the body. Defining what happens along the way as an ‘embryo’, ‘fetus’, ‘person’, ‘adult’, or ‘corpse’ requires an attempt to draw lines on the basis of criteria selected as holding significance for legal or other purposes. How and where we draw such lines is a tricky business, involving careful moral reflection informed by medical fact.

The “regulatory cliff edge” between the relatively permissive regulation of contraception and the criminal prohibition of abortion relies on a line drawn on the basis of the biological event of implantation, where the fertilised egg physically attaches itself to the wall of the womb some six to twelve days after ovulation. Yet while enormous legal weight has been placed upon it, little consideration seems to have been given as to why implantation matters morally. The voluminous philosophical literature on the ethical status of the human embryo and foetus offers little support for the view that implantation is an important marker.

Further, while it might once have been suggested that implantation offers a conveniently timed moment for a necessary gear change between the appropriate regulation of contraception and abortion, this argument is difficult to sustain in the light of modern medical science. more…

The Moral Desirability of Early Fatherhood

5 Jun, 15 | by Iain Brassington

Guest Post by Kevin Smith

It is well known that the risk of disorders resulting from chromosomal abnormalities, such as Down’s syndrome, correlates with advancing maternal age.  Less widely known is the correlation between the age of fathers and an increased risk of a range of disorders in their resultant offspring, the most prominent of which are neuropsychiatric conditions including schizophrenia and autism.  This is the paternal age effect, the importance of which has recently become clear through a growing body of molecular genetic and epidemiological data.

The paternal age effect results from new mutations occurring in the stem cells from which sperm cells are derived, resulting in an accumulating mutational burden as the male ages.  Genetic abnormalities resulting from these paternal mutations are usually subtle at the molecular level (involving as little as a single nucleotide change), highly heterogeneous, and do not usually result in detectable foetal abnormalities.  Accordingly, the opportunity for prenatal detection of such cases is very limited.  (By contrast, the genetic abnormalities associated with maternal aging typically involve substantive chromosomal aberrations, comprise a relatively restricted range of commonly occurring forms, and frequently produce marked foetal defects; these features ensure that routine screening and testing reveals the majority of such cases prior to birth, permitting termination of affected foetuses.)  Additionally, and again in contrast to genetic aberrations associated with maternal age, paternal de novo mutations are transmitted through successive generations of males, with a concomitant intergenerational accumulation of genetic abnormalities.  Moreover, at least in Western societies, the average age of fatherhood is increasing markedly, a situation that will increase the burden of these mutations.  It follows that the age of potential fathers is of significant ethical importance.

My paper explores the ethical aspects of paternal age, in respect of both individual procreative decisions and societal responsibilities.  I argue inter alia that, somewhat contrary to the commonplace disapproval of young parents, early fatherhood is ethically desirable.  The most immediate practical means to achieve a reduction in paternal de novo mutations and associated genetic disorders would be the promotion of sperm banking amongst young males.

Read the full paper here.

Does Religion Deserve a Place in Secular Medicine?

26 Feb, 15 | by bearp

By Brian D. Earp

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

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


Free Speech and the CMF

5 Jan, 15 | by Iain Brassington

Despite a slight reticence when it comes to quoting Mill approvingly, I do have to admit that sometimes he does articulate a thought clearly and pithily, and sometimes it’s a thought in which all right-thinking people ought to see the merit.  Like, for example, this, from the opening paragraph of chapter III in On Liberty:

An opinion that corn-dealers are starvers of the poor, or that private property is robbery, ought to be unmolested when simply circulated through the press, but may justly incur punishment when delivered orally to an excited mob assembled before the house of a corn-dealer, or when handed about among the same mob in the form of a placard.

The general point ought to be clear: whatever your prima facie right to say what you want, it doesn’t mean there’re no limits on the circumstances in which it can be said.  Mill is concerned about excitable mobs, but the basic principle could, I think, be extended without too much difficulty: if your free speech causes severe inconvenience or distress or inconvenience to others, you ought to moderate it or take it elsewhere.  Having the freedom to make a point is, and ought to be, compatible with others’ freedom not to be bothered by your making it.

I think that that’s pretty reasonable: your liberty is one thing, but it’s not the only thing.  There’s the liberty of others to avoid you to consider, for one thing.  Pushing things a bit further, we might be inclined to argue that liberty is a good because of its relationship with, and contribution to securing, the general welfare – but that there’re other things that contribute to that, too, which therefore ought also to be considered good things worth protecting.  Basic civility might be one such good.  Mill doesn’t make much of that, but there’s no reason why we couldn’t say that that’s a good worth preserving – and why we couldn’t fit that into a modified Millianism, should we so desire.  On Liberty isn’t Holy Writ: its good ideas might be extendable.

Keep that in the back of your mind for a moment.

Many readers will have seen the video posted a few weeks ago by Sunny Hundal in which a woman berates a group of pro-life protesters outside an abortion clinic.  The background detail is that there is reportedly an increasing prevalence in the UK of pro-life protesters congregating outside such clinics.  Sometimes those protests take the form of prayer vigils; sometimes – as in the video – they’re more direct, with posters of babies and foetuses, sometimes quite graphic.  Occasionally there’s barracking; I think that this is more common in the US, but I suspect that the trend may appear here soon enough, not least because these things do tend to escalate.  Yvette Cooper has apparently mulled the idea of buffer-zones around abortion clinics, within which pro-life protesters would not be allowed to protest.

Writing on the CMF blog, Cheryl Chin is not happy about Cooper’s idea; she thinks that “It would appear that once again, liberties are under threat of being curtailed by the proponents of the pro-abortion brigade”.* more…

Should Anyone get IVF?

25 Nov, 14 | by Iain Brassington

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

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

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

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

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


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

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

Film Review: “Obvious Child”

3 Sep, 14 | by Iain Brassington

We’ve not had a film review here before, have we?  OC-poster-screenshot-121013

As far as I can tell, the ratio of talked-about-ness to actual screenings of Obvious Child is unusually high; it doesn’t seem to have got all that much time in mainstream cinemas, which meant that I had to schlep along to Manchester’s Cornerhouse to see it.  (I have a theory about cinemas, which is that the artistic quality of the establishment is inversely proportional to the comfort of the seating.  The Cornerhouse is a nice example of this rule in action.)  Why it’s attracted so much attention is captured in the elevator pitch: it’s a romantic comedy about abortion.  It certainly got certain elements of the US commentariat all excited – RightWingWatch has a nice little compilation here – though admittedly, as far as I can tell, the objections haven’t been matched in the UK, where the emphasis has been much more along the lines of “It’s that film that got the American right all antsy”.

I can see why certain sectors of the commentariat have got upset about it; the film is remarkable in just how down-to-earth its handling of the plot is.  The plot is dead simple: a woman (Donna, played by Jenny Slate) loses her boyfriend and her job within the space of about three frames, gets drunk, has a one-night-stand, gets pregnant, decides to have an abortion, lets the father of the child know all this in the course of a stand-up routine, has that abortion, then decides to watch Gone with the Wind.  It’s that straightforward.

For Donna, it’s less a matter of obvious children than obvious decisions.  She doesn’t want to be pregnant, and sets about not being.  There’s no indication that she’ll regret the decision; there’re no lingering shots of Donna agonising over whether it’s the right thing to do; the father (Max, played by Jake Lacy) says he wants to be a grandfather in passing, but doesn’t try to talk her out of it, or even insist that he should have a say.  Donna is a little nervous about the procedure – but then, it makes sense to be a little nervous about having a mole removed or any other minor surgery.  There’s no moral freight, though.  Donna is not irresponsible – I mean, she might have done something a bit irresponsible in not taking more care with the contraception, but that’s a shared thing with Max; and making a decision about what to do in the wake of having done something a bit daft is responsible.

In other words, Obvious Child is just about a person making a decision. more…

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…

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…

Gaia Doesn’t Care where your Baby Comes From

25 Jul, 14 | by Iain Brassington

Guest Post by Dominic Wilkinson, Associate Editor, Journal of Medical Ethics

In a provocative paper published today in the Journal of Medical Ethics, US theologian Cristina Richie argues that the carbon cost and environmental impact of population growth in the West should lead to restrictions on artificial reproduction.  She points to the substantial carbon emissions that result from birth in developed countries like North America.  Seven percent of the world’s population contribute fifty percent of the world’s CO2 emissions, and children born by in vitro fertilization are likely to be in this seven percent.  Richie argues in favour of a carbon cap on artificial reproduction and argues that IVF should not be funded for women who are “biologically fertile”.

Richie is correct to point to the enormous carbon cost of additional human population. One of the most significant ways that individuals in Western countries can reduce global carbon emissions is by having fewer children. However, her focus on artificial reproduction and on the “biologically fertile” is not justified.

Richie ignores questions about the moral implications of climate change and climate cost for natural reproduction.  She sets to one side “the larger realm of sexual ethics and procreation”.  Yet there are two reasons for thinking that this is a mistake.  First, as Richie notes, “Reproduction-related CO2 is primarily due to choices of those who have children naturally: a huge majority of all births.”  Only 2% of all children born in the UK are conceived by IVF.[1]  Therefore interventions to reduce the number of children naturally conceived will potentially have a fifty fold higher impact on carbon emissions.  Secondly, it is profoundly unjust to apply restrictions to reproduction only on those who are unable to conceive by natural means.  It could be justified to limit the reproductive choices of women because of concern for the environment.  However, if this were justified, it would be equally justified to try to limit the reproduction of the naturally fertile and the naturally infertile.  It is ad hoc and unfair to confine our attention to those who must reproduce artificially.

Second, Richie proposes that public funding for IVF be confined to those who are “biologically infertile”, excluding same sex couples and single women.  However, she provides no reason at all for restricting the availability of IVF for these women.  Put simply, the carbon cost of artificial reproduction is exactly the same for a woman who is infertile because of endometriosis or polycystic ovary syndrome or because she does not have a male partner.  The only possible reason for making a distinction between biologically infertile and biologically fertile women is because Richie believes that lesbian and single women are less deserving of public funding because of their lifestyle choices.  However, that argument, as problematic and contentious as it is, is completely independent of the question of environmental impact.  The carbon cost of children born to gay couples is likely to be exactly the same as the carbon cost of children born to women with endometriosis.

The carbon cost of additional births might well be sufficiently important for the state to justify limiting reproductive freedom.  However, if the state is going to interfere in couples’ decisions about whether to have children or the number of children that they have, it should do so fairly and equally.  Carbon caps should be applied equally to those who conceive naturally and those who require artificial reproductive treatment.  They should not be used as a way to discriminate against those who are single or gay, or have some other ‘undesirable’ characteristic.



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