One of the objections to the HPV vaccine was that it might encourage promiscuity, and so should not be administered.  There was a number of reasons why the objection failed. more…

This looks like it could be interesting…

Department of Philosophy, University of Bristol

This is an informal workshop on topics in the philosophy of medicine.

Everyone is welcome.

•09.45–11.00 Kevin Brosnan (Cambridge) “Does nothing in medicine make sense except in light of evolution?”
•11.15–12.30 Jeremy Howick (UCL) “Defining a role for mechanistic reasoning in EBM”
•13.30–14.45 Havi Carel (UWE) “Phenomenology and its application in clinical medicine”
•15.00–16.15 Alex Broadbent (Cambridge) “Inferring causation in epidemiology: mechanisms, black boxes, and contrasts”

The workshop will take place in the Common Room, Ground Floor, Department of Philosophy, 9 Woodland Road.

There is no need to register—it will be fine if you just turn up on the day. (If you do know that you are coming, it may be helpful to let us know, to ensure that we have a large enough room.) If you have any questions, please contact Alexander.Bird {AT} bristol.ac.uk.

Stem cells have been in the news rather a lot lately.  President Obama has, it’s currently being widely reported, lifted Dubya’s restrictions on human embryonic stem-cell research, much to the chagrin of some, and the delight of others.  (Interestingly enough, among the worriers we find a surprisingly large number of British commentators who point out that scientists might be tempted to head back to the US to do their research after having come here in the past few years.)

The other hESC story of late has been the “breakthrough” that allows the “ethical” production of stem cells - that is, stem cells without the “embryonic” bit.

I ought no longer to be dissapointed by the flippant use of the word “ethical” in this sort of story - as if hESC researchers have been utterly devoid of any moral support for what they’ve been doing (because clearly finding cures for diseases has nothing in its defence…) - but, well, ho-hum.  Let’s allow for the sake of the argument that the word “unethical” means something substantial, and that hESC research is in some sense unethical.

Would that mean that new methods that allow us to reprogramme cells and thereby avoid hESC research is in some sense (again, allowing that the predicate is meaningful) “ethical”?  Not necessarily.  I’m reminded here of a paper given at the IAB conference in September by Katrien Devolder, which is currently in reviewerland, in which the point was made that foresaking hESCs now still implies complicity in past hESC research, since the technology relies on hESC research.  (I’ll leave aside debates about the scientific advantages of one technique compared to the other.)  So if you’re worried about dirty hands, you ought to be worried about the new technologies.  That is to say: if hESC research is morally tainted, then so is research into induced pluripoent stem-cells or other such technologies, since iPSCs are only possible thanks to hESC research.

For those who want the benefits of stem-cell research, but who would prefer minimal loss of embryonic life - and that group ought really to cover everyone who doesn’t have a pathological hatred of embryos, I suppose - then the way forward seems to be at most to accept iPSCs with a rueful smile.  But if we’re prepared to do that, then why not cut to the chase and embrace hESC research?

Some of you may be aware that the National Research Ethics Service has been trialling a Fast-Track system for dealling rapidly with applications that present “no material ethical issues”. They have recently published a report on this trial which can be found here: Developing NRES.

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Here’s a handful of moral statements that, I guess, many people would take to be trivially true: We ought to save lives where possible; Saving more lives is better than saving fewer; It is a good thing to save lives as efficiently as possible; Saving lives is more important than improving tolerable lives.  Nothing too controversial there, I don’t expect.  (OK - there may be rough edges, but this is a blog, not a peer-reviewed paper, dammit…)

I mention these because I’ve just been reading Rose George’s The Big Necessity: Adventures in the World of Human Waste.  It’s as much of an eye-opener as it as a nose-closer.  Take this, for example, from the introduction:

2.6 billion people don’t have sanitation [...] Four in ten people have no access to any latrine, toilet, bucket or box.  Nothing.  Instead, they defecate by train tracks and in forests.  The do it in plastic bags and fling them through the air in narrow slum alleyways.  If they are women, they get up at 4 a.m. to be able to do their business under cover of darkness for reasons of modesty, risking rape and snakebites  Four in ten people live in situations where they are surrounded by human excrement, because it is in the bushes outside the village, or in their city yards, left by children outside the back door.  it is tramped back in on their feet, carried on fingers onto clothes, food and drinking water

The disease toll of this is stunning.  A gram of faeces can contain 10 million viruses, 1 million bacteria, 1000 parasite cysts, and 100 worm eggs. [...] Poor sanitation, bad hygiene and unsafe water - usually unsafe because it has faecal particles in it - cause one in ten of the world’s illnesses.  Children suffer most.  Diarrhoea [...] kills a child every fifteen seconds. [...] Public health professionals talk about water-related diseases, but that is a euphemism for the truth.  These are shit-related diseases.

Now go back to the moral claims with which I started this post.  If you think that they’re at least in the vicinity of correct, then it seems that there would be some hard questions to answer about our health priorities. more…

It would appear that games like Tetris may help in the treatment of PTSD - there’s apparently a six-hour period in which traumatic memories become consolidated, so something like Tetris, in effect, allows the brain to be distracted for a time, thus reducing the consolidation.  Hence

[p]laying “Tetris” after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact.

There’s a bit more on this via the BBC.  And, reliably, posters to the b3ta community have been quick off the block doing intelligent and witty stuff with the story.  This one is by Bela Lugosi’s Dad.

The BMJ is having it’s once yearly wrangle about the regulation of research in the UK: It’s time to change how Europe regulates research

Many of the suggestions made and complaints are to some degree valid, the present system is cumbersome (though I think moving in the right direction in many ways such as the introduction the Intergrated Research Application System (IRAS)). Efficiency could be increased without a significant loss to the quality of scrutiny.

However two counter points deserve to be made:

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Writing in his usual uncompromising style Ben Goldacre describes the latest carry-ons in the “trial” carried out in Durham by the Council on whether fish oils improve GCSE performance:

You’ll remember the Durham fish oil “trial” story, possibly the greatest example of scientific incompetence ever documented from a local authority.

Initially they said - to blanket media coverage – that they were running a trial on fish oils, giving pills to 3,000 children to see if it improved GCSE performance. I pointed out, along with several academics, that their experiment was incompetently designed, for no good reason, and so would only produce false positive results. They responded that this was okay, as they hadn’t called it a “trial”.

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That “wooOOOooO” was the sound a ghost makes, just in case you were wondering.  I’m not sure if what follows is more of a tale about woeful reporting, or woeful research.

What I am more sure about is that many of you will have seen BBC reporting that “[a] large study is to examine near-death experiences in heart attack patients“.  By “near-death experiences”, we’re meant to understand the “floaty above my body” stuff.

Doctors at 25 UK and US hospitals will study 1,500 survivors to see if people with no heartbeat or brain activity can have “out of body” experiences.

[...]

To test this, the researchers have set up special shelving in resuscitation areas. The shelves hold pictures - but they’re visible only from the ceiling.

Dr Sam Parnia, who is heading the study, said: “If you can demonstrate that consciousness continues after the brain switches off, it allows for the possibility that the consciousness is a separate entity [... I]f no one sees the pictures, it shows these experiences are illusions or false memories. This is a mystery that we can now subject to scientific study.”

[...] He said: “Contrary to popular perception, death is not a specific moment. It is a process that begins when the heart stops beating, the lungs stop working and the brain ceases functioning - a medical condition termed cardiac arrest. During a cardiac arrest, all three criteria of death are present. There then follows a period of time, which may last from a few seconds to an hour or more, in which emergency medical efforts may succeed in restarting the heart and reversing the dying process. What people experience during this period of cardiac arrest provides a unique window of understanding into what we are all likely to experience during the dying process.”

Dr Parnia and medical colleagues will analyse the brain activity of 1,500 heart attack survivors, and see whether they can recall the images in the pictures.

Parnia gives his own account of the programme here - in slightly more measured terms than one finds on the main news site.  But he still mentions that

Although many independent studies have shown that the brain reaches a ‘flatline’ state during clinical death, it has consistently been shown that 10-20% of people who are revived back to life report some activity of the mind.
These take the form of lucid, well-structured thought processes with reasoning and memory formation as well as the ability to ’see’ and ‘hear’ actual events.
These observations have raised the intriguing - and controversial - possibility that the mind and consciousness may continue functioning after we have reached the point of death and the brain has shut down.
While an absolute impossibility to many scientists, for those who have experienced them and their respective doctors they are real. The key for science is to determine whether these experiences are illusions or whether they are real.
During AWARE, investigators will place images strategically in hospital bays, such that they will only be visible by looking down from the ceiling and nowhere else.
If after 36 months, hundreds of patients report being “out of body” yet no one can report seeing the images, then we must consider these reports to be nothing more than illusions.
If on the other hand there are hundreds of positive reports, then we will have to redefine our understanding of the mind and brain during clinical death.
For now though, only time will tell what the AWARE study will possibly reveal about our beginnings and our inevitable end.

 Now: I find myself thinking that there’s something odd going on here.  It seems straightforward enough to say that death isn’t a specific event, that we - medics, philosophers, and all stops between - don’t really understand what goes on during the dying process, that we might well have a good medical reason to understand it, and that the experience of dying is something that merits research.  I’m even open to persuasion that there’s a moral imperative of some sort to get to grips with what we don’t know not just on the basis of an appeal to the welfare of the dying patient, but also an appeal to the value of knowledge per se.

BUT…  I can’t help wanting to point out that a lack of understanding about death doesn’t seem to warrant a study into spooky ghosty floaty stuff.  Call me a cynic, but I’d've thought that investigations into three-dimensional solid objects like brains would be on much safer metaphysical ground.  If anyone does prove able to identify the pictures, this would be astonishing.  But I’m willing to bet that they don’t, and that there is no evidence at all turned up for out-of-body experiences - not that there was any in the first place, of course.  If I’m wrong, I’ll eat my ectoplasm.

Now, one might say that even if the “pictures on a shelf” test is a bit silly, it costs nothing to carry out in terms of time or finance, and there’s no reason to get all steamy about it. Was this the primary focus of the study - as the Beeb implies and as Parmia doesn’t - we’d have a problem: research funders ought to be spending their money better. But it isn’t, and we don’t.

This doesn’t wholly persuade me, though - and I think my worry has to do with something about what characteristics I want in a doctor. Of course, I want my doctor to be humane enough to see me as more than simply the kidney in bed six. But I want him to be a pretty hard-nosed scientist as well.  Actually, now I think about it, I want him to be a hard-nosed scientist above all other things.  If he’s rude to me but good at curing me, then that’s just dandy. I’ll dance out of the ward and never have to see him again all the sooner. Occam’s razor ought to be placed in his bag of surgical goodies right next to the scalpel, and I want it to be something that he uses long before the scalpel.

So my worry has to do with the possibility that ostensibly rational, down-to-earth scientists are willing to research - even to consider researching - this kind of hokey nonsense.  It seems a dereliction of a fairly fundamental obligation to keep the world as metaphysically pared-down as possible.

Actually, I’m now beginning to wonder whether the (ahem) possibility that consciousness can float free of the body might allow health providers to save money on anaesthesia.  After all, if one can be separated from the other, then there seems no particularly good reason why what we do to the body would have any correlation with what happens to consciousness.  Unless some kind of “two clocks” model is supposed to be correct, of course… Now: that would be astonishing!

*checks calendar*

Nope.  Not April 1^st

Meanwhile, over at b3ta, TheAlmightyBeev seems to have captured something in a rough-and-ready sort of a way, so I’ll give him the last word:

It would be an ethical nightmare though:
“This chap’s on his way out, can we shove him in your MRI to scan his bonce? Oh, and while you’re at it, put this picture of a duck on the shelf…”

Chris Bertram of Crooked Timber links to this 1958 piece of research on how children behaved when locked inside fridges…

Using a specially designed enclosure, 201 children 2 to 5 years of age took part in tests in which six devices were used, including two developed in the course of this experiment as the result of observation of behavior. Success in escaping was dependent on the device, a child’s age and size and his behavior. It was also influenced by the educational level of the parents, a higher rate of success being associated with fewer years of education attained by mother and father combined. Three major types of behavior were observed: (1) inaction, with no effort or only slight effort to get out (24%); (2) purposeful effort to escape (39%); (3) violent action both directed toward escape and undirected (37%). Some of the children made no outcry (6% of the 2-year-olds and 50% of the 5-year-olds). Not all children pushed. When tested with devices where pushing was appropriate, 61% used this technique. Some children had curious twisting and twining movements of the fingers or clenching of the hands. When presented with a gadget that could be grasped, some (18%) pulled, a few (9%) pushed, but 40% tried to turn it like a doorknob. Time of confinement in the enclosure was short for most children. Three-fourths released themselves or were released in less than 3 minutes; one-fourth in less than 10 seconds. Of those who let themselves out, one-half did so in less than 10 seconds. One-third of the children emerged unruffled, about half were upset but could be comforted easily, and a small group (11%) required some help to become calm. 1.

And suggests (I suspect somewhat in jest) that a modern university research ethics committee would not approve of this research. I’m not totally convinced that at least some analogue of this study could not get through a research ethics committee.

You might ask why was the research being carried out? Well the answer is “Behavior of young children in a situation simulating entrapment in refrigerators was studied in order to develop standards for inside releasing devices, in accordance with Public Law 930 of the 84th Congress.”

This sounds absurd but we have to remember that unlike modern fridges old fridges didn’t use weak magnetic seals to close, they instead used an array of catches and handles such as this charming example: 2
As such they were somewhat more difficult to escape from.

There is likewise a case to be made why this research had to be done using actual children and without their knowing participation (the full paper describes how the children are separated from their parents and then lured into the fridge simulator using cartoons!). They needed to know how children would react in a “natural” situation rather than one where they were trying to perform.

As one of the commentators over at Crooked Timber notes there is a strong case to suggest that this research did indeed do some good:

Kraus (1985) reviewed the effectiveness of the Refrigerator Safety Act in California over the period 1960–1981. Suffocation deaths in refrigerators and freezers fell from about 2 per million in 1960 to less than 0.5 per million in 1981 (see figure 3 of the paper).

J F Kraus (1985). Effectiveness of measures to prevent unintentional deaths of infants and children from suffocation and strangulation. Public Health Rep. 100(2): 231–240.

This obviously has to be balanced against the psychological costs of the study to the children who participated.

So do you think this research was justified and/or what modifications would you require for it to be approved by a research ethics committee?

1. Bain, K. Faegre, M. L.Wyly, R. S. ‘Behavior of young children under conditions simulating entrapment in refrigerators’ Pediatrics. vol. 22 no. 4 october 1958, pp. 628-647

2. Image sourced from: http://flickr.com/photos/jsarcadia/2343561019/