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The Art of Medicine

198!

23 Oct, 12 | by Iain Brassington

Seriously!  Theoretical Medicine and Bioethics has published a paper with a hundred and ninety-eight listed authors!

I’ve always been slightly puzzled by multi-authored papers – by just how many people get to add their names to a piece of work.  A friend of mine who is a proper scientist once tried to explain how it works in the sciences to me – about how you need to give credit to the people who ran the experiment, but also to those who did the titration and general donkey-work.  That seems fair enough.  Having said that, I suspect that there’s often a bunch of people who get credits that shouldn’t be there.  (I remember once seeing a CV from a guy that had 45 pages’ worth of publications listed.  Granted, it was double-spaced… but, still: there must have been the thick end of a thousand papers listed; there’s no way on God’s good Earth that he could have played a significant role in all of them.  So why was he entitled to claim them?  Why did he take the credit?  Apparently, it was because, although not all of the papers referred to work he’d done, they did all refer to work done by other people in a lab he ran.)  Anyway… the Steinhauser et al ad infinitum paper, with its 198 authors, isn’t lab-based, so the credit-where-it’s-due argument wouldn’t work.

(Jozsef Kovacs, writing in a paper currently available as a pre-pub in the JME, is also concerned about authorial inflation, and who should get the credit for a given paper, and how to improve things.  It’s definitely worth a look.)

The author list for the Steinhauser paper seems to have been generated at least in part via the membership of a Facebook group (and one that no longer exists, or at least one that is so private that it doesn’t show up on a search).  That’s just silly, and there’s no way that anyone can successfully marshall so many contributors.  That turns a paper into an open letter.  Indeed: the “authors” seem to think that their paper could be treated as such without loss: more…

Modesty, Conscience, and What it Takes to be a Doctor (with a bit of Comedy)

19 Oct, 12 | by Iain Brassington

Two apparently unrelated new and new-ish papers in the JME have caught my eye over the last few days.  One of them is this one: Salilah Saidun’s “Photographing Human Subjects in Biomedical Disciplines: An Islamic Perspective”.  We’ll come to the other in a little while.

There’s a couple of puzzling things about the paper.  One is that I’m not sure what the tone is supposed to be.

It could be a descriptive piece, along the lines of “Look, here’s what Muslims might think about medical photography, and if you’re going to take or use medical photographs, you might want to keep it in mind.”  Of course, it’s by no means certain that all Muslims think alike, or that if (mirabile dictu) they do, it has anything much to do with Islam – but we’ll put that to one side.  Similarly, the fact that some people do think this won’t tell us much about what practical implications there ought to be, beyond keeping it in mind.  It won’t tell us that we ought to adhere to those opinions.  Islamic rules might provide a reason to behave in a certain way; but there might be other reasons to behave in a certain other way – and they might sometimes be more compelling.  I’ll put that to one side, too, though.  As a descriptive paper, it might very well be the sort of thing that’s useful on the wards.

But a descriptive reading won’t explain the passages that appear to have a more normative dimension: more…

William Mager is having a Cochlear Implant.

9 Oct, 12 | by Iain Brassington

And he’s going to blog about the experience.

On Tuesday 6th November at around 7.30am I’ll be in a hospital room while a surgeon uses a marker pen to draw a line behind my ear. Soon after that, I’ll be wheeled into an operating theatre where they’ll make a small incision behind my ear, following the line of marker pen ink.

Once they’ve opened a flap of skin behind my ear, they’re going to drill into my skull, until they reach my inner ear. They’ll then hollow out a small cavity in the flesh beneath the ear flap, where they will insert a piece of technology worth about £10,000. Into the hole in my skull goes a tiny electrode extending all the way into my inner ear, with around 20 or more individual contacts stimulating my cochlear. Hopefully the general anaesthetic will do its job and I won’t feel any of this while it’s happening, because I’ve seen pictures of this procedure and it looks pretty painful.

[…]

When I’m switched on six weeks after the operation, I have no idea what will happen. Either I’ll feel a faint buzzing in my skull, or hear consonants for the first time. Either way, the hard work starts after that.

Subscribe!

He’s a film-maker in real life: so while you’re waiting for the next post, have a look at some of his films.  This one takes only a couple of minutes to show how there’s really very little that deaf people can’t do… er… so long as the… um… support is… as long as…  Yeah.  Watch it, anyway.

But what if you Don’t Want to be Regulated?

2 Oct, 12 | by Iain Brassington

The Malaysian Parliament has just approved a law about traditional medicine.  The Traditional and Complementary Medicine Act is largely about the regulation of practitioners of TCM – notably, setting up a regulatory Council.  According to section II (5)

The Council shall have the following functions:

(a) to advise the Minister on matters of national policy relating to traditional and complementary medicine practice;

(b) to establish the eligibility requirements for each practice area;

(c) to recognize qualifications conferred by any institutions of higher learning established under any written law in Malaysia or any institutions of higher learning recognized and authorized by any countries outside Malaysia for the purpose of registration under this Act;

(d) to specify the appropriate academic qualifications or recognized skills certificate issued pursuant to the National Skills Development Act 2006 [Act 652] which are or is necessary before a person may apply to be a registered practitioner;

(e) to specify the necessary apprenticeship and training requirements including rules for undergoing apprenticeship, the scope of responsibilities and permitted conduct or activities of apprenticeship, duration of apprenticeship and post-qualification apprenticeship;

(f) to register individuals who will provide traditional and complementary medicine services to the public;

(g) to issue practising certificates to registered practitioners who have satisfied the prescribed conditions and paid the prescribed fees;

(h) to develop codes of professional conduct, rules relating to the professional conduct of registered practitioners, including penalties for breach of such codes or rules;

(i) to develop, undertake, prescribe and mandate any matter relating to or connected with the practice of traditional and complementary medicine or the professionalism of such practice;

(j) to specify, provide for and administer a complaints procedure and process;

(k) to develop rules upon which registered practitioners are to refer their patients to medical practitioners or dental practitioners, as the case may be;

(l) to obtain such relevant information from practitioners, and to provide the same to the Minister;

(m) to carry out such functions as may be specified by this Act; and

(n) to carry out all such other activities as may be directed by the Minister and such direction shall be consistent with the purposes of this Act.

Section IV (21) says that

(1) No person shall practise in any practice area which is not a recognized practice area.

(2) Any person who contravenes subsection (1) commits an offence and shall, on conviction, be liable—

(a) in respect of a first offence, to a fine not exceeding thirty thousand ringgit [approx £6000] or to imprisonment for a term not exceeding two years or to both; and

(b) in respect of a subsequent offence, to a fine not exceeding fifty thousand ringgit [£10 000, or thereabouts] or to imprisonment for a term not exceeding three years or to both.

Is this a good law?  Clearly, it is not a particularly exciting piece of legislation; and there might be problems with it – there’re problems with a lot of laws. more…

Is Bioethics Really a Bully? Really?

11 Sep, 12 | by Iain Brassington

On his blog in The Independent, John Rentoul has a long-running feature called “Questions to which the Answer is No“.  In it, he examines the kind of screaming rhetorical-question headline much beloved of certain middle-market tabloids: “Is this photographic evidence of Nessie?”, “Does coffee cure cancer?”, “Does coffee cause cancer?”, “Does MMR bring down house prices?“* and so on.

Here’s the first in an intermittent parallel series from me: “Questions to which the Answer is Eh?  What are you on about?  No, really: what?“.  For the inaugural post, step forward Dan Sokol, the BMJ”s “ethics man”, who asks in his latest column, “Is Bioethics a Bully?”.  The answer to this is Eh?  What are you on about?  No, really: what?.

(A warning before I start: I’m about to go off on one.  Even by my standards, this is big.  You might want to go and make tea.)

The general thesis of the article is this:

Bioethics, in its current form, has bullying tendencies. Ironically, it often adopts a paternalistic attitude towards clinicians, treating them as an ethically deficient species.  Although bioethics should not shy away from pointing out ethical concerns in medical practice, sometimes forcefully, it must not give way to negativism or, worse still, to a zeal to condemn.  Clinicians are easy targets and, without a command of the fancy theories and language of the accusers, possess few means to respond formally.

Is the thesis true? more…

More on Circumcision in Germany

17 Jul, 12 | by Iain Brassington

Søren Holm sometimes jokes that, if you want your conference well-attended, you should have a paper on the ethics of circumcision.  I don’t know how well-attended the recent IAB satellite on the topic was – the first half clashed with Peter Singer doing his thing, which can’t have helped it, and I couldn’t go to the second because I was giving a paper of my own.

Anyway: though I mentioned the decision of the German court that ritual circumcision constituted assault, I’ve wanted to stay clear of saying more about it.  Partly it’s because I’ve been busy; but there’s another reason: it seemed too potentially toxic.  For example, Jonanthan Sacks’ column about the decision in the Jerusalem Post noted that many attempts to ban circumcision have been motivated by antisemitism; the not-so-subtly made claim is that there’s an undercurrent of antisemitism here.  (An appeal to human rights is, he claims “is the only form in which an assault on Jews can be stated today”.)  Of course, that won’t show that such attempts have to be motivated by antisemitism, or that thinking the court’s decision correct is an indication of latent antisemitism: they don’t, and it isn’t.  Even if it’s true that the only way to launch an assault on Jews is to use the language of human rights, it doesn’t follow that every human-rights claim is an assault on Jews – even when it touches on something that is associated with Judaism.  I didn’t want to open myself to an accusation of antisemitism, so thought it best to keep quiet.

But the debate is rumbling on (it was featured on the Today programme today, for example); and one of the notable things is the poor quality of most of the arguments brought against the decision.  This doesn’t in itself mean that the decision is correct – poor arguments might accidentally bring you to the correct answer – but if the general direction of the poor arguments is the same, and there haven’t been many decent arguments produced that go the same way, then that does raise questions about the conclusion in which they’re headed.  Having said that, there has been one better argument against the decision that I’ve come across; I’ll come to that later.  It’s some of the poor arguments, rather than the position in the service of which they’re advanced, that I have in my sights here. more…

CFP: Wellbeing and Public Policy

20 Apr, 12 | by Iain Brassington

This may be of interest to readers…

MANCEPT Workshops in Political Theory – Ninth Annual Conference
Manchester Centre for Political Theory (MANCEPT), University of Manchester
5th – 7th September 2012

Workshop on Well-being and Public Policy: Call for Abstracts

David Cameron, in a recent speech on introducing national measures of well-being to inform public policy, claimed that the UK government is aiming to measure the progress of the nation, “not just by how our economy is growing, but by how our lives are improving; not just by our standard of living, but by our quality of life.” In short, the UK government is looking to measure the nation’s well-being in order to “help make a better life for people.” Other governments and international organizations are also increasingly focusing upon well-being as a policy goal.

This workshop will focus on whether, and how, public policy can and should be informed, in some way, by considerations of the public’s well-being. There will be up to 12 speakers in total, who will be invited to give a 30 minute presentation, followed by a discussion. Potential areas of interest include (but are not limited to):

  • The role of well-being in public policy
  • The limits of political utilitarianism
  • Paternalism and well-being
  • The implications of different theories of well-being for public policy
  • The interaction between different measures of well-being and public policy

If you are interested to present during this workshop, please send to one or both of us an abstract of no more than 500 words with your full name and institutional affiliation before May 15th.

Convenors:
Sam Wren-Lewis (University of Leeds): samwrenlewis@gmail.com
Tim Taylor (visiting research fellow, University of Leeds): phltet@leeds.ac.uk

Further details about the conference available at
http://manceptworkshops2012.wordpress.com/.

Drugs and Sex – or Drugs and Less Sex

10 Apr, 12 | by Iain Brassington

Two slightly curious stories about drugs and sex.  Or, rather, two stories about drugs and sex curiously juxtaposed.

First, this story from Sunday’s Independent was inspired by this paper in The Journal of Sexual Medicine.  Quite how much weight we should put on the JSM‘s paper is a moot point – it’s a case study involving one person, rather than a full RTC – but I’m interested in the way that it was represented by the Indy:

Oxytocin, a hormone traditionally used to induce labour, is as sexually arousing to men as Viagra, according to new research.

Studies conducted in the US found that a married man who sniffed a nasal spray containing oxytocin twice daily became more affectionate to friends and colleagues and recorded a marked improvement in his sexual performance.  According to the actual breakdown of results, the man’s libido went from “weak to strong”, while arousal went from “difficult to easy”. Ego certainly wasn’t hurt either: sexual performance, according to feedback from his wife, was classed as “very satisfying”.

Let’s take it at face value, and ignore the leap from the experience of one man to all men, and the post hoc ergo propter hoc fallacy, and all the rest of it: a man who was apparently having some sex-related difficulties was helped by oxytocin.  Bravo for him. Hurrah.  Oxytocin for all!

Or maybe not. more…

Why Is Infanticide Worse Than Abortion?

2 Mar, 12 | by BMJ

Guest Post by James Wilson

The controversy over the Giubilini and Minerva article has highlighted an important disconnect between the way that academic bioethicists think about their role, and what ordinary people think should be the role of bioethics.  The style of this dispute – its acrimony and apparent incomprehension on both sides – are a sure sign that we as bioethicists need to think harder about what we are doing, and who we are doing it for.

At the heart of tempest has been the authors’ claim that abortion and infanticide are morally equivalent. Nearly everyone will agree that the authors are wrong about this, and that infanticide is and should always remain beyond the pale.

The US Born-Alive Infants Protection Act 2002 stipulates that the category of person – and the full protection due to persons – must be extended to “every infant member of the species homo sapiens who is born alive at any stage of development“.  The deep question – from the perspective of academic ethics – is why every human being that is born alive should count as a person.

Often in bioethics the most difficult task is to articulate just what it is that lies behind the sorts of intuitive moral certainties that we all have: that is, to make clear to ourselves, and to those who are inclined to hold opposing views, just what our confidence in our own intuitive moral judgments is based on.  This is often extremely difficult to do.

Why Some Bioethicists Think that Birth does not Matter

At the heart of Giubilini and Minerva’s claim that infanticide is morally on a par with abortion is the premise birth by itself does nothing to change the moral status of a developing human.

According to them (and like minded philosophers such as John Harris, Peter Singer and Michael Tooley) what makes the difference between a person and something that isn’t a person must be something to do with the capacities and abilities that a person has.  On such views, if we want to say that all human beings should count as persons then we need to provide some account of what feature or features it is that all human beings have that renders it appropriate to treat them as persons.  The feature of being born alive to a human mother does not – according to them – fit the bill.

According to these philosophers, this definition of “person” is both too narrow, and too broad.  It’s too narrow, because it’s clear that there could be intelligent alien species who had the ability to engage in moral thinking; but yet who clearly would not be born to a human mother.  They need not be born at all: perhaps the aliens from the planet Zog assemble themselves out of flatpacks from an interplanetary Ikea.  But so long as they are able to live and to value things as we do, why should we deny them the status of persons?  To do so looks like a human-centred chauvinism, no more than speciesism.

But the feature of being born alive to a human also looks too broad: what if the brain of the infant has been irreparably damaged, so that it will remain in its intellectual functioning at a level far below that of a chimpanzee and will never be able to love, to form plans or even to recognize itself in the mirror?  Why (and in what sense) does an infant like this count as an equal of a fully functional adult?

John Harris has argued that we should strike down the thought that it is being born that makes the difference.  As he once put it, “the geographical location of the developing human, whether it is inside the womb or not, is not the sort of thing that can make a moral difference”.  (Even here, he was careful to clarify – as he has on this blog, that he was neither advocating infanticide, nor arguing for a change in the law.)

A Poor Reply: Banging the Table

The cheapest and easiest response to this challenge is to merely bang the table and assert the sheer obviousness of the difference that birth makes.  As an example of this approach, Richard Nicholson once accused John Harris of indulging in “a philosopher’s mind game”.  He continued, “He is wrong in saying there is no moral change that occurs in the process of birth.  That is a change that is recognised in the law.  Most parents would recognise their views about their newborn baby are considerably different than their views about the foetus in the mother a day earlier.”

All this, one feels, may be true; but it is hardly intellectually satisfying.  Just because most parents would feel differently, it doesn’t in itself follow that they are justified in changing their feelings this way.  It’s weak to counter an argument that puts forward reasons by merely appealing to force of numbers – pointing out that most people judge the same way you do.

Explaining the Significance of Birth

If we want to defend the moral significance of birth, then we need to provide some positive account of why birth matters.  I want to outline very briefly three possible positive accounts.

(1) The infant now counts as a person because he or she is now a separate living entity: he or she is viable and is not dependent on anyone else for existence.

Some worries: it seems that this explanation misfires, because ‘being a separate living entity’ is both too broad, and too narrow, to serve as the feature that makes the difference between a person and a non-person.  It’s too broad because dogs and cats are separate entities in their own right, but this does not make them persons.  But it’s too narrow, because there can be persons who are not viable separate living entities: both of a pair of conjoined twins can count as separate persons, but in a severe case it might be quite impossible for both to be able to survive separation.

(2) The infant was already a person, previously it was lodged in the mother’s body like a guest lodged in a house owned by someone else.

On this view, there were conditions under which it would have been legitimate to expel the foetus despite the fact that it was a person (in circumstances such as those that Judith Jarvis Thomson considers in her famous defence of abortion, for instance). The significance of birth is that all these reasons that the mother may have to abort the foetus are then defeated.

Some Worries: This approach seems initially promising, but it may only push the problem further back: (a) we now need to give some non-arbitrary account of why the foetus was already a person, and how it became a person. (b) On this view it turns out that it isn’t birth that is actually doing the work here in making an entity a person.

(3) Ethical vision beyond explicit arguments

Charles Taylor makes a useful distinction between two different modes of ethical argumentation, which he calls offering basic reasons and articulating a vision of the good.  As he says in Sources of the Self, “It is one thing to say that I ought to refrain from manipulating your emotions or threatening you because that is what respecting your rights as a human being requires.  It is quite another to set out just what makes human beings worthy of commanding our respect, and to describe the higher mode of life and feeling which is involved in recognising this.”

Ethicists often place a very high degree of value on explicitness and arguments from consistency, invoking basic reasons in Taylor’s sense.  A key part of Giubilini and Minerva’s argument has the following structure, for instance:

1. Persons are creatures with feature F.

2. The newborn does not have feature F.

3. Therefore the newborn is not a person.

A large part of the acrimony of the dispute seems to arise from the fact that many feel that to adopt this kind of schema fundamentally misunderstands the foundations of ethical consciousness.  For them, what is foundational is the fragility of the life of the infant, and that once that has been appropriately noticed or articulated, one should be called upon to respond.  So on this view, the answer may not be to describe those valuable features of human beings in terms that are applicable to any potential being at all, but rather to draw attention to just what it is about human being that we mean when we talk about the intrinsic dignity and value of human life.

This is something that is extremely difficult to do within the confines of analytic philosophy.  For such articulation of the phenomenology of our fundamental moral commitments, literature is far more powerful.  I’ll conclude this post with a bit from Tolstoy’s Anna Karenin, which perhaps provides some of this vision.  Levin is struck by wonder at the birth of his son:

Meanwhile, at the foot of the bed, in Lizaveta Petrovna’s skilful hands flickered the life of a human being, like the small uncertain flame of a night-light – a human being who had not existed a moment ago but who, with the same rights and importance to itself as the rest of humanity, would live and create others in its own image… Whence, wherefore had it come, and who was it? He could not understand at all, nor accustom himself to the idea. It seemed to him too much, a superabundance, to which he was unable to get used for a long time.

Of Tusks and Tuskegee: A Problem in Research Ethics

1 Mar, 12 | by Iain Brassington

Xtaldave, by his own admission, has the horn.  Well, if you’re being accurate about it, he has the tusk.  But what’s important is that he has a whopping great piece of ivory to play with.

Dave works in the labs here in Manchester, doing clever things with chemicals and science and crystalography and that sort of thing.  The ivory has been confiscated by customs; it found its way into his lab because the dentine in a great big tooth is a useful medium on which to carry out research that may generate significant benefits.  In his words, the tusk is

an acceptable substitute for human bone in the sorts of assays that our lab does to test the effect of various substances on cells called Osteoclasts that are responsible for bone resorption (basically bone destruction).  During growth and development of the skeleton, bone is formed (by Osteoblasts) and broken down (by Osteoclasts) – it is thought that the bone disease Osteoporosis is caused by an imbalance of bone formation and destruction – i.e. too much Osteoclast activity.

If we can find a therapeutic agent that inhibits Osteoclast activity, we might be able to halt or slow the progression of Osteoporosis.  The upshot of all this is that our lab has obtained a section of Elephant horn that has been confiscated by the UKBA.  We will recycle this and use the dentine in our bone resorption assays.

Why’s this of interest here?  Well, the ivory trade is (a) illegal, and (b) deeply morally problematic.  The fact that it’s illegal means that the UK Border Agency confiscates ivory as it’s imported into the country in most cases.  (There are situations in which importation is legal, but they’re rare, and needn’t concern us here.)  And this confiscation means that the Agency ends up with a load of ivory on its hands.

One option might be to sell it; but that’s ruled out by the same considerations that make importation illegal to begin with.  Another is simply do destroy the lot.  A third is to allow labs like Dave’s to make use of it.  This is where the moral claims come in.  It would be, he says, immoral (as well as legally problematic) to sell the ivory, and

if someone has already killed the elephant and removed the Ivory, better that we use it to further medical research and perhaps save or improve some lives, than turn it into a bauble that sits on a shelf gathering dust.

Or, to put it another way: that the elephant has been killed is bad; but we can at least salvage something from the moral wreckage.

Is this correct?  Well, the structure of the argument seems to follow quite closely that which is sometimes presented in relation to the use of – for example – data derived from the morally repugnant experiments of the past.  If there is, in Stan Godlovich’s words, “demonstrably important and beneficial information gathered methodically through means completely unacceptable to us”, what should we do with it? more…

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