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Thinking Aloud

Why Brits? Why India?

3 Apr, 16 | by Iain Brassington

Julie Bindel had a piece in The Guardian the other day about India’s surrogate mothers.  It makes for pretty grim reading.  Even if the surrogates are paid, and are paid more than they might otherwise have earned, there’s still a range of problems that the piece makes clear.

For one thing, the background of the surrogates is an important factor.  Bindel writes that

[s]urrogates are paid about £4,500 to rent their wombs at this particular clinic, a huge amount in a country where, in 2012, average monthly earnings stood at $215.

It’s tempting, at first glance, to look at the opportunity to be a surrogate as a good thing in this context: these women are earning, by comparative standards, good money.  But, of course, you have to keep in mind that the standard is comparative.  If your choice is between doing something you wouldn’t otherwise do and penury, doing the thing you wouldn’t otherwise do looks like the better option.  But “better option” doesn’t imply “good option”.  So there’s more to be said there; more questions to be asked.  Choosing x over y because y is more awful doesn’t mean that x isn’t.  It might be a good thing; but it might not be.  There might be economic – structural – coercion.  Choosing to become a surrogate might be a symptom of there being no better alternative.

A related question is this: are the women really making a free choice in offering their reproductive labour even assuming that the terms are economically just?  Possibly not:

I have heard several stories of women being forced or coerced into surrogacy by husbands or even pimps, and ask Mehta if she is aware of this happening.  “Without the husbands’ [of the surrogates] consent we don’t do surrogacy.”

Note (a) the non-denial, and (b) the tacit acceptance that it’s the husband’s decision anyway.  That’s not good.

(In a wholly different context, I’ve recently been reading David Luban’s Lawyers and Justice, and – in a discussion about lawyers cross-examining complainants in rape cases, he makes this point:

([H]ere we have two people who are confronted by powerful institutions from which protection is needed.  The defendant is confronted by the state [that is: in any criminal trial, the defendant does need protection from the power of the state – IB], but the victim is confronted by the millennia-long cultural tradition of patriarchy, which makes the cliché that the victim is on trial true.  From the point of view of classical liberalism, according to which the significant enemy is the state, this cannot matter. But from the point of view of the progressive correction of classical liberalism, any powerful social institution is a threat, including diffuse yet tangible institutions such as patriarchy. (p 151)

(The sentiment would seem to apply here.  A view of human agency that sees liberty as being mainly or only about avoiding state interference is likely to miss all kinds of much more subtle, insidious pressures that are liberty-limiting.  Economic factors are such pressures.  The idea of the wife as property is another.)

I do wonder if readers of this blog might help out with answering one more question, though. more…

Thumbs Up for Privacy

30 Mar, 16 | by Iain Brassington

“Hey, Iain,” says Fran, a Manchester alumna, “What do you make of this?”  I won’t bother rehearsing the whole scenario described in the post, but the dilemma it describes – set out by one Simon Carley – is fairly easily summarised: you work in A&E; a patient is rolled in who’s unconscious; there’s no ID, no medic alert bracelet – in short, nothing to show who the patient is or what their medical history is; but the patient does have an iPhone that uses thumbprints as a security feature.  And it might be that there’s important information that’d be accessible by using the unconscious patient’s thumb to get at it – even if it’s only a family member who might be able to shed some light on the patient’s medical history.

It’s a potentially life-or-death call.  Would it be permissible to hold the phone to the patient’s thumb?

For those who think that privacy is a side-constraint – that is, a moral consideration that should not be violated – the answer will be obvious, and they’ll probably stop reading around about… NOW.  After all, if you’re committed to that kind of view, it’s entirely possible that the question itself won’t make a great deal of sense (tantamount to “Is it OK to do this thing that is plainly not OK?”), or at least not be worth asking.  But I don’t think that privacy is a side-constraint; I’m increasingly of the opinion that privacy is a bit of an iffy concept across the board, for reasons that needn’t detain us here, but that might be implied by at least some of what follows.  In short, I think that privacy is worth taking seriously as a consideration, but it’s almost certainly not trumps.  At the very least, that’s how I shall handle it here.  (Note here that the problem is one of privacy, not – as the OP has it – confidentiality; it’s a question about how to get information, rather than one of what you can do with information volunteered.  A minor quibble, perhaps, but one worth making.)  Even if I’m wrong about privacy in general, the question still seems to be worth asking, if only to confirm that and why it should not be violated. more…

Mature Content?

27 Feb, 16 | by Iain Brassington

There’s an aisle at the supermarket that has a sign above it that reads “ADULT CEREALS”.  Every time I see it, I snigger inwardly at the thought of sexually explicit cornflakes.  (Pornflakes.  You’re welcome.)  It’s not big, and it’s not clever: I know that.  But all these years living in south Manchester have taught me to grab whatever slivers of humour one can from life.

Anyway…  A friend’s FB feed this morning pointed me in the direction of this: a page on Boredpanda showing some of the best entries to the 2016 Birth Photography competition.  (Yeah: I know.  I had no idea, either.)

I guess that birth photography is a bit of a niche field.  The one that won “Best in Category: Labour” is, for my money, a brilliant picture.  Some of the compositions are astonishingly good – but then, come to think of it, childbirth isn’t exactly a surprise, so I suppose that if you’re going to invite someone to photograph it, they’re going to have plenty of time to make sure that the lighting is right.

A second thought that the pictures raise is this: no matter how much people bang on about the miracle of birth… well, nope.  Look at the labour picture again.  I can’t begin to express how glad I am that that’s never going to happen to me; and I’m even more convinced than I was that I don’t want to play any part in inflicting that on another person.

But my overriding response is something in the realm of astonishment that some of the pictures are blanked out as having “mature content”.

I mean… really? more…

R-E-S-P-E-C-T

24 Dec, 15 | by Iain Brassington

Here’s an intriguing letter from one John Doherty, published in the BMJ yesterday:

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes, but such constructs are culture bound.

When I worked in outback Australia the patients called me “Mate,” which is what I called them.

They still wanted me to be in charge.

Intriguing enough for me to go and have a look at what this Kennedy person had written.  It’s available here, and the headline goes like this:

The Title “Doctor” in an Anachronism that Disrespects Patients

Oooooo-kay.  A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all.  (Don’t ask me why I detest that so; I don’t know.  It’s just one of those things that I will never be able to tolerate, a bit like quiche.)  But let’s see…  It’s not a long piece, but even so, I’ll settle for the edited highlights: more…

Assisted Dying’s Conscience Claws

11 Sep, 15 | by Iain Brassington

Aaaaaaaand so the latest attempt to get assisted dying of some sort onto the statute books in the UK has bitten the dust.  I can’t say I’m surprised.  Watching the debate in the Commons – I didn’t watch it all, but I did watch a fair chunk of it – it was striking just how familiar the arguments produced by both sides were.  It’s hard to shake the feeling that, just as is the case with the journals, the public debate on assisted dying has become a war of attrition: noone has much new to say, and in the absence of that, it’s simply a matter of building up the numbers (or grinding down the opposition).  The Nos didn’t win today’s Parliamentary debate because of any dazzling insight; the Ayes didn’t lose it because their speakers were measurably less impressive than their opponents’.  If the law does change in the UK, I’d wager that it’ll be because of demographic brute force rather than intellectual fireworks.

(Every now and again I hear a rumour of someone having come up with a new approach to assisted dying debates… but every now and again I hear all kinds of rumours.  I live in hope/ fear: delete as applicable.)

Still, I think it’s worth spending a little time on one of the objections that’s been raised over the last couple of days to this Bill in particular; it’s an objection that was raised by Canon Peter Holliday, the Chief Executive of a hospice in Lichfield:

In an interview with the Church of England, Canon Holliday said: “If there is no possibility within the final legislation for hospices to opt out of being a part of what is effectively assisted suicide, then there is nervousness about where our funding might be found in the future. Would the public continue to support us and indeed would the NHS continue to give us grants under contract?”

Canon Holliday said the Assisted Dying Bill also contains no opt out for organisations opposed to assisted suicide in spite of high levels of opposition to a change in the law amongst palliative care doctors. Where hospices did permit assisted suicide the potential frictions amongst staff could be ‘enormous’ with possible difficulties in recruiting doctors willing to participate, he said.

“The National Health Service requires us, in our contracts, to comply with the requirements of the NHS. Now if the NHS is going to be required to offer assisted dying there is of course the possibility that it would require us or an organisation contracting with the NHS also to offer assisted dying. If we as an organisation were able, and at the moment under the terms of the bill there is no indication we would be able, but if we were able to say that assisted dying was not something that would happen on our premises, would that prejudice our funding from the NHS ?”

Is this worry well-founded? more…

“Our lives are not actually our own”

23 Jul, 15 | by Iain Brassington

Long-term readers of this blog will know that, every now and then, I have a look at the CMF’s blog.  This is largely because of my interest in the ethics of assisted dying, and the blog is actually a pretty good way into developments on the other side of the lines.  There is rarely, if ever, anything new produced that’d move the argument on – but then, those of us who’re sympathetic to legalisation really aren’t doing any better.  It’s become rather a sterile debate.

I do tend to blank out the apologetics; bet every now and again, something catches my eye: a part of this recent post, about the latest attempt to introduce an assisted dying Bill into Parliament, is one such.  There’s a part where Peter Saunders claims that the Sermon on the Mount moved away from a literal take on the prohibition of murder to something more in keeping with the spirit of the law.  This, though, prompts a question for me: why can’t we accommodate a person’s desire to die within the general law against killing?  Might that desire mean that assistance is properly described as something other than murder?  It is tempting to infer from what Saunders says elsewhere that he is at least not too worried about some forms of intentional killing: writing about the Kermit Gosnell story a couple of years ago, his headline noted that Gosnell may face the death penalty – but the body text did not mention that at all, let alone take a position on it.  Yet if all deliberate killing is so straightforwardly wrong, we might expect that killing at least to be noted.  If deliberate killing by means of the death penalty doesn’t raise a peep of objection, then we might wonder why assisting in someone’s death at that person’s behest is more of a worry.

Saunders does have an answer to this query, though: more…

Bad Surgeons and Good Faith

10 Jul, 15 | by Iain Brassington

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear.  It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links.  It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going.  It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted atKevinMD.com, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today.  This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear.  That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble.  Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow.  I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me.  This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole.  No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

[…]

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

[…]

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment.  However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now.  I’ll also note that I can’t check the flow of the original post, because it no longer exists.  Indeed, Hope Amantine’s whole blog would seem to have been taken down.  In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more.  This is noteworthy, because, as I said, the OP has now gone.  If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone.  Where it was, there’s this message: more…

How to be a good (consequentialist) bioethicist…

6 Jul, 15 | by David Hunter

There has recently been a pattern of papers (and I am not going to identify which ones) which I take as being slightly embarrassing to academic bioethicists because they portray us in a less than flattering light because of the naive mistakes they seem to make, or the outlandish poorly argued claims they make. I have noted a trend for these to have come from relatively new, consequentialist bioethicists and being the helpful sort that I am, the aim of this blog post therefore is to help consequentialist bioethicists from falling into these pitfalls.

more…

Eating Disorders and Ramadan

6 Jul, 15 | by Iain Brassington

One of those things that’d simply never occurred to me before was highlighted a few days ago in a story on Buzzfeed: how do you reconcile Ramadan fasting with recovery from an eating disorder?  Indeed: can you reconcile them at all?

“Food is obviously a big part of the holy month,” Sofia says. “Usually after breaking fasts, my family have bigger meals than usual, my mum cooks a lot of extravagant Pakistani dishes for iftar. It’s also a time when my extended family tend to visit more, or we go to the mosque and eat there.

“It’s really difficult to eat in public, especially because I’m still uncomfortable around a lot of foods. And what people usually don’t understand is how seeing all that food can make you feel so pressured. Last Ramadan I remember having to force myself to eat because everyone kept telling me to – and I couldn’t say no to them. When we came back from the mosque, I spent most of the night crying, because I felt I had no control.”

[…]

She adds: “I know in my head that I need to stick to the diet and do what my doctor says. But it’s still uncomfortable preparing food while my family aren’t allowed to eat or drink.” At times she “feels guilty while she’s eating”, she says, and there are moments when she’s tempted to go back to fasting again.

 

How central is the not-eating to Ramadan?  I mean: I know that there’re exemptions for things like medical conditions; but is there a mechanism for people not so much to be exempted, but to make an equivalent sacrifice?  Is fasting valued in itself, or because of what it symbolises?  If the latter, than some sort of substitution would seem possible without that counting as an exception.  If the former, then that wouldn’t be so clear.

Either way, the article suggests that part of the problem here is that there simply isn’t the support.  Inasmuch as that anorexic Muslims will be a minority of a minority, I suppose that that’s not surprising – and it’s compounded by apparent misunderstanding in south Asian communities.  But it’s no less worth noting for that.

Jeremy Hunt and Costs to the Taxpayer

2 Jul, 15 | by Iain Brassington

“Personal responsibility” is a strange phrase: while not as slippery as some, it can mean any number of things, and be put to use in any number of political contexts.  It was the title of the speech that the Health Secretary, Jeremy Hunt, gave yesterday.  In that, he spoke of three aspects to the concept.

First up, he talked about the need for personal responsibility for health – that while the NHS tops the leagues in a lot of respects, the UK as a whole is bad when it comes to “lifestyle illnesses”, particularly things derived from obesity and smoking.  I guess that telling us that that’s bad and we could look after ourselves better is something of a bromide; but slightly more jarring was the statement that

[t]hankfully people are starting to take more responsibility. Doctors report dramatic increases in the number of expert patients who Google their conditions and this can be challenging for doctors not used to being second-guessed. But it is to be warmly welcomed: the best person to manage a long-term condition is the person who has that long term condition. The best person to prevent a long term condition developing is not the doctor – it’s you.

This is worth noting for a few reasons: first, it’ll be interesting in the context of what I’m going to say in a couple of paragraphs’ time; but there’s a couple of other things worth noting.  While the final sentence may be fairly unobjectionable at first glance, the penultimate and antepenultimate ones seem much less obvious.  Management of long-term conditions may be best left to the patient in some cases; but in all?  That’s not nearly so obvious.  It’s particularly unlikely when Dr Google is the purported source of information.  Dr Google, after all, may send you to NHS Choices – but it may also send you to What Doctors Don’t Tell You*, or sites that are even more obviously written by and for what we may politely call aluminium milliners.  Sometimes, patients doing a bit of homework is a good thing.  But sometimes, they’ll just end up asking for colloidal silver therapy.  (What could possibly go wrong?)

I’ll come to the second theme in a moment; the third thing he talked about was taking responsibility for our families. more…

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