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Thinking Aloud

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, 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.


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…

On Being a Hypocrite

1 Jul, 15 | by Iain Brassington

A piece appeared in The Atlantic a few days ago that aims to prick the perceived bubble of professional ethicists.  In fact, the headline is pretty hostile: THE HYPOCRISY OF PROFESSIONAL ETHICISTS.  Blimey.  The sub-headline doesn’t pull its punches either: “Even people who decide what’s right and wrong for a living don’t always behave well.”

I know that headlines are frequently not written by the person whose article they head, and so these won’t tell us much about the article – but, even so, I’m beginning to twitch.  Do I decide what’s right and wrong for a living?  I don’t think I do.  I possibly thought that that’s what an ethicist does when I was a fresher, or at school – but I’m not certain I did even then.  And even if I did, I discovered pretty quickly that it’s quite a bit more complicated than that.  For sure, I think about what’s right and wrong, and about what “right” and “wrong” mean; and I might even aspire to make the occasional discovery about right and wrong (or at least about how best to think about right and wrong).*  But as for deciding what is right and wrong?  Naaaah.

Anyway: to the substance of the piece, which – to be fair – is more moderate in tone, pointing out that “those who ponder big questions for a living don’t necessarily behave better, or think more clearly, than regular people do”.  That’s probably accurate enough, at least a good amount of the time.  I’d like to think that I’m thinking better about a particular problem than most people when I’m working on it; but I’m also thinking better about in that context than I would be at other times.  (Ask me about – say –  genetic privacy while I’m drafting a section of a paper on genetic privacy, and I’m your man.  Ask me while I’m making pastry… not so much.)  If we allow that I’m better at dealing with (a) specific moral question(s) while “on duty”, that won’t mean I’m not susceptible to the same intellectual shortcuts and fallacies as everyone else at least most of the rest of the time.  I’m probably almost as susceptible to them even when I am on duty.  I’d assume that the same applies to others in the profession, too.

The article does make great play of the apparent inconsistencies between what ethicists say and what they/ we do.  So there’s the finding about how many more say that eating meat is morally problematic than actually avoid it, and the chestnut about how ethics books are the ones most frequently stolen from libraries.**  At least there are decent sources cited – peer-reviewed papers like this one that are philosophically informed, to boot.

So: ethicists aren’t reliably better behaved than others.  I don’t think that should surprise us, though.  But, there’s a couple of questions into which we might still want to dig more deeply. more…

Research Ethics: You’re Doing it Wrong!

1 Jun, 15 | by Iain Brassington

With any luck, the marking tsunami will have receded by the end of the week, and so I should be able to get back to blogging a bit more frequently soon.

In the meantime, I’ll fill some space by ripping off something from the “Feedback” page of the latest New Scientist:

The TV industry has […] yet another new mantra: “Not just more pixels, but better pixels”.  The marketeers’ problem is that few people can actually see the extra details in their newest, flashiest sets unless they sit very close or the screen is very, very bright.

A colleague found a demonstration unpleasant, especially when the image flashed, and wondered about the possible risk of this triggering photo-epilepsy or migraines.  One company said, yes, this was being looked into- but no, they could not identify the university doing the work.

Then in the tea break at a tech conference a senior engineer from a UK TV station confided the reason: “We are very aware of the risks and would love to do some real research.  But nobody dares to do it because it would involve tests that deliberately push subjects into epileptic fits, and might very possibly kill them.”

In other words: here’s an intuitively plausible risk associated with product p; we could test whether p is safe; but doing that test itself would be unsafe.  Were this a pharmaceutical trial, one would expect that things would stop there – or, at the very least, that things would move very slowly and carefully indeed.  (Maybe if the drug is highly beneficial, and can be used in highly controlled circumstances, it might be worth it.)

But with TVs… well, it looks like journalists have been invited to the product launch already.  My guess is that if the TV is found to be risky, it’d be quietly withdrawn ex post facto – which seems rather late in the day.

It is a bit strange that trials on a product aren’t being done not so much because of what they might reveal, as because even doing the test might be iffy.  Stranger yet that this is unlikely to make much of a dent in the marketing strategy.  Or, given the requirements of consumer capitalism, not all that strange after all: take your pick.

Sometimes, Big Pharma can seem like a model of probity.

Animal Liberation: Sacrificing the Good on the Altar of the Perfect?

24 Apr, 15 | by Iain Brassington

For my money, one of the best papers at the nonhuman animal ethics conference at Birmingham a couple of weeks ago was Steve Cooke’s.*  He was looking at the justifications for direct action in the name of disrupting research on animals, and presented the case – reasonably convincingly – that the main arguments against the permissibility of such direct action simply don’t work.  For him, there’s a decent analogy between rescuing animals from laboratories and rescuing drowning children from ponds: in both cases, if you can do so, you should, subject to the normal constraints about reasonable costs.  The question then becomes one of what is a reasonable cost.  He added to this that the mere illegality of such disruption mightn’t tip the balance away from action.  After all, if a law is unjust (he claims), it’s hard to see how that alone would make an all-else-being-equal permissible action impermissible.  What the law allows to be done to animals in labs is unjust, and so it doesn’t make much sense to say that breaking the law per se is wrong.

Now, I’m paraphrasing the argument, and ignoring a lot of background jurisprudential debate about obligations to follow the law.  (There are those who think that there’s a prima facie obligation to obey the law qua law; but I think that any reasonable version of that account will have a cutoff somewhere should the law be sufficiently unjust.)  But for my purposes, I don’t think that that matters.

It’s also worth noting that, at least formally, Cooke’s argument might be able to accommodate at least some animal research.  If you can claim that a given piece of research is, all things considered, justifiable, then direct action to disrupt it might not have the same moral backing.  Cooke thinks that little, if any, animal research is justified – but, again, that’s another, higher-order, argument.

One consideration in that further argument may be whether you think that there’s a duty to carry out (at least certain kinds of) research. more…

Incentives, Penalties, and Vaccination.

13 Apr, 15 | by Iain Brassington

This popped up on my FB feed yesterday: a proposal from the Australian government that certain child welfare payments should be withheld from parents who refuse to vaccinate their kids based on “conscientious objection”.

Parents who do not vaccinate their children will lose welfare payments of up to $2100 per child under a federal government policy set to be announced before the May budget.

Under changes that could save more than $50 million a year, Social Services Minister Scott Morrison is preparing to scrap a “conscientious objection” provision which allows anti-vaccination parents to still claim welfare benefits including childcare assistance and Family Tax Benefit A.

Fairfax Media understands the Family Tax Benefit A is worth up to $2100 per child.

What to make of the idea?

Well, I think that certain things can be taken more or less as read.  The first is that vaccination is a good thing, and is quite possibly a prima facie duty.  The second is that governments may, and perhaps must, encourage vaccination.  So it looks as though an argument in defence of the idea could be valid.  Measures to increase levels of vaccination are desirable; this is a measure that (if it works) would increase levels of vaccination; therefore this is desirable.  We’d have to do a bit of work to see whether the argument actually does work – formal validity won’t guarantee that – but in the meantime, the policy may be justified on the basis that it’s reasonable to believe that it would work.

But that is not, of course, the whole story.  Effectiveness is a necessary condition for a policy being justified, but it ain’t sufficient.  It’s likely that there’s more to say. more…

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