There’s a short piece in the latest JME about the use of social networking sites by medics that’s got me thinking.  In it, Guseh, Brendel and Brendel suggest that physicians need to be especially careful about accepting, say, a Facebook friend request from patients because of the nature of social networking sites and the possibility that normal privacy rules may be violated.  (For the rest of this post, I’ll talk mainly about Facebook, but that’s just for convenience.  The points will stand in relation to any social networking site.)

I can see something of the motivation for the worry here, but I’m not sure I share it.  The reason for this is that I have yet to be convinced that the online world presents us with any new problems: all it does is re-manifest old ones.  For that reason, there’s nothing about which we need to get all that excited.  Nor is there anything special about physicians, as opposed to anyone else, on FB.

Let’s start with the first area of dispute: is there anything special about online social networking?  more…

A convicted double murderer has won the right to have cosmetic surgery to remove a birthmark on the NHS.  Good.  Predictably, the foaming-at-the-mouth brigade is having a field day with this in the comments section of the Daily Fail’s coverage.  Equally predictably, they’re wrong.

The reason is straightforwardly to do with considerations of rights and justice.  I’m going to assume - fairly safely, I think - that the nub of the criticism is that being a convicted murderer means you lose the entitlement to certain social rights and benefits.  (Indeed, I’ve overheard many people at the bar saying things along the lines that, if you break the law, you lose all human rights - and it was only because I was busy serving other people that I could restrain myself from saying something withering in reply.)

The loss of rights claim is easily put to bed. more…

This is a very strange story that’s been picked up by the Daily Telegraph: a German Aids charity has been attacked for launching an advertising campaign - and a pretty sexually explicit one at that - in which people who spread HIV are presented as Hitler.  I’m not sure whether the target is people who have unprotected sex knowing that they’re HIV+, or just the sexually careless more generally.  Whatever: UK Aids charities aren’t happy:

“This advert has absolutely nothing to do with us or World AIDS Day campaigns in the UK, which we coordinate,” a spokeswoman for the National AIDS Trust said.

“Nor does it have anything to do with World AIDS Campaign who coordinate international campaigns and this year are focusing on human rights of people living with HIV.

“Of course there are many HIV organisations that run their own campaigns, however I think the advert is incredibly stigmatising to people living with HIV who already face much stigma and discrimination due to ignorance about the virus.

“On top of this it fails to provide any kind of actual prevention message (e.g. use a condom) and may deter people to come forward for testing.

“The advert is also inaccurate because in the UK thanks to treatment HIV is a manageable condition that does not necessary lead to AIDS.”

The Telegraph story has a link to the advert, which is also available via YouTube was available on YouTube before it was taken down for a terms of use violation (because it was vaguely pornographic, maybe?). Be warned, though: it’s not safe for work (at least, not if you share an office with people you don’t know well), and probably almost certainly not safe for kids either.  The actual campaign’s site is here; it’s less sexually explicit (apart from the advert, of course, which you can watch there if you really want), but you might want to turn down the speakers if you’re not into vaguely industrial music.

For what it’s worth, I kind of agree with the National AIDS Trust on this.  The implication the people with HIV are genocidal madmen manqué doesn’t seem to be quite right.  And, while I think that HIV/ Aids is one of the (many) areas in relation to which the media ought to stop being so prissy and prudish, I’m not sure that this is much of an improvement.  I don’t have any problem with people being shocked out of HIV complacency - the “Don’t Die of Ignorance” campaign was a hell of a jolt at the time, and right on the money; and little gratuitous nudity here and there adds to the gaity of nations (anyone who denies this being either a sexless robot or a liar).  But somehow the two don’t sit together all that well.  Maybe it’s just because I kind of suspect that the ad will mostly be watched by teenage boys who’ll simply not pay any attention to the at-any-rate facile slogan.  They’ll be looking elsewhere.

Ho hum.

One thing I’ve been pondering lately is what we might use to refer to a gathering of bioethicists?

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I can’t remember how I found it, but I feel I ought to pimp the Manchester Salon, a debating forum in this here rainy part of the country.  There seems to be a few events in coming months that are related to the concerns of this blog and journal, starting with one on assisted suicide on the 14^th of September.  I’ll certainly be going.

I’ve recently been reading some work on health incentives - the kind of incentive that may be used to encourage people to pursue ostensibly desirable courses of action in return for some kind of reward (frequently monetary).  Some schemes are aimed at promoting a vague healthy lifestyle, as when people are rewarded for losing weight or smoking less; others are directed at ensuring that people stick to a course of medication.

This has got me thinking about a debate in metaethics between internalists and externalists. more…

I found myself yesterday at the Wellcome Collection, one of my favourite museums in London and somewhere I visit reasonably frequently (not being too big, and conveniently located on the Euston Road, it’s perfect to fill those odd hours between the end of the hangover and the train back to Manchester).  The permanent exhibition has a couple of things that I could happily go and see again and again, but it’s the temporary ones that are the real draw - and the current one, Exquisite Bodies, is something I’d thoroughly recommend.

In the 19th century, despite the best efforts of body snatchers, the demand from medical schools for fresh cadavers far outstripped the supply. One solution to this gruesome problem came in the form of lifelike wax models. These models often took the form of alluring female figures that could be stripped and split into different sections. Other models were more macabre, showing the body ravaged by ’social diseases’ such as venereal disease, tuberculosis and alcohol and drug addiction.

It’s these waxworks on which the exhibition primarily focuses - and they are remarkable.  Joseph Towne’s models, made for teaching purposes at Guy’s hospital, are more than just educational tools: they’re works of art in their own right, the clear ancestors of work by Ron Mueck.  The exhibition has clear echoes, too, of Gunther von Hagens’ Body Worlds shows, and of the Spectacular Bodies show at the Hayward Gallery a few years ago.

Some of the works on show would be used as devices to educate not just medics, but also the general public, about their bodies - they would be shown at fairs, and used for public “dissections” (with men and women being admitted to separate shows, of course…).  Representations of the effects of VD seem to have been popular - and, let’s face it, we know why: there’s the same ghoulish attraction today.  Perhaps that’s why some of the exhibits are behind a curtain, and why the show’s not recommended for under-18s.

For myself, these worries seem to be unjustified.  There was a couple of children there with their parents yesterday, and there’s nothing that’d worry me were my hypothetical children to see it; as a poster advertising a “dissection” in Boston, Lincs, points out - to the enquiring mind, there should be no taboo; facts are facts are facts.  Besides: if it’s images of genitalia that you want, diseased or otherwise, my guess is that a serious-minded museum isn’t going to be your first port of call.  Under-18s with access to Google know that, too…

Dan Sulmasy has a piece on Bioethics Forum at the moment in which he considers the next 40 years of bioethics.  It’s a curious piece, making six main claims or predictions about the future, to which I’ll return in a minute: but before that, I think it’s worth looking at his scene-setting:

I suggest that bioethics has evolved through three phases: a religious phase in the 1950s and ’60s, a philosophical phase in the ’70s and ’80s, and a political-empirical phase from the ’90s to the present. Much as been written and said about the first two phases, but little about more recent history.

By the late 1980s, just as I was starting serious study in the field, philosophical bioethics had created a standard canon and had begun to rest on its achievements. Physicians, who found the language of philosophers alien but had been taking courses in bioethics, began re-engaging the field (or, in some cases, reclaiming it as their own). 

The general public, policymakers, and many of the new young students entering the field of bioethics by this time also began to complain that philosophy did not supply enough concrete answers to their pressing questions. They wanted solutions to social policy problems such as the distribution of health care resources, cost-containment, and physician-assisted suicide.

I’m interested to know whether this natural history of bioethics is accurate.  On the face of it, I’m not sure.  It - perhaps - describes the genesis of bioethics in the US, but I’m not sure that the subject has followed the same route in Europe, where there simply has not been a religious or political phase.  Bioethics has grown out of a renewed interest in applied ethics, which has grown out of good, old-fashioned, seminar-room ethics.  To the extent that claims are made about what should be done, and what the law should say, bioethics is “political” - but it isn’t political in the strong sense that I think Sulmasy uses the term; it isn’t about activism on behalf of this or that group (and it shouldn’t be, either).  And I’ve already articulated my suspicions of the supposed “empirical turn” in the subject; empirical studies may feed ethical debate, but they oughtn’t to be treated as a substitute.

But back to the six points, which I’ve edited down here.

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I’ve reached an important milestone: the first case of Pig Aids swine flu among people I know.  It’s quite exciting.

She’s been told to stay in, avoiding contact with others, for five days by one person, for 10 by another.  I’m wondering why this is.

In the early days of the illness, there might have been a point.  When we were dealing with a few tens of sniffly people, it might have been possible to contain the virus (assuming, of course, that we were willing also to close all ports and build a big glass dome over the UK just in case).  For the sake of public protection, there might have been some warrant for this.  Let’s not forget, of course, that not so long ago we were much more worried that’d it’d be a really serious illness - much more serious than it would appear to be at the moment.

But, at this stage, I’m wondering whether quarantine is any use - or justified at all.  Apparently, there were an estimated 50 thousand new cases in the UK last week.  Why quarantine someone to contain a disease that’s infecting fifty thousand a week?  That does seem a bit pointless.  Even if the worst predictions about the disease come true - the Chief Medical Officer for England and Wales predicts up to 65 000 UK deaths, but even that’s deaths associated with , not from, H1N1 - it’s hard to see how keeping people sort-of-isolated (until they’ve run out of coffee and have to nip to the shops, at least) would make any difference at all.

Actually - it will make a difference, come to think of it.  It’ll cause unnecessary worry and distress.

Besides - isn’t quarantine 40 days, by definition?

For quite a while now, I’ve had the idea that I’d like to write something about the purpose of medicine - it’s something I’ve been adding on job applications for about 5 years, but I’ve not got around to doing all that much about it yet.  The question as I saw it was whether medicine is properly concerned with making us well, or with assisting us in our projects.  The latter may be a condition of the former - indeed, it may be a criterion of the former - but it’s not the same, because we could have all kinds of odd projects that’re only tenuously health-related.  For example, cosmetic surgery - and here I mean potentially quite extreme body modification - might potentially belong to medicine if we go for the latter option.  It might not be the sort of thing that medics should prioritise, but it could still be on their list of concerns.

Where’s this preamble leading?  Well, Alice Dreger has been considering a similar sort of question over on the Hastings Center’s blog.  It’s cosmetic surgery that worries her:

I’m not naïve; as an historian of medicine, I know that medicine has always advanced itself by offering improvements of patients’ social status, primarily by making patients healthier, but also by legitimizing their complaints.

But the noble profession has historically been primarily about something nobler than boob jobs and Botoxing wrinkles. The medical profession’s primary goal, historically speaking, has been prevention and relief of real suffering.

I can’t believe I even have to assert that. If the great men and women of medicine could come back from the dead and watch television today, what would they make of the fact that a large percentage of the medicine that is represented is cosmetic?

They might conclude, reasonably, that this reveals medicine’s success. Only in a world of astonishingly good anesthetics, infection management, and surgical technique would patients dare seek these procedures. But they might also reasonably conclude that something very strange has happened.

There’re some interesting considerations raised in the piece - I do recommend it.  However, there’s also a couple of things with which I’d pick a dispute.  The conclusion doesn’t strike me as powerful, for example.

Let’s just call these practices what they are: barber surgery. That way, when one of my idealistic, smart, principled students hears that the student next to her is going into “cosmetics,” she can just answer, “Really? And here I thought we were in medical school.”

Dreger is fairly clear that she goes along with the first of my options above - that medicine is about wellness - but I’m not sure that that’s right: I don’t think I see wellness as an end in itself.  Rather, I see it as something that’s valuable (and comprehensible) only within the context of a certain set of projects.  So it’s those projects that do the work - in which case, cosmetic medicine (or barber surgery - call it what you will) is, if not exactly back on the menu, at least chalked up on the “Specials of the Day” board.  The “and I thought we were in medical school” retort wouldn’t stick.

And I think that the tone of the article more generally suggests something important and interesting about the cultural background of bioethics as pursued on the other side of the Atlantic. more…