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Editor-in-Chief Journal of Medical Ethics

5 Jul, 17 | by Kelly Horwood, BMJ

The Institute of Medical Ethics and BMJ are looking for the next Editor-in-Chief who can continue to shape the Journal of Medical Ethics into a dynamic resource for a rapidly evolving field. Candidates should be active in the field, keen to facilitate international perspectives and maintain an awareness of trends and hot topics. The successful candidate will act as an ambassador for the journal supporting both pioneering authors and academics publishing their first papers. The candidate will also actively promote and strengthen the journal whilst upholding the highest ethical standards of professional practice. The editor will work with IME to promote research and scholarship in medical ethics and attend IME board meetings regularly.

International and joint applications are welcomed. Interviews will be held in December 2017. Term of office is five years; the role will take 12-15 hours a week. Contact Richard Sands (rsands@bmj.com) for more information and to apply with your CV and cover letter outlining your interest and your vision for the future development of the journal.

Application deadline: 31 October 2017; Interviews: December 2017

Start date: 1 June 2018 (handover from February 2018)

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How Different are Female, Male and Intersex Genital Cutting?

16 May, 17 | by bearp

By Brian D. Earp  (@briandavidearp), with Rebecca Steinfeld, Goldsmiths, University of London 

Three members of the Dawoodi Bohra sect of Islam were recently indicted on charges of “female genital mutilation” (FGM) in the US state of Michigan. In Norway, meanwhile, one of the major political parties has backed a measure to ban childhood male circumcision.

Fearing that objections to female forms of genital cutting will be applied to male forms, some commentators have rushed to draw a “clear distinction” between them. Others, however, have highlighted the similarities.

In fact, childhood genital cutting is usually divided not just into two, but three separate categories: “FGM” for females; “circumcision” for males; and “genital normalisation” surgery for intersex children – those born with ambiguous genitals or mixed sex characteristics.

In Western countries, popular attitudes towards these procedures differ sharply depending on the child’s sex. In females, any medically unnecessary genital cutting, no matter how minor or sterilised, is seen as an intolerable violation of her bodily integrity and human rights. Most Westerners believe that such cutting must be legally prohibited.

In intersex children, while it is still common for doctors to surgically modify their genitals without a strict medical justification, there is growing opposition to non-essential “cosmetic” surgeries, designed to mould ambiguous genitalia into a “binary” male or female appearance.

Belgian model Hanne Gaby Odiele, for example, has spoken openly about the negative impact of the “irreversible, unconsented and unnecessary” intersex surgeries she was subjected to growing up.

In male children, by contrast, the dominant view is that boys are not significantly harmed by being circumcised, despite the loss of sensitive tissue. Some even point to potential health benefits, although most doctors agree that these benefits are not enough to outweigh the risks and harms. Even so, many people believe that parents should be allowed to choose circumcision for their sons, whether for cultural or religious reasons.

But these attitudes are starting to change. Over the past few decades, and even more strongly in recent years, scholars of genital cutting have argued that there is too much overlap in the physical effects, motivations, and symbolic meanings of these three practices – when their full range across societies is considered – for categorical distinctions based on sex or gender to hold up.

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Special “Editor’s Choice” Issue of the Journal of Medical Ethics Now Online

28 May, 16 | by bearp

by Brian D. Earp / (@briandavidearp)

On behalf of the Journal of Medical Ethics, I am excited to announce the publication of a special “Editor’s Choice” issue, now online at the journal website. In a rare turn for the journal, the entire issue made up of “Editor’s Choice” papers, with invited (peer-reviewed) papers from both up-and-coming and established scholars.

Editor-in-Chief Professor Julian Savulescu explains the significance of the issue: “Our self-imposed brief was to concentrate on excellent but less well-known scholars from a variety of perspectives, especially those who are young and up and coming, alongside some more established contributors.”

Although no particular topic assignment was given, Professor Savulescu remarks that “it is interesting that [the] contributions aggregate naturally around four perennial clusters: the concept of the good life, end of life, public health and new technologies (enhancement/selection).”

Here are some highlights from each contribution to the issue: more…

Oooops

25 Apr, 16 | by Iain Brassington

I inserted the wrong link into Udo’s guest post the other day.  It should have been this.  It’s corrected now, though.

*ahem*

No to Conscientious Objection Accommodation in Health Care

22 Apr, 16 | by BMJ

Guest post by Udo Schuklenk

Canada is currently in the midst of a national debate about the scope of assisted dying regulations and policies.  It’s a result of a 2015 Supreme Court ruling that declared parts of the country’s Criminal Code null and void that criminalises assisted dying.  As you would expect, there is a lot of forth and back happening between proponents of a permissive regime (à la Belgium/ Netherlands), and those who would like a restrictive regime.  Another issue is being debated as well as litigated in the courts, the seemingly intractable question of conscientious objection accommodation.

In preparation for incoming provincial policies on assisted dying, the provinces’ statutory medical bodies, such as for instance the College of Physicians and Surgeons of Ontario, have stipulated that while doctors are not obliged to provide directly assistance in dying to eligible patients, they must transfer patents on to a colleague who they know will provide that service.  A similar stance has been taken in the recommendations issued by an expert advisory group appointed by the country’s provinces and territories, who are ultimately responsible for health care.  The same holds true for a report issued by a special joint parliamentary committee of the country’s national parliament.  Unsurprisingly, religious doctors’ groups, but not only religious doctors’ groups, are all fired up about this and have taken, for instance, the Ontario College to court to stop this policy from being implemented.  Their argument is that conscientious objectors among its members must not be forced to provide even this level of assistance if their conscience dictates otherwise.

It is likely that the compromise reached will entail an obligation on health care professionals to transfer patients on to a willing health care professional.  That will not satisfy the objectors, because if you really hold the view that assisting a competent patient who meets the criteria stipulated by the Supreme Court is tantamount to murder, this compromise would simply translate into you passing on your patient to someone who you know would ‘murder’ that patient.  It is also not satisfactory from the patient’s perspective, because they could – depending on where they live – be forced to travel great distances in order to meet the obliging health care professional.  That could well prevent some patients from access to an assisted death.

The question arises why we should accommodate conscientiously objecting health care professionals in the first place.  It is somewhat taken as a given in much of the medical ethics literature that conscientious objectors are deserving of some kind of accommodation.  Arguments often focus on what makes a conscientious objection deserving of accommodation, and on what reasonable limits should be imposed on conscientious objectors, as opposed to the question of whether conscientious objectors deserve accommodation at all.

In our paper we develop a more radical argument for the view that health care professionals have no moral claim to conscientious objection accommodation in liberal democracies.  We put forward a number of arguments to support that conclusion.  For starters, it is impossible to evaluate the truth of the authoritative documents that motivate particular consciences.  The courts in many jurisdictions that have had to deal with conscience related cases have conceded that much.  It turns out that we also actually cannot test whether someone’s conscience claims are actually true, in the sense that that person actually has those convictions.  It might just be a convenient cop-out, and yet we readily accommodate objectors at great inconvenience to patients and significant cost to health care systems.

Why should we accommodate privately held convictions that objecting professionals would like to prioritise over their professional obligations to patients?   That demand seems unprofessional in its own right.  The promise to serve the public good and the individual patient first goes right out of the window, there and then.  These professionals joined their profession voluntarily and they knew that the scope of professional practice and their obligations to patients wouldn’t be defined by them personally, and also that changes to scope would invariably occur over time.  The content of conscientious objections is by necessity arbitrary and encompasses any number of practical refusals to provide services.  No health care system should permit its monopoly service providers that sort of freedom when it comes to the delivery of the very same services that they voluntarily contracted to deliver.  Permitting such conscience accommodations ultimately subverts the very reasons for why society has professions in the first place.

 

Udo Schuklenk tweets @schuklenk

Read the full paper here.

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…

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…

Does Religion Deserve a Place in Secular Medicine?

26 Feb, 15 | by bearp

By Brian D. Earp

The latest issue of the Journal of Medical Ethics is out, and in it, Professor Nigel Biggar—an Oxford theologian—argues that “religion” should have a place in secular medicine (click here for a link to the article).

Some people will feel a shiver go down their spines—and not only the non-religious. After all, different religions require different things, and sometimes they come to opposite conclusions. So whose religion, exactly, does Professor Biggar have in mind, and what kind of “place” is he trying to make a case for?

more…

Post Birth Streisand effect?

18 Jul, 14 | by David Hunter

While I am wary on this blog talking about what we commonly refer to as “The paper that shall not be named” for fear of inciting yet more criticism, complaint and work for myself and Iain there is a certain amount of schadenfreude to be had at the impact three years on of the controversy that ignited on the blog regarding that paper about post-birth abortion.

Google Scholar has recently published its 2014 ranking of top journals and in the subcategory of bioethics the Journal of Medical Ethics is tops and at least one person (you know who you are…) has suggested this is because of the post-birth abortion paper.

The impact factor of the Journal of Medical Ethics is 1.4 which implies the average number of citations a paper in the JME is 1.4. The post birth abortion paper has received an astonishing 74 citations thus far. And while I am sure it would have received some citations organically I am also sure that the vast majority of those citations would not have happened without the controversy. This is the academic equivalent of the Streisand effect (the effect whereby trying to hide something makes it much much more well known and readily available).

At the very least there is a lesson here for those who want to shut down particular areas of academic debate, giving these issues oxygen and attention makes them more rather than less likely to succeed. I’m hoping that anyone bothered by this post takes that lesson on board…

Back(wards) to the Future: The ethics of trading present health care for research

19 May, 14 | by David Hunter

Those outside of Australia are probably at best peripherally aware of the furore that the current budget announced by the new government last week is causing – it is in many ways an unsurprising budget for a broadly rightwing socially conservative government and quite reminiscent of the policies the Con-Dems have brought in the UK (attacks on public services, deregulation of higher education) against the background of a similar rhetoric of economic necessity and being all in it together, needing to clean up the mess left behind by the (kinda, almost, nominally) leftwing former government. It has managed thus far to reverse the popularity of the preferred leaders, and political parties so the fall out may be quite significant.

One interesting winkle it introduced was the introduction of a new medical research future fund (we are told ultimately it will be the largest in the world) which the majority of the significant cuts to public expenditure on health care would be channelled into and in particular of the new $7 co-payment that patients would be asked to pay to go to the GP(doctor) $5 would go to this new fund.

Obviously this is at least partially a cynical attempt to force the health cuts through the Senate (since if Labour votes against it as they say they will and succeed in stopping this policy then the Liberals can cast them as wanting the electorate to die of cancer…) sort of the equivalent of what is known as pork barrelling in the US.

And here you go a direct quote from the Minister for Health:
“People should understand that if they don’t want to put money into medical research then they can go down the obstructionist path of Labor and the Greens,”

Nonetheless there is an interesting question of whether this tradeoff is ethically acceptable? I wrote a little something about it here.

Unsurprisingly I think typically it won’t be because the cut backs to public health and new co-payments being imposed disproportionately disadvantage those worst off in society and the benefits will disproportionately accrue to those already well off – due to the cost of entry for new medical treatments, differing life expectancies and the likely focuses of medical research.

If the fund focused on disadvantage, health generally conceived and there was a guarantee that evidence generated would be listened to by government then it could be a force for good, but how likely is that?

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