It first focused on Conscientious objection within warfare and in particular the historical tradition of conscientious within the UK. It then moved to the medical context and objection within and as part of professional practice. Finally the role of religion as a basis for objection was explored. While I knew a fair bit about conscientious objection within the context of euthanasia, I hadn’t really thought about its application in other situations and the format of this workshop really encouraged the cross-fertilisation of idea.  Thanks to my colleagues at Keele for organising it, and the Wellcome Trust for funding it.

the true goal of medicine has always been curing, rather than taking care of the patient. Caring has never been the goal of medicine.

In fact, in the context of palliative care, he takes this one step further:

Thus, if the type of care specific to medicine is curing, then palliative care has nothing to do with medicine…

I came across this essay a few years ago while preparing a session for students on Keele’s MA in the Ethics of Cancer and Palliative Care, when the cohort was split between doctors and non-doctors.  More recently, it gets trotted out to my intercalating MSc ethics students here at Manchester: they’re all taking a year out from their medical studies.  But the reaction tends to be similar: Gracia’s claim will be dismissed… and then one person will say, “Hang on, though…”, and a genuine and probing debate will emerge.  The claim is not so easy to dismiss as would seem.

I mention this here because, in the replies thread to a post below, I mentioned the possibility that medicine displays a pro-life bias.  By this, what I mean is that it is possibly built into medicine that death is seen as always being the outcome we’d most want to avoid - it’s not only a defeat, but an indication of the failure (or, at best, incompleteness) of the medical project.  (Indeed, we might be able to go further, and say that even non-life is seen as something of an insult, which is why we try so hard to “cure” infertility.)  On this account, a discipline like palliative care, just because it’s not concerned with cure, would seem to have an ambiguous relationship with medicine - which seems perfectly compatible with Gracia’s point.  Moreover, the imperative that drives medicine does not seem to be the same imperative that drives palliative care - or, if it’s the same imperative, it’s very differently manifested.

If it’s true that medicine is somehow essentially about cure and about saving lives by curing, it’d go some way to explaining the opposition to euthanasia in parts of the medical profession.  It’d also go some way to explaining the hostility that does appear from time to time to respecting refusals of treatment - one of the most extreme examples of which I’ve seen in the comments to this BBC article:

I am a doctor specialising in accident and emergency medicine and I have no intention of following any such instructions. I will continue to strive to save the lives of all my patients so long as I feel that there is a reasonable chance of recovery. That decision will be made on clinical grounds and I will not be influenced by any “right to die” card. It is my right to treat my patients as I see fit in accordance with Hippocratic principles, and the GMC would have to strike me off the Medical Register to stop me following my conscience in these matters.

OK: maybe that’s not exactly representative, but it’s the kind of response that I - and I suspect others - do see in essays, and it’s not exactly rare either.

Moreover, a couple of the standard objections to euthanasia are that a cure might yet be possible, or that the desire for death is actually a desire for better end-of-life care.  I don’t think either of these is convincing, but they’re frequently trotted out.  And it is, of course, fairly intuitive that death is, in most cases at least, the worst possible outcome.  We’d also be able to explain why health outcomes are frequently measured in terms of survival rates.

Is this the only way of thinking about medicine, though?  Lest I get accused of presenting a pro-death or anti-life bias, I’m proposing no such thing, and that would be a false dichotomy.  Moreover, I don’t think that “bias” has to be seen as a pejorative term (yep, I’ve read my Gadamer, and am willing to bastardise what I found).  What I am wondering, though, is whether there might be alternative ways of thinking about biomedical ethics that aren’t predicated on the notion of saving life as being the primary goal, and whether they might be cogently applied to conventional medical practice.

I think that it probably is possible to avoid a pro-life default.  Palliative care shows a possible way: death here is not seen as a defeat, but as just something that happens to a person.  The aim is not to preserve life, but to preserve its quality to the greatest extent possible.  Strip away all the nonsense about “spiritual” needs, and I think that that’s quite an attractive way of thinking.  But even if you take away that tacit pro-attitude there, you can still accept that it’s coherent and makes a lot of sense.  What we see in palliative care is not the privileging of life in its own terms, so much as the desire to promote a particular kind of life.  And I don’t think that anyone in the palliative care field would claim to be in competition with medicine “proper” - they’d claim to be doing something that compliments it.

Does the same attitude about complementarity work the other way?  Increasingly, I suspect it does.  Palliative care has become increasingly respected, and rightly so.  Nevertheless, I suspect that there’s still a lingering sense that we should be trying to save lives.  At risk of transferring the debate in the replies below to this post, some of the comments regarding Kerrie Wooltorton could, perhaps, indicate that much.

Other areas of medical practice might be interesting to examine through a “non-vitalic” lens, and the task may have been begun.  I’m thinking here of Hursthouse’s account of virtue ethics and abortion, the important bit of which I take to be the idea that the moral status of the foetus, and its putative entitlement to life, is actually less important than understanding how the pregnancy fits into the mother’s life and her more generalised account of the good.  The idea here might well be that it’s bad that a life ends, but that it’s also far from the whole story: the end of a life is a characteristic, but it’s not the central one.

But even away from an Aritotelian field, there might be things to say.  For example, there’s a lot of utilitarian thought that has death as the greatest harm that can befall a person, and, implicitly, continued life as a way to avoid that.  There’s a significant number of people, not all of whom are cranks, who’re seriously interested in immortality or something like it as a goal.  But why should this be?  Presumably, it has to do either with the idea that life is valuable in its own right - which I find implausible (and the Cumaean Sibyl agrees with me) - or with life as being the criterion for achieving any goal whatsoever - which I think is more likely to be right.  But if it is right, then life as a default good doesn’t look tenable: it would make sense to ask a person what they want to be alive for, and life’s importance would be a function of this.  Put another way, it would be the reason for being alive that did the important moral lifting.  Our focus would be on projects, not on life.  And if a person decided not to be alive any more, then the loss of that life would be considered to be correspondingly less of a loss.  Finally, the focus of medical care when seen through these glasses would not be on saving a life, but on underwriting projects.  We could still assume that most people would not want to die, and so it’s not as if I’m advocating no more life-saving medicine, but it wouldn’t be merely being alive that really counted.  It probably isn’t anyway.

Granted, this is probably at best a rough-and-ready account.  Any suggestions?

Yes, it is shocking that he was ditched for pointing out the mathematical truth that taking ecstasy is less dangerous than horse-riding and smoking cannabis is less harmful than drinking alcohol. But this is how the war on drugs has to be fought. The unofficial slogan of the prohibitionists for decades has been: The facts will only undermine the war, so invent some that show how successful we are, fast.

[...]

Imagine a country with no drug dealers killing to protect their patch or terrorizing whole estates. Imagine a country where burglary fell by 60 percent. Imagine a Britain where we spent all these billions treating addicts as ill people who need our help, not hunting them down as criminals who need punishment. We can be that country. We just have to come down from chasing the dragon of a drug-free world – and start looking soberly at the facts.

Meanwhile, Drugscope has produced this table of harms:

Table 1 Drug-related deaths in England and Wales 2000 to 2004[4]

Cocaine	575
Amphetamine	384
Ecstasy	227
Solvents	246[3]
Opiates (heroin, morphine & methadone)	4,976
Alcohol	25,000 - 200,000 approx.
Tobacco	half a million approx (UK - [1]

(Hat-tip: Dr Grumble)

Note that we’re talking about drug-related deaths here - so the number of people killed directly by, say, Ecstasy is likely to be lower.  Given the vast number of disco-biscuits taken every week in the UK, it’s not a bad record at all.

We are very pleased to announce a new partnership between PEA Soup and the distinguished journal, Ethics.  In addition to our regular postings, PEA Soup’s editors will select one article from each issue of Ethics to be the focus of a featured discussion on our blog.  Ethics, in turn, will make an on-line copy of the featured article available to our readers for free (for three months).  At the time of the article’s publication, we will post a link to the open-access copy, and then a week later an open discussion of it will be introduced with a critical précis by an invited discussant.

We expect that this partnership will give rise to a series of lively and productive conversations.  Stay tuned for details on the first featured article, which will be selected from the next issue of Ethics (Volume 120, Number 1).

Special thanks to everyone at Ethics, especially its Editor, Henry S. Richardson, and Managing Editor, Catherine Galko Campbell, for their help and participation.

Nice idea!

David Nutt tells his side of the cannabis sacking story in The Guardian, based on a longer piece here.

A sample - or, if you will, a ‘teenth:

What we can say is that cannabis use is associated with an increased experience of psychotic disorders. That is quite a complicated thing to disentangle because, of course, the reason people take cannabis is that it produces a change in their mental state. These changes are a bit akin to being psychotic – they include distortions of perception, especially in visual and auditory perception, as well as in the way one thinks. So it can be quite hard to know whether, when you analyse the incidence of psychotic disorders with cannabis, you are simply looking at the acute effects of cannabis, as opposed to some consequence of cannabis use.

[...]

The other paradox is that schizophrenia seems to be disappearing (from the general population), even though cannabis use has increased markedly in the last 30 years. So, even though skunk has been around now for 10 years, there has been no upswing in schizophrenia. In fact, where people have looked, they haven’t found any evidence linking cannabis use in a population and schizophrenia.

[...]

Does deterrence impact on drug use? We don’t know. In fact, the outcome may be the opposite of that predicted. It may be that if you move a drug up a class, it has a greater cachet.

It’s powerful stuff - though I’m not so sure about that last bit.  I’m not sure that classification makes the blindest bit of difference to use, and though I’ve come across plenty of people talking about their consumption of class As, none of them has consumed them because they’re class A.  However, I am pretty sure of one thing: criminalisation forces drugs underground, which forces up prices and keeps users dependent and with a disincentive (or at least an imagined one) to seek support to stop.  Socially, it’s a disaster.

The aims of this conference are:

To examine the nature, scope, causes, and grounds of progress in medicine.

To provide a forum for developing the unified study of the history and philosophy of medicine, and in particular raising the profile of the philosophy of medicine in the UK and its engagement with the history of medicine.

To create interdisciplinary bridges between the medical, philosophical, and historical professions, enabling medical professionals to become more theoretically engaged, while philosophers and philosophically-minded historians of medicine engage with the actual practice of medical professionals, so that their research reflects the realities and needs of modern medicine.

To facilitate the wider dissemination of research into the philosophy and history of medicine beyond the boundaries of those disciplines, and especially in medical practice.

To identify opportunities for public engagement concerning the relation between medical progress and changing attitudes to medical knowledge, the medical profession, and medical authority.

Conference website (with link to CfP) here.

A Scenario:

Apparently there are some sites on the web just now claiming that the world is going to end in 2012. Some teenagers are becoming agitated.

I don’t want to be around when the world ends, so I’m going to drink some poison and present to my local A and E department on Halloween 2011. If conscious I will refuse treatment but ask to be kept pain free and as comfortable as possible while I make a “dignified exit” anticipating the end of the world.

I will also carry an AD in case I become unconscious before arriving at A and E.

If conscious, I will be assumed to be competent until proven otherwise. I will pass the competency test. I do not have a mental health problem. I have just been spending too much time surfing the web.

Should the medical staff allow me to die when the time comes and if not, why not?

It’s a good question - though I’d rephrase it slightly to “if so, why; and if not, why not?” at the end.

I’m curious to know what the readership here thinks.  Since I’ve posted my reply in the old thread, I’ll keep out of it as much as possible.

Details here

As has been all over the news for the last 24 hours, Nutt has been sacked asked to resign by Home Secretary Alan Johnson, again for pointing out that current drug policy isn’t all that well directed, since a disinterested appraisal of the facts would lead one to the conclusion that Ecstasy, cannabis and LSD are all less dangerous than alcohol and tobacco, the drugs of choice for (ahem) “nice” people.  (There’s a nice little piece in the Indy about this here.)

Meanwhile, Chris Huhne, Lib Dem shadow Home Secretary, has accused Johnson of caring little for independent advice, and that ministers

should save public money by sacking the entire group of experts and instead appointing a committee of tabloid editors.

And this might be amusing, were it not for the fact that it’s not so far away from reality: the Daily Fail is already calling Nutt a “serial offender”, and Amanda Platell, in her sorry excuse for a column in that sorry excuse for a newspaper, proclaims that

For one thing, it was never made clear that the fear of HPV would stop people having sex in the first place.  In fact, it plainly doesn’t - and the evidence for this is that - gasp! - people were having sex with each other even before the vaccine.  So, if someone is going to be having unsafe sex, then it’s not likely that the vaccine would make all that much difference - except to minimise at least one of the risk factors.  Nor is it clear that vaccination would make it less likely that people would use a condom.  Maybe the objectors had strangely powerful-yet-quiescent libidos, and they’d be hopping into bed and having unprotected sex at the drop of a hatwere it not for the vague threat not just of a sexually transmitted disease, but of this particular sexually transmitted disease.  Who knows?

Of course, the real point of the objection was nothing to do with the safety of sex - it was to do with the possibility that people (notably, the objectors’ own utterly sexless teenage daughters) might want, have, and enjoy sex at all.  The objection was, in essence, that if horizontal dancing were less risky, it might happen more.  That is (somehow) clearly bad, and the only way to stop it is, the thought goes, to keep it as dangerous as possible.  (Phew!  At least that way we might be able to pretend it doesn’t happen.)

Am I building an Aunt Sally here?  I don’t think so.  For example, in a letter to the Christian Medical Fellowship, a Newcastle paediatrician suggested that

providing such a vaccine to teenage girls will [...] anticipate fornication and therefore condone it. Christian doctors should have no part in this.

[... Y]oung people will perceive that the consequences of fornication have been lessened and therefore fornicate more.

Obviously, there are people - the kind of people who use words like “fornicate” and “sin” - who do manage to think that the objection is powerful.  For the sake of the argument, let’s imagine that you’re one of them.  Are the worries warranted by the facts?  Well, it would appear not.  According to a paper just out in the British Journal of Cancer

Girls were asked to indicate their agreement (agree/disagree) with six statements that students had made during the piloting stages relating to how they, and others, perceived vaccination against a sexually transmitted infection. The majority agreed that HPV vaccination made them think about their health and future sexual relationships.

Of course, teenagers of both sexes spend quite a lot of time thinking about sexual relationships.  What’s actually meant here is that it would appear that awareness of the vaccine led girls to take their own sexual health more seriously than they otherwise might.  93% agreed with the statement “Having the vaccine shows that you are serious about your own health.”  78% agreed with the statement “Having the vaccination reminds me of the possible risks of sexual contact.”  In other words, the vaccine does not seem to be seen as a licence to shag.

On the other hand,

[a]lmost 14% (73) thought that being protected against HPV might lead them to take more sexual health risks in the future and 19% (99) said that boyfriends might expect them to.

Still, this doesn’t mean that the worries are well-founded.  Even if you think that being vaccinated will make a difference to your sexual behaviour, it doesn’t follow that you’re correct: there’s nothing to suggest that the girls questioned actually expected the vaccination to make a difference, or that any such expectation would be justified.  The figure could be explained by the fact that there was such a noise made by the proponents of the promiscuity objection: it wouldn’t be surprising if some of the fears had been translated to the girls themselves, and that the 14% figure simply reflects a report of those fears.  The point is that “I think it might make a difference” doesn’t mean “I’m going to let it make a difference.”  And, of course, noone ever said that the vaccine was a substitute for decent sex-education anyway.

The authors also note that

Approximately 20% of the total study population of girls completed this questionnaire and their parents may have held more liberal views on adolescent participation in consent than those of nonresponders.

If there’s anything worrying about the paper, then this is it.  The evidence is that kids who come from the most open families are the kids who’re least bashful about sex, and so those who’re most likely to seek out information and to know what’s what, and most likely to be confident enough in their sexuality to stand up agaist pressure to do things with which they aren’t comfortable.  In other words, we’re talking about the kids who’re probably least at risk to begin with.