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.

Anyway - there’s a link to No’s own blog in one of the comments, and it, should you follow it, it’ll take you here.  You know the aphorism about pictures being able to represent a thousand words?  Here’s a picture:

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The post makes a couple of unwarranted jibes at lawyers in respect of the Wooltorton case, one being that they’re keeping quiet because they know they’ve got the law wrong.  This is false on both counts.  Lawyers are not keeping quiet - it’s just that there’s no real legal point to be argued.  And that tells us the other thing: the law hasn’t been got wrong.  But I’m not a lawyer, so I’m not to fussed about No’s attack on them.

Nor am I a doctor, so I’m not going to take issue with this claim:

The doctors are a divided camp. Some hold that their duty is to save life, and sod the law if it is at odds with this sacred duty, while others are of a more menial mind, and hold that the law is sacred, and sod the patient if the law demands that the patient should die.

- except to point out that British law hasn’t said that anyone should die since 1964.  What it has said is that it’s sometimes wrong to prevent a death.  But that is not the same by a long way.

What really rankles about No’s post is what he has to say about ethicists.  I’ll quote at length here, albeit removing a bit of stuff for the sake of clarity.

And then there are the ethicists, with their argument and debate, and absence of conclusion, who all the while sow their malicious seeds of mischievous doubt.

Now, the first thing to note is that is that two of the main groups – lawyers and ethicists – are trained in the arts of argument and debate. Doctors, on the other hand, are not. One might suppose, therefore, that the doctors are at a disadvantage, and indeed they are; at least this one feels he is. Lawyers have a habit of tripping up doctors, and so Dr No is being careful where he treads.

The ethicists, on the other hand, appear to be playing a different game, a game of skirmishes on shifting sands, of shimmering chimeras, and arguments being popped out from behind bushes. As philosophers, they have mastered the unmasterable, and penetrated the impenetrable. They have even got their heads round the ideas of the likes of Kant and Heidegger, which enables them to explode the occasional deontological bomb when it suits them.

Now, the trouble with the ethical approach is that, as I have said before, it takes us to a place where the moral compass spins, anything goes, and nothing is beyond contemplation. Dr No does not have a problem with examining ideas, indeed he welcomes the process. In the safety of the debating chamber the compass can spin, and the world be turned inside out, just so long as we don’t export half-baked or chimerical ideas into the real world where they may mutate into doctrines of sinister lethality.

Whenever malicious seeds of mischievous doubt are sown, we should be on our guard. We must join the lawyers and the ethicists at their games, and play as hard as we can to ensure that those who are more skilled in the arts of argument and debate do not carry the day merely because of their greater skill in these arts.

Medical ethicists referring to Kant and Heidegger?  Um… I suppose that might be me, then.  It’s just a shame that No doesn’t know enough about philosophy to realise that Heidegger is certainly no deontologist, and is barely an ethicist at all unless you jump through some fairly hefty hoops (which is why the papers I’ve been meaning to write on him have been mainly unwritten for the past five years).  But maybe that’s not a problem, because a lot of what motivates the post is that ethicists should be treated with suspicion because they - we - do occasionally upset the apple-cart.  What else would underpin the suggestion that ethicists ought to be quarantined to some degree just in case what we think should make a difference to the world?  This looks perilously close to the idea that ethicists are fine for as long as they make trivial comments or suggestions that cohere with everyday intuition, but that anything more than that happens, they’re a threat.  To the idea that, in a clash between lay intuition and reflection, lay intuition has the trump card because… er… reflection clashes with it.  And that’s just nuts.  You might just as well have said that we should treat medics with suspicion because of their unsettling insistence that disease is frequently caused by the invisibly small blobby creatures crawling all over everything.

Besides: doubt is neither malicious nor mischievous.  As a person with a broadly scientific training, No should know that doubt is fundamental to the scientific method.  The same applies in the humanities.  Doubt is good.  It should be encouraged.

As for penetrating the impenetrable and mastering the unmasterable…  God only knows what that means.  I’ll take it charitably, though, as indicating that ethics is often harder than it looks.  Fine: it is.  It’s frequently counterintuitive.  That doesn’t mean that ethicists are engaged in charlatanry - much less that there’s anything lethally sinister about what we do.  It just means that ethics is often harder than it looks.  Quick: someone tell the internet.  What makes the difference between a philosopher and Dr No, though, is that if a counterintuitive conclusion is reached based on an apparently sound argument, it’s the conclusion that bites the dust.  That’s not charlatanry: it’s brutal, cold, unflinching and steely honesty.  If I don’t like my conclusions, then I’m willing to accept the possibility that it’s me, not they, that’s wrong.

Dr No?  No, no, no.

(Oh, and this post is somewhere around 950 words long below the fold.  So not far off the thousand painted by the picture.)

Department of Philosophy, University of Bristol

This is an informal workshop on topics in the philosophy of medicine.

Everyone is welcome.

•09.45–11.00 Kevin Brosnan (Cambridge) “Does nothing in medicine make sense except in light of evolution?”
•11.15–12.30 Jeremy Howick (UCL) “Defining a role for mechanistic reasoning in EBM”
•13.30–14.45 Havi Carel (UWE) “Phenomenology and its application in clinical medicine”
•15.00–16.15 Alex Broadbent (Cambridge) “Inferring causation in epidemiology: mechanisms, black boxes, and contrasts”

The workshop will take place in the Common Room, Ground Floor, Department of Philosophy, 9 Woodland Road.

There is no need to register—it will be fine if you just turn up on the day. (If you do know that you are coming, it may be helpful to let us know, to ensure that we have a large enough room.) If you have any questions, please contact Alexander.Bird {AT} bristol.ac.uk.

However, in my finding-a-trolley reverie, it occurred to me that there could be a solution.  There’s already a couple of papers that run debunk columns - the most high profile of these is obviously Ben Goldacre’s “Bad Science” in the The Guardian (with its corresponding blog, to which I’ve linked from here more than is absolutely healthy), but there’s also Tim Harford at the FT whose “Undercover Economist” pieces throw light onto often highly-spun news stories; he also presents Radio 4’s “More or Less”, which does its bit to look behind the headlines.  From the blogosphere, Lay Scientist, Ministry of Truth, and many, many others all provide sterling work evaluating science, the reporting of science, and the integration of science into policy.  (Peter Sinclair’s films on global warming, for example, are wonderful.)  There’s no shortage of people that care about accuracy.

What they have in passion, they lack in organisation.

So here’s the idea: its that there should be convened a panel of independent experts drawn from science, medicine and a few other fields: most importantly, statistics.  Every so often, this panel would meet and give news media a “reliability rating”.  In return for this, each member of the panel would be given a small honorarium - say a couple of grand a year - from a fund supported by the newspapers (rather as they fund the PCC).  Or maybe fewer members would be able to farm out consultancy work to academics.  Whatever - let’s not sweat the details yet.  Newspapers then would be able to print a little logo - say, a test-tube that’s more or less empty - next to their titles, to give readers a sense of the paper’s scientific trustworthiness.  The odd daft story would get through, but over the course of, say, a year, it’d be possible to build a picture of reliability.  The papers themselves would have an incentive to contribute to the scheme, and to be as reliable as possible, because they could use their trustworthiness as a selling point.  Papers that don’t participate in the scheme would, by omission, be flagging their own worthiness for scepticism.  Granted, there’re weaknesses in the picture: my guess is that people buy the Daily Fail for its scientific insight.  But they’d at least have an implicit warning that, if they were going to believe its on-occasion utterly daft health reporting, they’d only have themselves to blame.

There has to be a fatal flaw in this scheme (unless it is, so far, so sketchy right now that there’s nothing in which there could be a flaw).  Tell me what it is.

It’s not only in respect of health that journalism gets things wrong or sensationalises the trivial, of course - it happens all the time in science journalism more generally.  There is, the wisdom goes, a terrible lack of understanding about science among journalists and - worse - a perception that they don’t care that they don’t understand.  Ben Goldacre keeps returning to this theme: in the last few days, he has picked up on this particularly egregious example - the same story was noted and demolished by EoR (among others) a little while ago - and PZ Meyers has highlighted another in the recent past.  And, of course, bad science journalism and bad medical journalism come together, since it’s in respect of health that much scientific reserch gets into the papers to begin with.  (It’s either health, dinosaurs or global warming…)

So we can construct an argument about bad journalism.  It’d go something along the lines that lazy or incompetent writing is misleading, and thereby puts people’s health and welbeing in danger.  Parents are not getting their children vaccinated because of HPV and MMR stories that are simply not true, and that’s generating a serious health threat.  Others are making other decisions that have effects ranging from unnecessary anxiety to threats to life based on the way that health stories get reported.  Perhaps this might not be quite so worrisome when we’re talking about the way the mainstream press covers a story about, say, the expression of a gene in zebrafish (assuming that it got any coverage at all), since noone sane is going to change their life on the basis of how that gets reported.  But in respect of matters of health… well, that’s potentially a bit different.  And by “a bit”, I mean “very”.

Or we could construct a rather less consequentialist argument, and say that journalism that distorts the facts is blameable without any appeal to the outcomes at all - it’d still be blameable if it made people do optimific things.

A secondary charge is that the press treats “balance” as demanding equal time for all sides - which means allowing vaccination cranks as much space as people who know of what they speak.  (On which topic, Dara O’Briain is worth a watch…)  Again, this is misleading, and perhaps culpably so.

I’m beginning to wonder whether this is correct, though - or, at least, whether there might be at least a limited case for the defence.  With no small trepidation, here goes…

Suppose we want to call the journalism bad.  By what standard are we applying the term?  An intuitive answer would be that the reportage distorts the story - that it is untrue.  However, there’s a few questions that we need to ask about this assertion.

First, what do we mean by “untrue”?  An account of an event could be an outright lie, but that’s not the only way for it to be divergent from the truth or to be misleading.  Clearly, one can be truthful while still diverging from a complete account of the matter in question - and this seems not only unproblematic, but inevitable and perhaps even desirable.  A truthful account will always and inevitably have to be framed by the rules of narrative.  By giving an account of something, there will be some things that will be given importance, others that are not.  That can’t be helped.  A truthful account isn’t wertfrei - it has to be built on some value structure; for it not to be would be the equivalent of showing a film without putting a lens on the projector.  “Truth is un-truth” says Heidegger (somewhere) - to tell the truth is not the same as to give a truthful account; we can’t help but to be partial, and that’ll mean having to tailor any account to fit finite time and finite vocabulary.  (Think of this analogy: we don’t say that a map is untruthful because it simplifies the landscape or because lines of longitude aren’t actually parallel.  Yes, I know that’s Borges’ example.)  So a truthful account isn’t going to be complete, an incomplete account doesn’t necessarily lack truthfulness, and a complete account would be unmanageable.  An account of affairs that’s tailored to fit may diverge from “The Truth” in some abstract, utterly objective, undistorted (and quite possibly wholly etiolated) sense - but since that divergence is unavoidable, it seems odd to blame people for not avoiding it.  Some kind of distortion is built into giving any account of the world whatsoever, and so it doesn’t seem just to blame the scribe.

I suspect that this is likely to be controversial - and I’m not wholly convinced of it myself; there might still be an obligation to be truth-tracking (although such an obligation would be compatible with the account I’ve just offered).  But let’s put those worries to one side, and move on to something else: Were it actually possible for journalists to give a complete and undistorted account of affairs, would doing so actually be their primary duty?

It’s not obvious that it would.

Leave aside all the trivial stuff about lying - as I think I’ve just suggested, you don’t have to be a liar not to tell the truth; you don’t have to be deceitful to deceive.  We might have a duty not to lie, but that doesn’t imply a positive duty to tell everything we know, notwithstanding Kant’s bizarre claim about murderers.  The question stands: Is it actually true that journalists have a primary duty to tell the truth?

There’s a couple of considerations here.  The function of journalism is to tell a story; the function of a journalist is to tell a story and sell it.  This means that his story has to have something about it that’ll make people want to buy.  Moreover, qua employee of a given publication, a journalist’ll have a duty to his employers to generate sellable copy.  And sellable does not seem to have much to do with being dispassionate.  (Granted, there’s a possible exception here for the publicly-funded media; and there might be commercial media whose USP is that they are unsensational - but, even then, the lack of sensation in a commercial medium is a selling point, and it’ll follow in the wake of public demand.)

Moreover, it’s not just the metaphysics of truthtelling that mean stories have to be tailored: the same pressure’ll come from this saleability criterion.  Scientific discoveries are often - let’s face it - very boring indeed, and equally often they don’t contribute more than incrementally to the sum of human knowledge.  And the public isn’t all that bright a lot of the time, either: a large portion of the UK adult population doesn’t even have the literacy and numeracy skills that one could reasonably expect of an 11-year-old, so there’s no point pitching a survey in such a way as would only be understood by a graduate if you want to sell it.  Add to that the demands of space within a newspaper or time within a news broadcast, and it’s hard to avoid the conclusion that the press release from the lab has to be cherry picked and the story retold.

So my worry is this: could it be that the problem with sensationalist journalism is less that it is misleading - all kinds of things can be misleading - than that we’re wrong-headed in our expectations of journalism?  It might be that the press is morally blameable for presenting itself as - in the words of Fox “News” - fair and balanced.  But, again, if this is right, then the criticism that what is presented actually is unbalanced (or uncritical, in the case of the equal-space objection) falls out of contention.  If only the medium in question would admit that it’s telling a story based on the truth, rather than telling us the truth an sich, then things’d be different.

This isn’t about giving carte blanche to idiots and to the press to be deceitful.  It’s just a matter of admitting that it’s hard to tell the truth and it’s not clear that this is what the media are for anyway.  This is a lesson that applies to both sides.  We shouldn’t look to the commercial press for truth (although we could reasonably expect it to be truthful); nor should that commercial press pretend that it is telling The Truth.  At most, it’s telling a story truthfully - that is, not disingenuously (which is why I’m not about allowing the Daily Fail or the Sexpress to continue with their fictitious vaccine scares, just because they are not only misleading, but they are based on claims that are known to be false).

The reason why Kant thought deceit wrong had to do with the expectation of truthfulness; deceit can’t, he thought, be universalised because it’d undermine the expectation of truthfulness upon which it depends.  But not all false statements demand this, which is why jokes aren’t forbidden by the Categorical Imperative.  Noone expects them to be reliable accounts of the world.  And maybe the same applies to much of the media.  If we relinquish the expectation of reliability, it no longer matters that the stories are misleading.

Maybe we just have to have lower expectations.

Trust me: I want to be wrong on this.  And you can rely on me to tell the tr… oh, bugger.

Miss Wooltorton, 26, who was suffering depression over her inability to have a child, drank poison at home and called an ambulance. However, she remained conscious and handed doctors a letter saying she wanted medical staff only to make her comfortable and not to try to save her life.
Doctors said her wishes were “abundantly clear” and although it was a “horrible thing” there had been no alternative but to let her die.
They feared they would be charged with assault if they treated her because they believed she understood what she was doing and was mentally capable of refusing treatment.

It is, by anyone’s standards, an incredibly sad case - and one can only speculate how hard it must have been for the doctors treating Ms Wooltorton to accede to her request.  I think that, from a legal point of view, what they did was straightforwardly correct (and, as the BBC tells it, the coroner thought so too: ”Any treatment… in the absence of her consent would have been unlawful”).  Wooltorton was competent at the time, and her refusal of treatment ought to have been treated as definitive while she was still conscious.  And while the obligation in respect of incapable adults is to act in their best interest - which would have meant intervening to save the patient’s life in many cases - the fact that Wooltorton had so recently and so capably made it clear that she did not want intervention, leads me to suspect that there’s not really room to doubt that her refusal ought to stand.

(The Telegraph goes on to suggest that “[this] is thought to be the first time someone has used a living will to commit suicide”, which I think isn’t quite right; she used a living will not to have her suicide bid stymied; this isn’t quite the same as suicide by refusal of treatment.  But that’s a minor quibble.)

From an ethical point of view, I think that the doctors did the right thing in this case - but this is because it’d've been hard for them not to.  By this, what I mean is that the story tells us something - actually, a couple of things - important about the nature of moral decisionmaking.

Primary among these things is that moral problems are problems.  This sounds tautologous, but that doesn’t mean that it’s a trivial statement.  It’s worth remembering that moral deliberation comes into its own not when deciding whether or not to do the right thing - what kind of question would that be? - but when deciding which of a range of differing and exclusive options, each of which has a claim to be right, good, or justified, ought to draw us.  Moral dispute, in this picture, is not about criticising people for being immoral, but for having made a mistake in their evaluation of which option is the most pressing in a given situation.  For example, the doctors in this case had a very good moral reason to intervene based in beneficence, and a very good moral reason not to intervene based in self-determination.  Quite possibly, given Ms Wooltorton’s history of suicide attempts, doctors would have wondered whether it was really worth striving to save her.  (They might disavow such thoughts, but I think that there’s nothing unforgivably unworthy about entertaining them; what counts is whether they’re given proper consideration.)  For all these options, and for more besides, a defensible case could have been made.  The medics had to wade through a number of possible options they’d've identified, each of which had some kind of claim to be the right one.  Saving lives could be the right thing.  Letting someone die could be.  And they had to perform this moral task against the clock, too.

How we choose between these candidates will often be formed by our methodological and metaethical commitments.  One could be rationalist about decisions, or one might be more inclined to allow emotional considerations to play a part, and each of these options might generate an answer, or a kind of answer.  But there’s still a problem to solve about which approach one should choose and - more importantly - what the standard is by which to choose.  Bluntly, a lot comes down to choosing between the right and the good, because though the good thing and the right thing might be the same in many cases, there’ll also be times when they come apart.  (For example, a doctor in the Wooltorton case might think that intervening would be optimific, but that abiding by the refusal would be right.)  Yet it’s hard to see how we can say that one ought to be concerned for the right over the good (or vice versa) without either begging the question (”It’s good to be good”) or undermining our own position fatally (”You should be concerned with goodness because it’s just the right conern…”).  It’s also tempting to think that the two might be incommensurable anyway - in which case, a preference for rightness over goodness (or goodness over rightness) looks to be the kind of thing that can entertain arbitrariness.  And that looks like an itchy position to occupy.

Now, we might think that this is precisely where guidelines and principles come into their own - they help us cut through the noise.  However, the point here is that following some kind of decisionmaking rubric would not have solved the moral problem - it’d've meant pretending that there was no such thing, and that you can determine what to do by putting all the variables into a morality machine and turning the handle.  Moreover, guidelines and principles have to be justified somehow, so the puzzle has only really been deferred.

And I think, too, that we ought not to lose sight of the fact that Wooltorton’s story is a story about people.  Adverting to guidlines, principles and rubrics might be an “efficient” way of doing ethics, but it’s also banal.  The doctors who saw her in A&E were in a tragic situation, in the truest sense.  And there’s a sense in which trying to be dispassionate about a tragic situation does nothing but belittle it.