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ARTs in a Warming World

25 Jul, 14 | by Iain Brassington

There are some people who disagree, but we can take some things as read: there is such a thing as global climate change, it is at least substantially anthropogenic, and there are moral reasons to try to minimise it.

With that in mind, how should we think about reproductive technologies?  These are techniques whose intent is to create humans, and – presumably – those humans will have an environmental impact.  This is a question that Christina Richie confronts in her paper in the JME:

The use of ART to produce more human-consumers in a time of climate change needs to be addressed.  Policymakers should ask carbon-emitting countries to change their habits to align with conservation.  And though all areas of life – from transportation, to food, to planned technological obsolescence – must be analysed for ecological impact, the offerings of the medical industry, especially reproductive technologies, must be considered as well.

One of her suggestions is of carbon-capping for the fertility industry; she’s more reluctant to suggest a moratorium on the use of ARTs.  But she does suggest thinking quite seriously about who should get access to fertility treatment.  After all, she points out, fertility treatment is unlike other medical treatments in a number of ways.  Not the least of these is that someone whose life is saved by medicine will go on to have a carbon footprint bigger than it might have been – but that’s not the intention.  The whole point of fertility treatment is to create new humans, though – and therefore the treatment has not just a footprint, but a long-lasting carbon legacy.

I wonder, actually, whether the argument could be radicalised. 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…

Are FIGO’s Regulations Risking the Lives of Pregnant Women?

10 Jul, 14 | by Iain Brassington

Guest post by Douwe Verkuyl

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women’s Health believes that there is never an indication for a tubal occlusion (TO) to be performed at the time of caesarean section or following a vaginal delivery in cases where this sterilisation has not been discussed with the woman in an earlier phase of her pregnancy.  This applies even if there is a uterus rupture.

But what if a mother of 5 children, living in rural Africa near a Catholic clinic, unexpectedly needs referral to a government hospital because of arrested labour, and faces a journey of at least 4 hours over a dirt road?  Does the Committee’s recommendation against belated TO counselling still apply if referring establishments have deliberately ignored its advice to counsel pregnant women early in pregnancy about the option of a concurrent sterilisation in the event that a caesarean section is needed?  Catholic institutions – which are often the only health facility for miles around – not only ignore this advice, but also fail to assist a woman with “sinful” modern contraception after she has returned with a scarred uterus.  In many Western, developed countries, Catholic contraception doctrines are mostly inconvenient, guilt-provoking and expensive.  In rural Africa, Latin America and the Philippines, they often kill.

Imagine a 37-year-old woman in labour in a well-equipped and staffed Doctors Without Borders (DWB) emergency hospital which happened to be located near her home.  She has previously given birth, with some difficulty, six times at home, and now there is a full civil war.  The doctors detect foetal distress.  They think there might be a 10%-30% chance her child will be damaged or die before it is born.  On the other hand, with the uncertain political situation – consider that on 17 June a DWB hospital was bombed in Sudan – and poor infrastructure, it might be the case that her chance of dying from a uterine scar during a subsequent labour is around 30%, and the probability that she has continuous access to reliable reversible contraception for the next 13 years is zero.  If she would choose to have a TO with a caesarean section that would solve the quandary.  Is it really unethical to ask her, or unethical not to give her that choice?

Read the full paper in the latest edition of the JME here.

Legal Comment on Nicklinson, Lamb and AM Appeals

27 Jun, 14 | by Iain Brassington

Guest post by Alexandra Mullock, University of Manchester

The Supreme Court, in the long awaited verdict in the Nicklinson appeals, essentially delivered both good news and bad news for all concerned. The appeals by Jane Nicklinson (continuing her late husband’s battle), Paul Lamb and AM (known as Martin) were all rejected. The DPP won her appeal against the court of Appeal’s decision that a more specific prosecution policy was needed. However, the upshot of this highly unusual judgment is that the losers have good reason to feel quite cheerful and the DPP has won a rather hollow victory.

To recap on the facts, the late Tony Nicklinson, who suffered from locked-in syndrome following a catastrophic stroke several years ago, began his legal challenge in the High Court with an application for a declaration that it would be lawful for a doctor to give him a lethal injection or to assist him in terminating his own life by virtue of the common law defence of necessity. If that was not possible, Mr Nicklinson asked the court to declare that the current law (regarding murder and assisting in suicide under the Suicide Act 1961) was incompatible with Article 8 of the Convention. The High Court rejected all these arguments. Immediately following his defeat, Mr Nicklinson refused all food and medical treatment, dying a few days later. However, Mrs Nicklinson continued her late husband’s legal battle and she was joined in the Court of Appeal by another man, Paul Lamb, who applied for the same relief as Tony Nicklinson. A third man, Martin, wants a carer or health care professional to assist him to travel to Dignitas in Switzerland in order to have an assisted suicide, but, in view of the current prosecution policy – which places professional assistors at greater risk of prosecution – such a person would run the risk of a criminal prosecution. Consequently, Martin asked for an order to compel the DPP to clarify and modify her policy so that a compassionate carer, doctor or nurse could assist him. Martin’s claim also failed in the High Court but unlike the others, he won a partial victory in the Court of Appeal.

Following media reports that the Supreme Court Justices were at loggerheads over their verdict, the judgement reflects this conflict and is remarkable in a number of ways. more…

Nicklinson Loses Right-to-Die Case

25 Jun, 14 | by Iain Brassington

No surprises at the result, but the ruling itself looks like it might make for interesting reading.  Analysis to follow…

Intentionally Exposing Patients to HIV: When Might it be Ethical?

7 Jun, 14 | by BMJ

Guest Post by Bram Wispelwey, Ari Zivotofsky, and Alan Jotkowitz

Much has been made of the fact that over the last two decades HIV has transformed from an inevitable, agonising killer into a controllable chronic disease.  But have we reached a point where infecting someone with HIV in order to avoid other, potentially worse health outcomes might be justified?  In the realm of organ transplantation we found that if we are not yet there, perhaps we should be.

Our paper was in part inspired by what many considered a shocking ruling by former Israeli Chief Rabbi Eliyahu Bakshi-Doron, who decreed that it was consistent with Jewish religious law for HIV-negative individuals to receive HIV-positive organ transplants, even if the evidence indicates a possibility for the recipient to contract the disease.  Many considered this opinion premature because only recently had HIV-positive individuals been found to be good candidates for solid organ transplantation, and doctors in South Africa were still in the early research stages of examining kidney transplantation between HIV-positive individuals.  But in examining the ethical considerations of autonomy, beneficence, non-maleficence, and justice, we argue in our paper that Rabbi Bakshi-Doron’s opinion is ethically sound.

Focusing on the history of HIV in transplantation and using a comparison to current practice with regard to another infectious disease, cytomegalovirus, we demonstrate that disallowing HIV-negative candidates from receiving HIV-positive organs would be a significant limit on patient autonomy.  The elimination of the ban on this type of potentially life-saving (and improving) donation may also represent a more socially just option, as it would expand the donor pool and engender cost savings. HIV-positive to HIV-positive donation will soon be a reality in several countries; it’s time to think about going one step further.


Read the full paper here.

How Not to Argue against a Proposed Law

5 Jun, 14 | by Iain Brassington

Yes, yes: it’s tedious and internecine, but it’s almost a year since I had a pop at Kevin Yuill’s book on assisted dying; how about an update?  Well, conveniently, there’s this, in which he tries “to convince my fellow liberal minded atheists to reconsider their support for legalized assisted dying”.  OK, then.  First up, this isn’t a pro-legalisation post: I’m much more interested in looking at the arguments presented in their own terms.  I think they’re bad; but that is to do with their form rather than their content.  Indeed, one of Yuill’s opening moves is something to which I’m sympathetic: in respect of Lord Falconer’s latest Bill to legalise assisted dying, he points out that

the chief sponsoring agency (Dignity in Dying) lamely differentiates between the dying (those with six months or less to live) and those with more time.
If the latter ingest poison in a room by themselves – well, that’s suicide.  But if those with less than six months take poison with the intent to end their lives, that is not suicide at all but <ahem> assisted dying. Nope, me neither.

I agree that the six-month time limit is arbitrary, and probably morally indefensible.  But…

*deep breath*

But note how Yuill botches even this point. more…

Their Poor Little Heads might Explode

1 Jun, 14 | by Iain Brassington

There’s a nice little piece by Martin Robbins in this week’s Guardian in which he talks about the fact that women seem to be less supportive of abortion than men.  That does seem counterintuitive, given that… well, given the obvious physiological facts and the relative burden of risks related to pregnancy.  So there’s an interesting little anthropological puzzle here; and he suggests a number of factors that might explain the phenomenon. For example, there’s some research that finds that women are more likely than men to agree that life begins at conception – though, as he points out, while that might help explain the different views of termination, we’d still need to know why more women think that to begin with. Another potential explanation is that men like the idea of not having to do the right thing by their pregnant partners by paying child-support or, if you’re reading this in the 1950s, marrying them: abortion gives a way out of that.  But – and Robbins doesn’t mention this – that again presupposes keeping the baby as the default position to which people are looking for an alternative.  We could also talk about social pressure, and the way that women are still expected to be mothers, and how that feeds into attitudes.  In fact, we could talk about a lot of things:

So which is it? Internalised sexism, men’s liberation, fundamentally different ideas about the point at which life begins, or something else entirely? I doubt only one factor is at work, but it seems that we lack a definitive answer. And that’s a shame, because in the ongoing battle of ideas it seems like a very important question to ask.

I suspect some will deride his “we need to do more research” conclusion, but it seems eminently sensible to say that, faced with a quirk of attitudes, a full explanation would be at least aesthetically satisfying, even if not especially urgent.  He also provides lots of useful links.

Over at the CMF blog, Philippa Taylor’s suggestion – which also has lots of useful links – is a little different. more…

Consigned to the Index

28 May, 14 | by Iain Brassington

There’re probably times when all of us have had a solution, and just had to find a problem for it.  It’s an easy trap; and it’s one into which I suspect Gretchen Goldman may have fallen in an article in Index on Censorship about scientific freedom and how it’s under threat from disputes about Federal funding in the US.  No: I’m not going to be arguing against scientific freedom here.  Only against a certain use of the appeal to scientific freedom in response to a particular problem. First up, let’s note the points on which Goldman may well be correct.  She notes that the disputes in the US about federal funding that have led to big cuts and a short-but-total government shutdown are very bad for science.  She points out that political machinations even meant that researchers working in government-funded areas couldn’t access their emails.  This had direct and indirect consequences, all of which were pretty undesirable.  For example,

[m]any government scientists were not allowed to access email, much less their laboratories. One scientist noted that his “direct supervisor … confiscated all laptop computers on the day of the shutdown”.

Without access to work email accounts, federal scientists were also prevented from carrying out professional activities that went beyond their government job duties. Several scientists pointed out that their inability to access emails significantly slowed down the peer-review process and, therefore, journal publication.

In the wider sense, to have science and funding bodies that are vulnerable to political shenanigans isn’t good for science, and is probably not good for humanity.  You don’t have to think that research is obligatory to think that it’s often quite a good thing for science to happen all the same.  And shutdowns are particularly bad for students and junior researchers, whose future career might depend on the one project they’re doing at the moment; if a vital field trip or bit of analysis or experiment is liable to get pulled at almost any moment, they don’t have a reputation yet to tide them over.

So far, so good.  However, things are iffier elsewhere. more…

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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