Practical Ethics

Cold and Calculating NICE

Yesterday's Daily Mail online contains an opinion piece bemoaning the decision by NICE - the UK body responsible for rationing healthcare resources - to decline funding for four new treatments for Kidney Cancer. The Mail complains:

...what does NICE offer by way of explanation? A cold, calculating statement that, while the drugs work for many of those with advanced kidney cancer, they are not 'cost-effective'.

What a clinical way to assess whether a person should be afforded precious extra months and years of life, or consigned to a 'death sentence'.

I don't want to defend NICE's decision in this particular case, but the Mail's attack on NICE's "clinical" decision-making process is clearly unjustified.

The point of death

The Guardian yesterday reported the death of the man who had been so tragically shot in Antigua, with his wife, three weeks after their wedding. It began like this:

"Ben Mullany, the newlywed who was shot on honeymoon in Antigua in an attack that killed his wife, Catherine, died in hospital in Wales yesterday after his life support machine was switched off.  The 31-year-old trainee physiotherapist, who had suffered a fractured skull and had a bullet lodged in the back of his head, was flown back to Britain while in a coma on Saturday. Tests carried out when his condition stabilised after the 24-hour journey established he was brain dead." 

This is a familiar way of describing such happenings, even among clinical professionals.   Brain death is pronounced, so the life support machine is switched off, and the patient dies.   The clear implication is that brain death is not death.  The machine is still keeping the patient alive, and it is switching off the machine that causes real death. 

Unpopular policy and public rationality

The BBC reports that the Japanese town of Kamikatsu has become the first ‘zero waste’ town. Residents compost all of their food waste, and must sort the rest of their rubbish into 34 different categories—all of which they must take to public waste centres, since there are no rubbish collections from people’s homes. It seems that the inhabitants of the town are generally enthusiastic about the scheme, which offers small financial rewards for recycling, and has encouraged people to make an effort to reduce the rubbish they produce.

This is one of those relatively rare, uplifting stories about a scheme designed to reduce environmental damage that is not only successful, but supported by the community. Could something similar work in the UK? Recently, many UK councils reduced domestic refuse collections from once-weekly to once-fortnightly, with recyclable waste being collected in the intervening weeks. Whilst this has boosted the amount of rubbish being recycled, some news reports reveal that the new measures are unpopular, and some councils have bowed to public pressure by re-introducing weekly collections. Given the environmental impact of adding to landfill waste sites, ought the government to placate the public by relaxing measures designed to reduce waste, or should unpopular measures be enforced regardless of public opinion?

Sport, Sudden Cardiac Death and Liberty

Sport, like life, is dangerous. Several fit young footballers have died of sudden unexpected heart attacks. Doctors are now calling for mandatory testing using ECGs of all athletes. Italy has been pursuing mandatory testing for 25 years. This has revealed over 5% have some abnormality. Some people have congenital heart rhythm abnormalities which place them at high risk of sudden heart attack during or after sport. The call for mandatory testing is a sensible one. The interesting question is what is to be done with the results.

When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.

In Canada this week, an 84 year old man died after 9 months of treatment in an intensive care unit. He had severe brain damage and multi-organ failure, but his family sought a legal injunction to prevent doctors in the intensive care unit from withdrawing life-support. Over the course of his long intensive care stay, intensive care beds at a major trauma centre were closed so that nurses could used instead to support his care, and three doctors resigned from the hospital in protest at being required to provide what they felt was ‘unethical’ treatment.

The viability of fetuses and the abortion debate

A paper has been published online in the British medical journal today suggesting that survival of extremely premature infants (less than 24 weeks gestation) has not improved in the last decade. This comes less than a week before a debate in the House of Commons on the Human Fertilisation and Embryo Authority bill. It has been claimed that this paper “completely blows out of the water” the arguments of anti-abortion MPs who hope next week to push for a reduction in the cut-off for legal abortion (currently 24 weeks).

The Choice to Have Artificial Blood: Less than the Best?

Controversy has erupted around whether experiments to test artificial blood should stop. Experimental blood substitutes raised the risk of heart attack and death, yet U.S. regulators allowed human testing to continue despite warning signs, says a scathing new report.

Blood substitutes, or artificial blood, could be stored for years without refrigeration, and be used in battlefield situations. It would carry no risk risk of infection with hepatitis or HIV. It would be an acceptable alternative to Jehovah’s Witnesses who refuse life saving blood transfusions.
In a new report, researchers pooled data from 16 separate studies of five different blood substitutes, involving over 3,700 patients. Researchers found a 30 percent higher risk of death overall for patients who received transfusions using the blood substitutes. The risk of heart attack was nearly tripled in the groups receiving blood substitutes.

“Experts speculate that hemoglobin in the blood substitutes scavenges nitric oxide from the blood, causing blood vessels to constrict and sticky platelets to build up. That increases the risk of heart attacks.”

Reverse Prostitution: cognitive biases and conditional cash transfers

Stuart Rennie writes a thoughtful blog on bioethics.net, Can you buy changes in health behaviours? on how the World Bank backs an anti-AIDS experiment paying young people to not contract sexually transmitted infections. The basic idea is not new, conditional cash transfer programs in poor countries have had successes in improving health and education but applying it to sexual health moves it into more controversial territory. Is there anything wrong with “reverse prostitution”?

Do we own our bodies? Should we?

There was a sad story last week about a young woman who died unexpectedly at the age of 19.   She was on the organ donor register, and her own mother was on the waiting list for a kidney donation, but the mother was refused one of the kidneys.  Even the transplant coordinator was ‘crying her eyes out’, but there was apparently no escape.  Rules were rules.  Cadaveric donations must go impartially and anonymously to the most compatible people at the top of the waiting list, and the authorities decreed that these organs must go to three strangers – whose identity the mother will never even know.

Trading on Testosterone: Doping and the Financial Markets

Two cambridge researchers have found that  found that the amount of money a male financial trader makes in a day is correlated with his testosterone level. The pair - John Coates and Joe Herbert - also found that a trader's testosterone at the beginning of a day is strongly predictive of his success that day, suggesting that testosterone causes improved stock market performance, rather than the reverse.