Practical Ethics

We're all guinea pigs, and it's not so bad

The outrage provoked by Professor Anthony Mathur’s suggestion that patients should sometimes be obliged to enrol in clinical trials (discussed already on this blog by Steve Clarke: 11 December) continues to rage on.  Armies of shrill autonomists tell us that all our worst nightmares are real: that Mengele walks again.

Switzerland gets tough on suicide clinics

The Swiss government (the Federal Council) has recently announced its intention to crack down on “suicide tourism” and to severely restrict the activities of suicide clinics like Dignitas and Exit, which have regularly made the headlines outside Switzerland in the last few years (particularly Dignitas), as foreigners make up a large proportion of the hundreds of people they help to die every year. The government is proposing two draft Bills for public deliberation until March. The first option is an outright ban on suicide clinics; were it to become law, clinics like Dignitas and Exit would simply have to close down. Such an extreme measure, however, doesn’t have the favors of most members of the Federal Council, and probably won’t have those of the Parliament either. The second option is more likely to prove popular, and I will thus focus on it: it would involve much stricter regulations – rather than a ban – being imposed on the activities of these clinics. Violations of those regulations would involve sanctions of up to five years in prison.

Speaking truth to power

The sacking of Professor David Nutt from the Advisory Council on the Misuse of Drugs has led to a spirited row between politicians and scientists. Colleagues in ACMD are resigning, refusing to be used as mere rubber stamps for pre-determined agendas. The home secretary seems to want to reorganize it to his liking.

The origin of the conflict is Nutt's staunch harm-reduction and evidence based policy position: he thinks drugs should be legally classified by the harm they do, not so much by political expediency. Alcohol and tobacco are more harmful than cannabis, taking ecstasy appears to be less risky than horse riding (when counting injuries and death). Hence he has criticised policies ministers for upgrading medically less harmful drugs. While certainly controversial in the anti-drug community his arguments appear to be based on solid science. As a scientist he should also sound the alarm if the government is "devaluing and distorting" the scientific evidence.

Alan Johnson sees things differently: "He was asked to go because he cannot be both a government adviser and a campaigner against government policy." The role of an advisor is only to advice, while the government decides policy. But if the policy is against the evidence, should not the advisor advise to change the policy?

Academic freedom isn't free

Should scientists be allowed to publish anything, even when it is wrong? And should there be journals willing to accept everything, as long as it seems interesting enough? That is the core of a debate that has blossomed since the journal Medical Hypotheses published two aids-denialist papers. Medical Hypotheses is a deliberately non-peer reviewed journal: the editor decides whether to publish not based on whether papers are true but whether they are bold, potentially interesting, or able to provoke useful discussion. HIV researchers strongly objected to the two papers, making the publisher Elsevier withdraw them. Now there are arguments for removing Medical Hypotheses from PubMed, the index of medical literature. Ben Goldacre of Bad Science and Bruce G Charlton, editor of Medical Hypotheses, debate the affair on Goldacre's blog. Are there scientific papers that are so bad that there should not be any journal outlet for them?

Telling porkies: should the doctor tell her patient where the medicine comes from?

In a column in the New York Times this week Randy Cohen fields a question from an anaesthetist. Should the doctor ask a devoutly religious patient whether he minds that his anticoagulant (heparin) is derived from pigs? In reply Cohen suggests that the doctrine of informed consent requires the doctor to consider the non-medical preferences of the patient and make sure Muslims, Jews and vegetarians know where their medicine is coming from.

Four... three... two... one... I am now authorized to use physical force!

Noel Sharkey, Professor of Artificial Intelligence and Robotics at the University of Sheffield, warns that we are well on our way to get military killer robots that have great autonomy in applying deadly force. Current military "robots" such as UAVs have limited autonomy. They are remotely controlled by humans, but increasingly given ability to patrol, find targets and attack on their own. It would be a natural progression to give them increasingly free reign, with the humans merely granting permission - but in an active situation human reactions might be too slow. Will the current convention that a properly trained military human operator has to make the final decision still hold true in the future?

In a world of low risk obstetrics, is home birth unethical

It is reported that women who give birth at home with an independent midwife are nearly three times more likely to have a stillbirth than those who give birth in hospital; many other outcomes were “significantly better”. 

 

Perinatal deaths following home birth were associated with an underestimation of the dangers of high risk pregnancies such as preterm birth, twins, vaginal breech births and fetal distress (Bastian H et al.  BMJ. 1998; 317: 384–388). Even some IVF pregnancies were managed at home.

 

Midwives are trained in carrying out normal deliveries, not complex high risk manipulative deliveries such as breech deliveries; these should not be performed by unskilled operators. In addition, caesarean section is advocated for most women with a breech presentation or twins. 

 

Home birth in high risk patients is inadvisable and experimental (Bastian) and is opposed by professional colleges and here and here. Women with an increased risk of complications should be delivered in hospital where obstetricians can spot those complications. Women should be told this - in the recent study there is no suggestion that UK midwives told them. 

 

Oxford Debates Cont'd - Opposer's Closing Statement

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster
Closing Statement

The criterion 'self-inflicted' is unworkable in practice. One simply does not know in many cases whether a particular disease or injury is self-inflicted. Yes, there is ample evidence to show that smoking can cause lung cancer. But some lung cancers are not caused by smoking. How can medical decision-makers decide in the case of Patient A, a smoker, that her cancer is a result of her smoking?  Such matters of medical causation are notoriously hard to resolve even in the courts, with the luxury of expert evidence, unlimited time and prolonged argument from counsel.
Many illnesses are caused by a (generally mysterious) interaction of genes and environment. How does Dr. Sheehan take account of the genetic contribution? Suppose that Patient B has a familial predisposition to high cholesterol. She only discovered this in her thirties. Until then she ate a diet that would be fine in someone without her predisposition, but is dangerous in her case. She gets atherosclerosis and needs a coronary stent. Should she have one? Is her condition self-inflicted? Would Dr. Sheehan's decision about her treatment depend on whether she should, with the exercise of appropriate care (what's 'appropriate'?), have cut down on the pies earlier than she did? These questions are horrifically difficult. We can multiply them ad nauseam. They are all raised by Dr. Sheehan's purportedly straightforward criterion.

Oxford Debates Cont'd - Proposer's Closing Statement

Part of the debate "The NHS should not treat self-inflicted illness"
Proposer: Dr Mark Sheehan

Closing Statement

What is most difficult about topics such as this one is that there are clear intuitions on both sides. These intuitions pull against each other and tempt us to focus on extremes at either end. The solution lies in the middle, where we can respect the desire to care for all those who are suffering as well as taking seriously the network of rights and responsibilities on which society is based.

Oxford Debates Cont'd - Opposer's update 2

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster
Update 2

Dr. Sheehan has fairly and inevitably surrendered. The motion as it stands is wholly unarguable.

But he contends that there are still important matters to discuss. I agree. Let's look at the 'subset of extreme examples' he relies on, where it is blindingly obvious that injury has been self-inflicted. The three clearest examples are perhaps attempted suicides, injuries resulting from dangerous sports, and some road traffic accidents.

We need to start by chasing away one red herring: insurance.  Of course bungee jumpers and parachutists should be insured. Insurance is mandatory for drivers. I have no difficulty with the proposition that the NHS should recoup the cost of care from the bungee jumper's insurer. But let's suppose that the insurance company won't pay. There could be many reasons. The jumper's wife might have failed to post a letter; the tour operator, unbeknown to the jumper, might not have been on the insurer's approved list; the insurer might litigate long and hard to avoid liability on a technicality.