Practical Ethics

How bad are heatwaves and flu epidemics?

The UK health media is currently focused on two natural threats to public health: one from swine flu, and the other from the heatwave currently affecting the country. Both flu epidemics and heatwaves frequently cause many deaths. For example, the August 2003 heatwave had a death toll in Europe of around 30,000, and a typical seasonal flu epidemic causes hundreds and thousands of deaths. Yet my impression is that, in the majority of the population, flu epidemics and heatwaves are not regarded as particularly great evils (flu pandemics, such as the current one, may be a different story).There's an obvious explanation for why they are regarded as less bad than killers such as road traffic accidents, wars and terrorism: these involve human action - and often human wrongdoing - in a way that flu epidemics and heatwaves do not. But flu epidemics and heatwaves also elicit a weaker reaction than many other natural events that typically kill far fewer people: for example, floods and earthquakes.

Neonatal euthanasia without parental consent

A provocative article soon to be published in the Journal of Bioethical Inquiry argues that parental consent should not be a prerequisite for neonatal euthanasia. At present, the only country to permit neonatal euthanasia is the The Netherlands. Medical personnel there are not prosecuted for actively euthanizing infants in great suffering, provided that they satisfy the requirements of the Groningen Protocol, which include obtaining consent from the infant's parents. In the forthcoming article, Jacob Appel argues that the requirement for parental consent should be dropped. 

Let's first consider the question of whether it could be ethically permissible for medical staff to end the life of a child without the consent of the parents.

Compulsory chemical castration for sex offenders

A month ago, the Polish Prime Minister, Donald Tusk, called for the introduction of forced chemical castration for sex offenders. The call followed a particularly nasty case of incest and paedophilia in the country: a 45 year old man was found to have sexually abused his 21-year-old daughter over a period of six years, and to have fathered two children by her. A poll showed that 84% of the Polish population supported the Prime Minister's proposal, however many commentators condemned it as an affront to human rights. In response, the Prime Minister, Donald Tusk, claimed that the sex offenders he has in mind cannot be described as human beings, and therefore have no human rights (see here). Nevertheless, high level opposition has forced the government to replace the proposal with a plan for voluntary chemical castration, which is already allowed in Great Britain, Denmark, Sweden, Germany, Switzerland, and some US states. 

It is interesting to compare the claims that have been made for and against Mr Tusk's proposal with those that we might expect to surround alternative proposals for reducing rates of re-offending among sex offenders. Suppose the Prime Minister had instead suggested the introduction of a compulsory education programme for sex offenders in which they would be forced to confront the devastating effects that their actions can have on their victims. It is difficult to imagine such a proposal being greeted with the claim that it breaches human rights. And it is also hard to imagine the proponents of such a programme resorting to the claim that sex offenders aren't human. Instead, the debate would probably focus on weighing the costs and benefits of the proposed programme.

Can these differing responses be justified? Is there any good reason to think that compulsory chemical castration is a matter of human rights, while compulsory re-education is not?

Bailing out banks

Last week the US congress agreed to a US$7 billion bail-out for the banking sector. This Tuesday, the UK government followed suit with its own bail-out - though with some fairly serious strings attached. In the US case in particular, there was some strong public opposition to the bail-out, with many people claiming that bankers should be made to feel the consequences of their own bad decisions. In response, those who favoured the bail-out tended to make one or both of two main responses. First, they claimed that the bail-out would make everyone better off, and/or second, they implied that the feelings of resentment which many harbour towards bankers are not really the sort of consideration on which economic policy should be based.

A Nasty Dilemma for NICE

After a prolonged disagreement with patient groups, the NHS's funding guidance body, NICE, has approved the £10,000-an-eye blindness treatment, Lucentis. The drug has been shown to halt the progression of wet age-related macular degeneration (AMD), the most common cause of blindness in developed countries. But as the BBC  note, in approving it, NICE may have unwittingly deprived the NHS of a much cheaper alternative.

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.

Testing alternative therapies

The journal Science is today reporting on a controversial plan by the US National Institute of Mental Health (NIMH) to test an alternative treatment for autism on children. The treatment, known as chelation therapy, involves the use of drugs that remove heavy metals from the blood. It's based on a the theory - unsupported by conventional science - that mercury in vaccines triggers autism.

Chelation therapy is widely used, but its benefits and effects are not well understood. The NIMH have therefore argued that there is a "public health imperative" to test the drug. But opponents claim that any such study would be unethical, since the quality of the trial is likely to be poor, and any results - especially negative ones - would be unlikely to alter the behaviour of parents who support the therapy.

Paying to top up NHS treatment

The BBC has this week published a story on co-payment in the UK's National Health Service. Sue Matthews, a Buckinghamshire woman with terminal bowel cancer, would like to top up her NHS care by paying for a £30,000 course of cetuximab - a drug which could extend her life, but which is not funded by her NHS trust. However, if she does so, she may also have to pick up the tab for her standard NHS treatment. That's because the NHS guidelines advise against allowing such co-payments: they require that a given instance of treatment be either fully privately funded, or fully publicly funded.

Should co-payments be banned?

Is there a duty to execute prisoners humanely?

An article published this week in PLoS Medicine discusses the ethics of research on US lethal objection protocols. The authors conclude:

While lethal injection and the death penalty present a host of ethical questions, the specific, pressing issue now faced by 36 US states, the federal government, and the 3,350 prisoners on death row is the movement to amend lethal injection protocols to comport with Eighth Amendment requirements and to minimize the potential for pain and suffering, in itself a commendable goal. As jurists demand lethal injection protocol changes, however, corrections officials, governors, and their medical collaborators are left in a legal and ethical quandary. In order to comply with the law and carry out their duties, they are employing the tools and methods of biomedical inquiry without its ethical safeguards. Given the current guidelines for human experimentation, it is difficult to conceive of circumstances in which lethal injection research activities could be carried out in a fashion consistent with these ethical norms, and yet those engaged in such research would seem to be required to do so.

This passage raises many questions. Is is the movement to amend lethal injection protocols really the pressing issue? Can a movement to execute prisoners more humanely really be commendable? But let's focus on the authors main claim: namely that the states in question face a legal and ethical quandary since, (i) they are under "duties", as well as legal requirements, to execute more humanely, but (ii) they cannot do so without breaching the ethical and legal requirements.

The authors devote most of their attention to the second claim, (ii), but arguably (i) is more problematic.

Genetic discrimination and the future of health insurance

The US Congress today passed legislation banning the use of genetic information by insurance companies, unions and employers. As Dominic Wilkinson noted in his post on 26 April, this legislation might have interesting implications for professional sport. The reform also raises questions about the future of insurance markets.