The academic conversation over brain death continues, with the American journal of Bioethics publishing a special issue on the status of death determined by neurological criteria (DDNC).
The issue contains 20 articles offering different perspectives brain death. Most of the papers refer a recent legal battle in Texas over Marlise Munoz, a brain dead woman carrying a second trimester foetus.
The papers are highly technical and difficult to summarize in a short post. There are, however, a number of clear themes:
Doctors who failed to raise concerns about colleagues could be struck off, under new guidance being considered by the UK’s General Medical Council (GMC).
The GMC has launched a public consultation on the proposed changes. Current guidance for the fitness to practice panels of the Medical Practioner Tribunal Service (MPTS) states “it may be appropriate to remove a doctor from the medical register when their behaviour is fundamentally incompatible with being a doctor.”
The proposed changes would augment the MPTS’s scope for disciplinary action. New scenarios covered include cases where a doctor has “failed to raise concerns where there is a reason to believe a colleague’s fitness to practice is impaired” and cases where a doctor has failed to raise concerns “where a patient is not receiving basic care to meet their needs”.
The MPTS will also impose more serious sanctions where doctors have “used their professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them” and where doctors have failed to work collaboratively, “including bullying, sexual harassment, or violence or risk to patient safety.”
Commenting on the proposed changes, Niall Dickson, the GMC’s chief executive, said, “The guidance on which we are consulting is vital for case examiners and the independent panels who decide on the sanctions doctors should face, both to protect patients and uphold the reputation of the profession”.
Germans and British make up the bulk of the numbers, with neurological conditions, such paralysis, motor neurone disease, Parkinson’s, and multiple sclerosis, accounting for almost half of the cases, the findings show.
611 non-residents had been helped to die between 2008 and 2012, all but four of whom had gone to Dignitas. Their ages ranged from 23 to 97, with the average being 69; over half (58.5%) of the ‘tourists’ were women, who were 40% more likely to choose assisted suicide in Switzerland than men.
In all, residents from 31 different countries were helped to die in Switzerland between 2008 and 2012, with German (268) and UK (126) nationals making up almost two thirds of the total. Other countries in the top 10 included France (66), Italy (44), USA (21), Austria (14), Canada (12), Spain and Israel (each with 8). Overall, the numbers of people being helped to die in Switzerland doubled between 2009 and 2012.
Virtually all the deaths were caused by taking sodium pentobarbital. Four people inhaled helium—deaths which were widely publicised and described as “excruciating,” and possibly responsible for the dip in numbers of suicide tourists to Switzerland between 2008 and 2009, say the researchers.
Around one in three people had more than one condition, but neurological conditions accounted for almost half of the total cases, followed by cancer and rheumatic diseases.
The researchers suggest that the phenomenon of suicide tourism, which is unique to Switzerland, has prompted legislative changes and/or serious debate in Germany, the UK, and France—the principal sources of this type of tourism.
But Dr Charles Foster, of Green Templeton College at the University of Oxford is not convinced that this is the case in the UK. In an accompanying commentary, he argues that there are two possible connections between suicide tourism and policies surrounding assisted suicide in the UK.
“The first is the liberalisation of public opinion that comes naturally, if irrationally with familiarity,” he writes. “And the second is the slowly growing public acknowledgement that there is something intellectually, if not morally, uncomfortable, about getting another country to do your dirty work.”
How to deal with the Ebola outbreak in West Africa seems to be splitting bioethicists. Some applaud the World Health Organisation's recent decision to allow experimental drugs to be released "for compassionate use". For Arthur Caplan, of New York University Langone Medical Center, this seems to be the right decision:
"In a plague that kills 90% of its African victims complaints about unwarranted exploitative research seem a bit ridiculous even against a long history of misuse and abuse of poor desperate persons in poor African nations."
However, bioethicists Ezekiel Emanuel, of the University of Pennsylvania, and Annette Rid, of King's College London, want to be a bit more restrictive about "compassionate use" and believe that experimental drugs are not the main way to beat the disease. In an article in The Lancet, they write:
"Adoption of containment measures with a view to strengthen health systems and infrastructure is the most effective way to curb this epidemic and prevent future ones; it has positive externalities for health promotion and offers fair benefits to communities who engage in research in this outbreak. Experimental Ebola treatments or vaccines should only be deployed in clinical trials."
One reason for being restrictive is that untested drugs could actually be dangerous. They say:
"irrespective of hope, we need to be realistic. The distance between preclinical promise and clinical use is vast and littered with failed compounds. Only 10% of new molecular entities succeed from the point of preclinical candidate selection to commercial launch. Although promising in non-human primates, there is no reason to believe that the experimental Ebola interventions will be more successful. In other words, it is more likely than not that the interventions will not improve or save patients, and might even weaken them as they battle a life-threatening disease."
They also believe that lessons should be learned from the Ebola epidemic about how to strengthen health systems in these impoverished countries. In the long run, this is what will save lives:
"Although Ebola's rapid spread and high rate of mortality capture our attention, the disease needs to be put into perspective. Cumulatively in the past four decades, Ebola has claimed less than 3000 lives.By contrast, the death toll in sub-Saharan Africa was 547 322 from diarrhoeal diseases and 222 767 from pneumococcal pneumonia in 2010 alone; many of these deaths could have been prevented through access to basic health care, including cheap vaccines, and improved sanitation. Thus, strengthening of health systems and infrastructure will have positive externalities for health promotion after this epidemic subsides."
The war between Hamas in Gaza and Israel has been treated very gingerly by most of the major medical journals. Except The Lancet. This prestigious British publication ran an incendiary letter from a score and more of academics and doctors with Palestinian sympathies and subsequently a strong defence of its editorial policy.
“It is surely the duty of doctors to have informed views, even strong views, about these matters; to give a voice to those who have no voice; and to invite society to address the actions and injustices that have led to this conflict. Our responsibility is to promote an open and diverse discussion about the effects of this war on civilian health.”
The Lancet’s sympathies are clearly with the civilian population of Gaza, who “have no Iron Dome, the Israeli air defence system designed to intercept and destroy Hamas rockets. The children, women, and men of Gaza have had no protection from shelling that has so far claimed 852 civilian lives.” A number of readers attacked the editors for taking sides – to which their response was:
“In the conflict taking place in Gaza, our position is very clear. We do not support any side whose actions lead to civilian casualties. The role of the doctor is to protect, serve, and speak up for life. That, too, is the role of a medical journal.”
The incendiary letter by Paola Manduca et al spoke of Israeli “lies” and described the 95% of Israeli academics who did not openly oppose the war as “complicit in the massacre and destruction of Gaza”.
Enraged Israeli doctors responded immediately. The President of the Israeli Medical Association, Leonid Eidelman, and the Director General of the Israeli Ministry of Health, Arnon Afek, compared the letter to Nazi doctors’ anti-semitism and denounced it as “a clearly political and biased letter”. They pointed out that Israeli hospitals treat Israelis, both Arabs and Jews, without distinction and even treat Palestinians. Another denounced “the dehumanisation and bigotry” of Manduca et al’s letter and urged The Lancet “to reassess its practice of biased publishing in the service of polarising political interests of one group”.
The Israeli correspondents stressed the implacable hostility of Hamas towards Israel, its refusal to allow Gazans to receive Israeli health care and the thousands of rockets which it has launched at Israel. Eidelman and Afek wrote:
“We agree with Manduca and colleagues that the military action ‘terrifies those who are not directly hit and wounds the soul, mind and resilience of the younger generation’. This is certainly the case regarding the children of the 6 million Israelis (including Arabs), of a population of 8 million, who live in terror of the rocket attacks. The younger generation is also being harmed by Hamas itself, who not only indoctrinates them with hatred but uses them as child labour in building tunnels, resulting in the deaths of 160 children.”
In summary, hundreds of civilians are dying but the politics of the conflict are so bitter that no one who expresses an opinion escapes unscathed. “The role of the doctor is to protect, serve, and speak up for life,” wrote the editors of The Lancet – a noble sentiment with which everyone will agree. But unfortunately it is a bit more complicated than that…
There are currently over 123,000 people in the US on the organ donation waiting list. Only 29,000 organ transplants took place in 2013 – a consequence of the dire shortage of organ donors.
A number of healthcare commentators are now calling for ‘compensation’ for donors.
Sally Satel of the American Enterprise Institute believes that some form of monetary incentive is the only way to address the donor shortage: “altruism, as a strategy, is simply not producing enough organs. It needs to be supplemented with compensated donation”.
Alan Langnas of the University of Nebraska and Daniel R. Solomon of the Scripps Research Institute make a similar argument.
“Organ donors, and in particular the live kidney donor, are being asked to altruistically support a system with sizable financial costs to themselves. These costs represent a considerable disincentive to organ donation. To begin to move the dial on this we must engage in a process of identifying and removing those disincentives.”
They argue that the government should pay for the lost wages of the donor and perhaps even their future medical insurance.
But could ‘compensation’ lead eventually to an organ market? And are we overlooking a deeper problem in the organ transplant process?
Dr. Jeremy Chapman of Sydney’s Westmead Hospital argues that the US is better off fixing problems in the current system, rather than abandoning altruism as a basis for donation:
“[Many] ignore the hundreds of donated kidneys that must be discarded each year in the United States. They ignore the lessons that can be learned from the successful organ procurement regions of the country that derive twice as many organs per capita as the least successful programs.”
An revealing new study in the Journal of Medical Ethics examines the attitudes of medical students towards conscientious objection. The study, conducted by a group of researchers from the University of Oslo, canvased the views of 531 fifth and sixth year medical students in Norway. Students were asked about a range of procedures including abortion, euthanasia, ultrasound in the setting of prenatal diagnosis and assisted reproduction for same sex-couples. Students views varied significantly depending on the issue.
62% of respondents said they would object to participating in euthanasia – a surprisingly high proportion considering that the majority of Norwegians are said to support legalising euthanasia.
A far smaller number said they would object to participating in abortions (between 12.5% and 19%, depending on the stage of pregnancy and whether the foetus had disabilities).
Only a small number of students said they would object to referring patients for abortions (4.9%), and just 10.2% said that they would tolerate other doctors refusing to refer.
Norway has strict regulations on conscientious objection to abortion. Doctors are required by law to refer patients to abortionists, even if they have moral reservations.
A British cosmetic surgeon has been struck off for putting commercial interests before patient care.
The UK’s Medical Practitioners Tribunal Service found that Dr. Krishna Murthi Nulliah of Harley Health Clinic had “subordinated his proper responsibilities as a doctor to the pursuit of a commercial enterprise.”
Four women who had attended Dr. Nulliah’s clinic testified to various instances of misconduct. Dr. Nulliah failed to adequately examine patients, take a proper history, or obtain informed consent.
All four patients reported that he had failed to discuss the risks of surgery or alternatives such as dieting and exercise. When one patient said that she wanted more time to consider, Nulliah told her that his diary was booking up quickly and that she would need to leave a 50% deposit to secure the date.
He offered another patient a discount if she opted for more extensive surgery than originally requested.
Dr. Nulliah denied any negligence, and argued that patients didn’t need a ‘cooling off’ period.
Barrister David Kyle, the chair of the panel, rejected Nulliah’s defence. “Patients who seek out cosmetic treatment may well have underlying anxiety and worries, which may in turn render them vulnerable . . . Dr Nulliah should have recognised this.”
Medical law expert Julianne Moore welcomed the decision as a reminder of the paramount importance of patient care.
“Patient safety rather than commercial gain must be the top priority of all surgeons, regardless of whether they work in the private sector or NHS.”
Iran is to ban vasectomies and female sterilization in an effort to reverse its plummeting birth rate and ageing population. A bill has passed parliament and only remains to be approved by the Guardian Council. Doctors who perform procedures such as vasectomies or tubal ligation, could face fines and prison sentences. Journalists will also be prosecuted if they publicise birth control or other family planning measures.
The bill follows years of concern by Iran’s rulers about its demography. After the Iran-Iraq war in the 1980s, the government encouraged large families. Afterwards, however, a big population was regarded as a drag on development. The government promoted contraception, so much so that the birth rate fell from about 6.0 to less than 2.0.
Ayatollah Khamenei has been criticising contraception and has said that the country should aim at doubling its population from 77 million to at least 150 million.
On Iranian state television in May, Khamenei told Iranians that they should “save yourselves from this ominous culture of one child or two children nonsense” and to choose an “auspicious Shiite number” to determine how many children they should have. “Have five children as in the Five of the Purest, or eight children as in the eighth Imam of the Shiites, the holy Imam Reza, or have 12 children in the name of the 12 Shiite Imams, or 14 in the names of the ‘Fourteen Sinless’ saints,” he said.
Dear old Dick Dawkins is in hot water again after asserting on Twitter that it is “immoral” to allow Down Syndrome babies to be born. Dawkins, a popular genetist, campaigner for atheism and the former Simonyi Professor for the Public Understanding of Science at Oxford University, found it a bit difficult to explain the subtler points of his thought in the 140-character limit of tweets.
However, he appears to have embraced Peter Singer’s version of utilitarianism, animal rights and veganism. He said that the central question in the abortion debate was not “is it 'human'?" but "can it suffer?”. He went on to insist that people should object to abortion if they eat meat.
He made the remarks in the context of a Twitter debate over abortion in Ireland. One person said that she would find it difficult to abort a Down syndrome child. Dawkins responded, “Abort it and try again. It would be immoral to bring it into the world if you have the choice.”
Dawkins was astonished at the “feeding frenzy” which erupted on the social media site following this interchange and apologised for it. As for his remarks about Down syndrome, he dug in his heels and composed an amplified version for his own website. In it, he writes:
“For what it’s worth, my own choice would be to abort the Down fetus and, assuming you want a baby at all, try again. Given a free choice of having an early abortion or deliberately bringing a Down child into the world, I think the moral and sensible choice would be to abort. And, indeed, that is what the great majority of women, in America and especially in Europe, actually do. I personally would go further and say that, if your morality is based, as mine is, on a desire to increase the sum of happiness and reduce suffering, the decision to deliberately give birth to a Down baby, when you have the choice to abort it early in the pregnancy, might actually be immoral from the point of view of the child’s own welfare.”
Dawkins acknowledged that some of the people who objected to his tweet had family members with Down syndrome and were very attached to them.
“I have sympathy for this emotional point, but it is an emotional one not a logical one. It is one of a common family of errors, one that frequently arises in the abortion debate.”