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  8:15:00 PM

Probe into death of Joan Rivers

As more details of the death of American comedienne Joan Rivers come to light, her doctor’s behaviour is being questioned. The 81-year-old Ms Rivers died after a cardiac arrest during a routine endoscopy at Yorkville Endoscopy clinic in Manhattan. She was being investigated for a sore throat and hoarse voice.

The clinic issued a soothing statement to the press after the death about the kind of anaesthesia it used and the high quality of its care.

CNN alleges that the comedian’s personal doctor, Gwen Korovin, took a selfie while her patient was sedated and also, without her consent, took a biopsy of her vocal cords. "Even though you are a licensed physician, you still should have, if you will, the checks and balances to get your approval to practice in that particular place," said bioethicist Arthur Caplan, of New York University's Langone Medical Center. CNN says that Dr Korovin, a respected otolaryngologist, has denied taking a selfie with her cell phone.

The American Association for Accreditation of Ambulatory Surgery has placed the clinic on "emergency suspension." and asked it stop procedures and surgeries "until accreditation questions are settled."

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  8:00:00 PM

Interview: the global trade in reproduction

Dr Carmel Shalev, of Israel’s Haifa University, is organising a session on helpful and harmful practices in the ethics and regulation of inter-country medically assisted reproduction in Jerusalem in January. It will be part of the 10th World Conference on Bioethics, Medical Ethics and Health Law.

BioEdge: “inter-country medically assisted reproduction” – do you basically mean a market for surrogate mothers and babies? 

Shalev: Yes, that’s a major concern, but not the only one. For example, there is also a market in inter-country egg donations. The problem is that there have been too many cases of harm to children and to the third-party women who agree to take part in reproductive collaborations for the benefit of others, as genetic mothers (egg providers) and birth mothers (surrogate mothers).

What are the “products” in the market?  

The products in surrogacy are children. In other practices the products are human gametes (eggs and sperm) and embryos (fertilised eggs). Unfortunately, women are being used as a means of production, and objectified in the process.

How much has the market for surrogacy grown over the past 20 years? 10 years? Can you put a dollar figure on it? 

Inter-country surrogacy has been going on for about 10 years. Transnational practices involving egg donations have been around for a little longer. It’s difficult to put numbers to a market that is private and unregulated, but estimates indicate that the size of the industry (including other repro-genetic practices such as IVF for sex selection) is in the range of billions of dollars. We know the market is growing rapidly, even in those countries where surrogacy is allowed and regulated. In Israel, for example, fewer than 100 children are born each year from local surrogacy agreements, while in 2012 there were approximately 130 cases of requests to register the births of children born of inter-country surrogacy.

What is pushing it? Women delaying motherhood until it is too late? Gay couples who want kids?

The demand of prospective parents is related to changing social norms about family, combined with innovations in assisted reproductive technology (ART). Gay couples want to have families, and single women want to become mothers but often need egg donations, in addition to sperm, to get pregnant. The desire of individuals and couples who want children and can’t have them without medical assistance translates into a right to parenthood.

But the demand for access to ART also reflects a consumerist culture. Legal restrictions in countries of demand are one incentive to seek medical care abroad. Global economic disparities mean that services provided in lower income countries are far less costly, and that too is an incentive.

Finally, the market is driven by sometimes unscrupulous medical entrepreneurs and intermediary agents, who capitalize for personal profit on consumer desire, and on the ignorance and vulnerability of all those involved.

India and Thailand used to be the main destinations for people looking for surrogate mothers. Now that they have more or less shut the doors to foreigners, how will the market adjust? 

Hopefully, the market will shrink, but it might well go underground, which would increase the risks. And it appears that new markets might be opening in Central and South America. The global ART market is similar in some ways to the global arena of organ transplantation, although the latter is relatively well regulated under international law and convention. Illicit organ transplantation practices are called “trafficking” and are punishable.

Nonetheless organ trafficking continues, and intermediaries are ingenuous in shifting locations to circumvent legal changes. This is evident, too, in inter-country surrogacy. For example, women who become pregnant in a surrogacy collaboration can be transferred across borders to give birth, if surrogacy is no longer allowed in their countries of residence. So long as medical practices are unregulated, the birth of a child is the most concrete evidence. All the stages that precede birth (throughout the process of conception, impregnation, gestation) can go undetected. That is why we know far less about inter-country egg donation that we do about surrogacy.

What are a few of the helpful and harmful practices to be canvassed in the conference? 

Lessons learned from experience with local surrogacy can inform a model for inter-country reproductive collaborations, based on an ethic of care and responsibility, and values of respect, reciprocity and integrity.

Unfortunately, in some extreme cases, the current situation has incurred grave violations of the human dignity and rights of women and children. Abuses include the fraudulent use of surrogacy to create and sell babies. In other cases, new-born infants have been rendered parentless and stateless.

As for the women, double standards of care for invasive medical interventions have carried health harms, including collateral infertility. Medical procedures often involve violations of bodily integrity and patient autonomy – eg, in relation to multiple-embryo implantations, pregnancy terminations and C-section deliveries.

In some cases, intermediaries advertise the possibility of parallel pregnancies. This means, that if there are more pregnancies than the desired number of children, the surplus ones are terminated, and the pregnant woman is led to believe falsely that there was something wrong with the fetus. In other cases, women have been deprived of their liberty and confined for the duration of their pregnancy in controlled housing with 24/7 surveillance. A general concern is the invisibility of the third-party women, which creates conditions that are conducive to dehumanisation and exploitation. I think it’s really important that these women have faces, that they be seen as playing a role in a relationship. It’s also important to preserve information, so that children can know the circumstances of their birth.

What outcomes would you like to see?

We want to provide a forum for people to share what they know about inter-country reproductive collaborations, what works and what doesn’t, to discuss views on how best to address matters of concern, and to join a process which has as its long-term aim the adoption of an international code of ethics and human rights convention.

All welcome? 


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  7:00:00 PM

Remember Savita?

A new style of journalism has emerged in the UK: slow journalism. “Because today's ultra-fast news cycle rates being first above being right. It tells us what's happening in real time, but rarely what it means,” says the website for its flagship magazine, Delayed Gratification. Perhaps one of its writers should revisit the death of Savita Halappanavar in Ireland in 2012.

Mrs Halappanavar was an Indian dentist who began to miscarry her first child. Thinking that the child was dead, she asked for an abortion. The staff at Galway University Hospital refused and she died of a massive infection. The world media went wild: “Ireland's law and Catholic culture allowed Savita Halappanavar to die” was the headline in the normally sober UK magazine, New Statesman. The next year Ireland relaxed its strict laws on abortion.

However, a report released last week by Ireland’s  Health Information and Quality Authority shows that Savita’s death had nothing to do with the abortion law. It was caused by incompetence

“The findings of this investigation reflect a failure in the provision of the most basic elements of patient care to Savita Halappanavar and also the failure to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner. The Authority identified, through a review of Savita Halappanavar’s healthcare record, a number of missed opportunities which, had they been identified and acted upon, may have potentially changed the outcome of her care.”

As a result 9 members of the medical team involved in Savita’s treatment have been disciplined.

However, compared to the blanket coverage of the woman’s death, almost nothing has appeared in the media. Opponents of abortion in Ireland are incensed. “Those who pushed the distorted version of the story hardest from the start have never bothered to set the record straight in light of all the reports that have contradicted their initial presentation of the case,” said Cora Sherlock, a solicitor and deputy chairman of Prolife Campaign. “These journalists and politicians were happy to hard wire a false account of what happened into people’s minds and to this day they have no intention of disturbing their original narrative.”

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  12:03:00 AM

Defending human dignity

English barrister and medical ethicist Charles Foster has penned defence of “human dignity” as the foundation of bioethics in the Cambridge Quarterly of Healthcare Ethics. He believes that it is more adequate than the reigning view that autonomy is its fundamental principle. In particular dignity does a far better job of explaining why body parts or patients in a vegetative state deserve respect.

Foster is well aware that the concept of dignity has weaknesses:

 Dignity has a smug tendency to rest on its laurels. Its advocates have often responded to criticism of the use of dignity by philosophical name-calling—along the lines of “You don’t like dignity, and therefore you must be a Nazi/communist/utilitarian/shallow reductionist.” That’s not argument. It rightly produces derision from the dignity deniers. They tend to respond in kind, saying words to the effect of “You’re a credulous, theologically contaminated mystic.” And so it goes on. A lot of the literature on dignity is comprised of these sorts of exchanges. It is not amusing for long, and not productive at all.

However, autonomy is “hardly more satisfactory and less question-begging”. In particular, it fails to take into account the web of relationships in which we all exist.

What is dignity? “Dignity is about being human well. A dignity-enhancing measure is a humanizing measure. There are things that are objectively humanizing and things that are not.” Good things include health and companionship; bad things include isolation and arsenic.

Even if human dignity sounds airy-fairy to those of a utilitarian cast of mind, Foster points out that it has already been enshrined in law in the European Convention on Human Rights:

Article 8(1) provides that “(1) everyone has the right to respect for his private and family life, his home and his correspondence.” But this right is not absolute. …
It is now clear that Article 8 is the natural home of dignity. It is a rather tense home. The space is shared with autonomy, and there are sometimes silent, icy breakfasts and sometimes shouting matches. Also the landlords (the Strasbourg court) won’t leave the place alone. They are always redecorating and adding on extensions. But there is no danger of dignity being ousted. Indeed, it now holds, with autonomy, a perpetual joint tenancy. It used to have a bare license, and autonomy kept it in a shabby spare room. Dignity is here to stay, and its main address is Article 8.

Foster is clever debater and stylish writer (unlike most bioethicists). This is an essay which is well worth reading as a defence of an often maligned concept. 

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  10:10:00 PM

Ebola in West Africa: the stakes rise

Wrapped into US President Barack Obama’s speech on the threat posed by ISIS in the Middle East was a commitment to send the US Army to West Africa to contain the Ebola epidemic. “It is America – our scientists, our doctors, our know-how – that can help contain and cure the outbreak of Ebola,” he said.

The haemorrhagic fever, which has a fatality rate of between 50 and 90%, has spread from Guinea to Sierra Leone, Liberia, Democratic Republic of Congo and Nigeria. Over 2,000 people have died already and some experts believe that this could increase exponentially.

"The US Military is uniquely poised to help with this disease," says Timothy Flanigan, an infectious disease researcher at Brown University, told NPR from Monrovia. "We've trained for it, we've got the logistics, we've got the support and we have the matériel."

However, Obama has only allocated US$88 million for the mission --  $58 million for production, development and research of Ebola therapies, and $30 million to the Centers for Disease Control and Prevention helping on the ground in Africa. How far will $30 million go?

Dr Flanigan was disheartened by the response. The military is planning to send only a $22 million, 25-bed field hospital.  “It's not going to make any dent in Ebola treatment for the people of Liberia,” he says. “It's such a small number of beds and they may well be directed toward non-Liberians."

Furthermore, containing the epidemic and treating the sick is immensely labour-intensive. The World Health Organization estimates that about 760 foreign volunteers will be needed over the next six months, when the epidemic may begin to wane. Another 12,900 workers must be recruited from the affected countries. It takes about 200 to 250 healthcare workers to treat for 80 Ebola patients at one centre. The ratio is so high partly because people can only work in the protective suits for an hour.

As Roll Call, a US politics site, put it, “the worst epidemic in the four-decade recorded history of the disease has made the challenge one of manpower rather than financial resources.”

Médecins Sans Frontières (Doctors Without Borders) is advertising frantically for international volunteers, in addition to the 210 it has already deployed. The US government’s response will help, says its spokesman, Jason Cone, but more is needed. Some health workers in the affected countries refuse to work unless they receive protective gear and their salaries.

Some experts are very pessimistic. Jonas Schmidt-Chanasit, of the Bernhard Nocht Institute for Tropical Medicine in Hamburg, told Deutsche Welle that the battle has already been lost in Liberia and Sierra Leone. He believes that the epidemic will burn itself out by infecting more or less everyone and half the population will die. (The WHO refused to comment on this.)

Given the scale of the problem, there is no possibility whatsoever of defeating this epidemic with drugs. Hence bioethical commentary on the issue has shifted away from the ethics of the “compassionate use” of experimental drugs to public health issues.

The observations of Udo Schuklenk, the Canada-based editor of Bioethics and Developing World Bioethics, about his colleagues were scathing:

“Did we stress that WHO’s choice of topic and the supposed urgency of its recommendation to provide access to experimental agents in Ebola regions amounted to pointless grandstanding in the face of a pandemic that requires a public health response, and not the tinkering with experimental agents? Some of us did, but it didn’t stop most of us from entertaining questions on the ethics of who should get experimental agents, whether it was ok that white religious activists with a health care background were prioritized over local dying health workers, and other reportedly important questions. In the rush to be seen to do something the WHO managed to convene said meeting without a single representative from a country affected directly by Ebola.”
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  10:00:00 PM

The ethics of running scared

It’s all very well to sit in an armchair and bloviate about Ebola. If you are a doctor or a nurse or a hospital cleaner with a dying patient in the next room, it is an altogether different question. If you help the poor soul, you and your family could die.

As one Liberian nurse told Associated Press, “We are not equipped to face the situation ... When you go through this and return home, you lie in bed asking yourself: I am still safe? Or I have contracted the disease?”

An article in the Journal of Medical Ethics by four Nigerians and two Americans argues that healthcare workers are not obliged to risk their lives if their government cannot provide adequate safeguards.

“In the absence of clear guidance, healthcare workers face a moral dilemma. Their conscience urges them to treat all patients, but a convergence of failed health system factors, the danger to life, emotional considerations like danger posed to family and friends, and the absence of commensurate compensation for engaging in such high risk service can make following one's conscience costly.”

Traditionally, public health ethics has focused on the rights of the public. But the authors point out that healthcare workers have also have a right to be protected. If the government is incapable of keeping htem safe, there is not unconditional obligation to give care.  

“Requiring healthcare workers to provide care to patients with EVD puts undue burden on them. Since the principle of justice requires fair distribution of benefits and risks, it is only fair that affected countries make arrangements to adequately compensate healthcare workers who become infected in the course of duty.”
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  5:00:00 PM

Pistorius verdict - disability is not a defence

Oscar Pistorius is set to be convicted of negligence but not murder, following a six-month trial obsessively followed by the international media.  

Judge Thokozile Masipa found that prosecutors had failed to prove beyond reasonable doubt that Pistorius intended to kill his girlfriend Reeva Steenkamp. “There just aren’t enough facts to support such a finding”, she said. She did, however, find that Pistorius had been negligent in firing four shots into the bathroom of his house. “I am of the view that the accused acted too hastily and used excessive force,” Ms. Masipa said. “It is clear that his conduct was negligent.”

Judge Masipa rejected Pistorius defence that disability-induced anxiety had led him to overreact to the situation. "The accused isn't unique in this respect. Women, children the elderly and all those with limited mobility would fall under the same category," Ms. Masipa said, one of several admonishments she delivered to Mr. Pistorius. "Would it be reasonable if without further ado they armed themselves with firearms? I don't think so”.

Late in the trial medical expert Wayne Derman testified that Pistorius was a complex individual suffering from “stress and anxiety”. “You have a paradox of an individual who is supremely able and an individual who is significantly disabled”, he told the court. Derman claimed “the accused lacked criminal capacity at the time he fired the shots because of an involuntary, reflexive response.”

Ms. Masipa said she disagreed with Derman’s submission. “The accused clearly wanted to use the firearm”, she said.

Disability rights groups have criticised the Pistorius’ defence team. The president of the (US based) National Organisation on Disability described Pistorius’ disability defence as “exploitation”. 

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  4:48:00 PM

Should we criminalise scientific misconduct?

Scientific misconduct is bad, but should it be a crime? One high profile academic says yes.   

In a recent interview with New Scientist, Dr. Richard Smith, former editor of the British Medical Journal, argues that the criminalisation of research fraud is a necessary measure.

Smith suggests that scientists found guilty of misconduct “can’t be trusted” and yet many “have simply carried on with their careers.”

“Science itself has failed to adequately deal with misconduct”, he said.

Smith argues that scientific fraud causes serious social harm, citing as an example disgraced autism researcher Dr. Andrew Wakefield. Wakefield’s now discredited study on the link between vaccination and autism caused a massive drop in the number of childhood vaccinations.

Smith also argues that the nature of science means scientists should be held to a higher standard than the general public.

“The temptation to ignore, undermine, or even falsify the offending data is huge. Only those with the highest levels of honesty can accept, let alone be delighted, when data destroy their theories.”

Smith's comments echo the remarks of Dr Zulfiqar Bhutta, Robert Harding Chair in global child health and policy and Co-Director of the Centre for Global Child Health at the Hospital for Sick Children, Toronto, in a BMJ interview last year. Dr Bhutta argued that current sanctions against fraud are insufficient. "additional deterrence through punitive measures such as criminal proceedings should be added to the repertoire of measures available", he said. 

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  4:28:00 PM

Executed prisoners may be part of cadaver exhibition

A human rights group is calling on Canadian authorities to investigate the possible use of executed Chinese prisoners in an exhibition of ‘plastinated’ corpses. 

Bodies Revealed, an exhibition open in Niagara Falls, contains 20 preserved full human bodies, displayed in various positions, as well as 200 specimens of body parts. The specimens are preserved using a technique know as ‘plastination’, in which water and fat from the body are replaced with reactive resins and polymers.

Choose Humanity, a group that aims to draw attention to human rights abuses in China, claims that the bodies may come from Chinese prisons without individual consent. “We’re concerned that the presenter of these exhibitions does not have any form of consent whatsoever to show these bodies,” said Joel Chipkar, spokesman for Choose Humanity. “If these bodies do not have consent to be shown, these bodies are being shown illegally in Canada.”

Premier Exhibitions, the owners of the exhibition, offered no response to the complaint.   

However, a disclaimer on their website confirms the remains are from Chinese citizens or residents “originally received” by Chinese police. “The Chinese Bureau of Police may receive bodies from Chinese prisons. Premier cannot independently verify that the human remains you are viewing are not those of persons who were incarcerated in Chinese prisons,” the disclaimer states. “Premier relies solely on the representations of its Chinese partners and cannot independently verify that they do not belong to persons executed while incarcerated in Chinese prisons.”

Joel Etienne, a lawyer representing Choose Humanity, believes there may be a criminal offence related to causing an indignity to a body. He has requested that an inquiry be conducted and that authorities stop the bodies from leaving Canada. 

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  4:19:00 PM

Having a laugh at euthanasia

A new Israeli film attempts to offer a humorous look at euthanasia. The Farewell Party, directed by young auteurs Sharon Maymon and Tal Granit, is a dark comedy about a group of Jerusalem retirement-home residents who create a euthanasia machine to put a dying friend out of his misery — and then face a moral dilemma when others come seeking the same service. Maymon and Granit say that want to teach people how to “laugh about death”.

“We really believed in this movie, what it says. It's very important for us to raise these questions”, Maymon said.

The film has met with significant criticism both within Israel and abroad, and it has been difficult for its producers to find distributors. Nevertheless, it received positive reviews at the Venice Film Festival and has been selected for screening at the 2014 Toronto Film Festival. 

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