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  9:55:00 PM

War in Gaza prompts war in The Lancet

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.

In its editorial, The Lancet declared that:

“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… 

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  3:30:00 PM

Should we compensate organ donors?

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.”

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  3:13:00 PM

What students think about conscientious objection

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. 

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  2:59:00 PM

Putting patient care first

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.”

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  12:27:00 AM

Iran to boost birth rate by banning birth control

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.

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  11:57:00 PM

Dawkins disses Down syndrome babies

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.”
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  11:14:00 PM

Who is most vulnerable?

who is more susceptible to euthanasia or assisted suicide?    

In the on-going debate over euthanasia, there are seldom any new arguments. A favourite of those in favour of legalisation argue that the wishes of people who are competent and able to make a rational choice deserve to have their autonomy respected. A favourite of those against contend that the vulnerable – the poor, the disabled and the elderly – will be victimised.

One strand of evidence favours euthanasia supporters. In Oregon, where assisted suicide is legal, most of the people who take advantage of it, according to the figures for 2013 are white (94%), male (62%) and well-educated (53% with a college degree). There are no estimates of income, but well-educated white males tend to be wealthier than average and, significantly, not vulnerable.

However, a fascinating article in the Journal of Medicine and Philosophy turns this argument on its head. Erik Krag, of Southern Illinois University–Edwardsville, suggests that it may be members of the dominant social group – white men -- who are actually most vulnerable to the temptation to request euthanasia.

Men have been socialised to believe that life is not worth living if they are not dominant, independent and fully in control. When illness or indigence strike, some men will believe that their lives are completely useless, especially if they are not connected to others in a loving family structure or committed to a belief in transcendent values.

“… what happens when, through illness, injury, or simply old age, the rich, well-educated white male’s fragile source of value is broken irretrievably and he loses the ability to conform to the masculine ideals that he has been socialized to attain?”

So, paradoxically, the fact that wealthy white men are the principal “beneficiaries” of physical-assisted suicide shows that they are even more “vulnerable” than many physically disabled people. Dr Krag writes:

“… we should be no less wary of the effects of society’s influence on those who ‘would rather be dead’ than lose their privileged status. When the rich, well-educated, white male loses his privileged status, he finds himself cast suddenly into the role of the one whose life he had deemed not worth living. He is socially humiliated by his failure to measure up and unable to use the tools that he has worked so hard to develop.
“With the loss of his privileged status, the weight of society’s disdain for him hits him all at once; his sense that society sees him as worthless is magnified all the more by the self-aversion that the last remnants of his former identity cause him to feel. He has lost his source of value, and the isolating competitiveness of his upbringing has left him ill-equipped to find value in defiance, persons, or a transcendent reality.
“Certainly, if ever a person was vulnerable to feelings of depression and self-disregard, this is he. We should thus not be surprised that it is well-educated white men who seek and obtain PAS/VAE most often.”
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  10:35:00 PM

Australia could recognise multiple parents

Australian law could be revised to allow more than two parents, if recommendations in a major report are accepted by the government. A “Report On Parentage And The Family Law Act”, was released this week.

Adoption and new reproduction technologies are placing new strains on what “parent” means in contemporary society. Because of “the evidence of family diversity and children’s views about who is a parent”, the Council has recommended that the word “parent” be replaced by “other significant adults” or “other people of significance to the child” and that references to “both” (which implies only two) parents should be omitted.

There are many kinds of parents, the Council points out: legal, adoptive, genetic, intending, psychological, social and surrogate, amongst others.

The report was commissioned by the previous Labor government and was completed last December. The delay meant that it was released when commercial surrogacy is being placed under a microscope.

Although legalising commercial surrogacy – which is currently banned in Australia -- was not included in the report’s terms of reference, the Family Law Council, which produced the report, clearly is in favour. It is “conscious that the number of children conceived as a result of overseas commercial surrogacy arrangements has increased dramatically in the past several years, despite the existence of Australian laws prohibiting such arrangements.” It favours an international convention on surrogacy.

International commercial surrogacy already involves hundreds of children. “According to community group Surrogacy Australia, in 2011 the estimated numbers of births to Australians via surrogacy arrangements were 45 Australian babies born in the US, 45 in Thailand and 315 in India.” (Now that both Thailand and India have closed their doors to international surrogacy, this is bound to change.)

Some of the background unearthed by the Council is thought-provoking. For instance, it says that commercial surrogacy is potentially quite corrupt. In countries like India, Thailand and Malaysia, “The lack of a legal framework in these countries, coupled with the poverty of many of the population, increases the potential for exploitation of the surrogate mother as well as the risks of child trafficking.”

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  8:52:00 PM

Paolo and Francesca’s IVF mix-up

An Italian judge has settled a bitter custody battle for IVF twins by awarding them to the birth mother. The case, which has gripped Italy, is a worst case scenario for IVF clinics. Two women with similar names underwent IVF in Rome’s Sandro Pertini  hospital. The embryos were switched and one couple miscarried.

Three months later the woman bearing the twins had a genetic test which revealed that they were not related to her. The genetic parents claimed the twins but the birth mother, Francesca, and her partner, Paulo, are refusing to give them up. Under Italian law, the birth mother is clearly the legal mother.

The babies were born this week by Caesarean section. "We are happy. Very happy: our children are born, they're very well and we have already registered their birth," says Francesca. "No one will be able to take them from us," she told La Stampa.

Although the law is clearly on the side of the birth parents, the National Bioethics Committee has suggested that the couples somehow collaborate in raising the children.

(Has anyone noted the irony that this 21st Century couple is named Paolo and Francesca? You can't make this sort of thing up. Dante meets another Paolo and Francesca in the second circle of Hell in the Inferno. The heart-rending story of their passionate affair was the theme of many paintings, plays, and operas in the 19th century. Is there a message here about evolving attitudes toward love and fertility?)

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  2:55:00 PM

Thailand moves to ban surrogacy

The new Thai military government is moving swiftly to crush the lucrative surrogacy industry. This week two Australian same-sex couples and two American couples were prevented from leaving Thailand with a baby. The as-yet-unwritten legislation leaves 200 more surrogate mothers and their Australian clients in legal limbo.

Until now, commercial surrogacy was banned in Australia and discouraged in Thailand. However, taking advantage of numerous loopholes, it has become an important feature of Thailand’s booming medical tourism industry.

Under a new law women will be forbidden to carry babies for commercial purposes and surrogacy will be restricted to relatives. The penalties will be severe: 10 years in jail and a fine.

However, Nandana Indananda, a Bangkok-based lawyer who helped draft the new surrogacy law, told Deutsche Welle that surrogacy as such will not be banned.

“Firstly, it prohibits a doctor or surrogacy clinic from performing a surrogacy for commercial purposes. Secondly, no one is allowed to establish or operate a surrogacy agency for commercial purposes. Thirdly, no one can publish any advertisement about surrogacy for any purpose, either commercial or non-commercial …
“As for the parenthood issue, the bill determines that, if certain conditions are met, the intended couple will be considered the parents of the child, even if the intended parents pass away before the birth of the child.

No one knows how this will affect the increasing demand world-wide for surrogate mothers. Both India and Thailand have recently banned international commercial surrogacy. A few other countries, (Russia, Ukraine, Belarus, Georgia, Armenia, and the US), permit it. However, the number of countries with ideal conditions for commercial surrogacy -- enabling legislation, high-quality medical care, and desperately poor women – is shrinking fast. 

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