Bioethical debates about whether to administer an experimental drug for Ebola victims are interesting and necessary. But only a handful of doses are available anyway and hundreds of people are dying in Guinea, Sierra Leone and Liberia. According to the latest update from the World Health Organisation, 2,127 cases and 1,145 deaths have been reported. But it has also declared that “the numbers of reported cases and deaths vastly underestimate the magnitude of the outbreak”.
“Extraordinary measures,” are needed, it says, “on a massive scale, to contain the outbreak in settings characterized by extreme poverty, dysfunctional health systems, a severe shortage of doctors, and rampant fear.”
In view of the emergency, the three worst affected countries have taken the most drastic step possible – drawing a “cordon sanitaire” around the areas where the outbreak is most virulent. The perimeter is guarded by soldiers and no one is allowed in or out until the plague runs its course. It is a primitive method but in mediaeval times it was the only way to keep infection from multiplying.
This method was used to control an outbreak of Kitwit, in Zaire (now Democratic Republic of the Congo), a city of half a million in 1995. According to Laurie Garrett, writing in The New Republic, it was “brutally successful, as all trade to the Kikwit region ground to a halt, the desperately poor people were fully isolated to war with Ebola on their own”. She received a Pulitzer Prize for her reporting on the epidemic and the lesson she drew from her experience is tough and utilitarian:
“Despite all the brouhaha here in the United States and Canada about application of experimental drugs and vaccines never clinically tested for safety or effectiveness to the African crisis, this siege will end not with magic bullets, but smart, heroic strategies that find infected people swiftly, place them behind cordoned quarantine barriers, and bury the dead rapidly after their demise without families’ contact or viewing. Yes, it is heartless and can seem cruel, but strategic isolations, coupled with vast urban campaigns of capture of the infected constitute the only hopes for ending the state of siege.”
However, other observers contend that tough love has to supplement tough measures. “It might work,” Dr Martin S. Cetron, of the Centers for Control and Prevention. “But it has a lot of potential to go poorly if it’s not done with an ethical approach. Just letting the disease burn out and considering that the price of controlling it — we don’t live in that era anymore. And as soon as cases are under control, one should dial back the restrictions.”
More probably depends on organisation than vaccines at this stage. “The bottom line with Ebola is we know how to stop it: traditional public health,” says Tom Frieden, Director of the CDC. “Find patients, isolate and care for them; find their contacts; educate people; and strictly follow infection control in hospitals. Do those things with meticulous care and Ebola goes away.”
India’s child sex ratio (CSR) – the number of girls for every 1,000 boys under the age of 6 — has deteriorated sharply over the past 20 years, dropping to 918 in 2011 from 945 in 1991, even though levels of education and wealth have risen significantly.
The report emphasises that sex-selective abortion has decreased in traditionally problematic regions, mostly in the north, but increased significantly in other areas. In the northwestern state of Punjab, where the CSR was extremely low, the number of female children per 1,000 male children rose to 846 in 2011 from 798 in 2001.
However, in regions like Manipur, in the northeast, and Andhra Pradesh, in the southeast, the traditionally even CSR has dropped below 940.
Dr. Mary E John, author of the report and senior fellow of New Delhi’s Centre for Women’s Development Studies, argues that the decline reflects a common gender-biased family plan: “families are actually ‘planning’ to have at least one son and at most one daughter.” Dr. John suggests that parents are concerned about dependent female adults, rather than female children. Women in India are marrying later and tend to stay live at home for longer, she writes in the report.
The trajectory of gendercide is a little-know feature of the problem. When the British colonised India in the 18th century, they were shocked to discover “missing girls”. Some accounts describe villages without a single girl. In that era, the principal causes seem to have been large dowries and hypergamy, the practice of women marrying men of a higher caste. According to census figures in 1901 put the ratio was at 961 women for every 1000 men, which fell to 946 in 1951, 941 in 1961 and 930 in 1971.
Why does the ratio keep falling even as India becomes more “modern”? The report says:
… two broad claims emerge. On the supply side, as we have repeatedly seen, we have medical technologies, granted fullest agency in the hands of the aggressive radiologist who takes his mobile machine into the hinterland of rural India to vend his wares, unmindful of the criminality of such actions. Such unscrupulous practitioners in turn are being ably supported by multinational capital, and several activists have pointed to the role that companies like General Electric are playing in pushing the market for ultrasound machines, further and further, into India’s rural heartland.
On the demand side, what appears with equal frequency is, quite simply, ‘dowry’. “Like a black shadow in the wake of dowry demands, is the spread of sex selection”.
This is an extremely interesting report which sheds much light on a complex problem.
Two incidents this week show opposing responses to publicising suicides. In the US, comedian Robin Williams committed suicide, leading to an outpouring of grief by the public and horror by experts in media ethics. In Australia, controversial assisted suicide activist Dr Philip Nitschke resumed publicity for his do-it-yourself suicide kits.
The “sensational headlines” and “unnecessary detail” of media reports -- as exemplified by the New York Post's lurid page -- were slammed around the globe. Dr. Mike Jempson, lecturer at the University of the West of England, called some of the media reports “textbook examples of how not to report a suicide”:
“[Williams death] seems to have given some newspapers a green light to “go off on one” – delving into his psyche with gay abandon, detailing the precise method of his suicide, and indulging in unhelpful speculation about its causes with little regard for the grief of his family, friends and fans.”
“If we are to prevent imitative suicides all reporting must simultaneously provide the public with enough information to understand the death, while providing an image of suicide that is sensitively managed through careful reporting.”
Media ethics lecturer Douglas Chalmers suggested that the issue is systemic, and stems from an obsession with ratings and circulation, as well as a refusal to adopt existing media guidelines:
“I believe the problem cannot be placed solely at the door of the individual journalist, but rather it is due to the increasing work pressure piled upon journalists by their employers’ insistence that it is circulation, rather than consequence, that counts. Most journalists do not receive adequate training from their employers on this or other ethical questions. Many editors are also clearly failing to adopt existing guidelines although these are not new issues, and guidance has existed for many years.”
Meanwhile in Australia, Dr Nitschke, whose medical registration has been suspended because of his links to a suicide death, is openly promoting ways to commit suicide painlessly -- mostly the barbiturate Nembutol, but also asphyxiation using cylinders of nitrogen gas from a company linked to him.The Medical Board of Australia described him as "a serious risk to public health and safety".
Dr Nitschke told ABC News that he had been inundated by requests for information about suicide despite the bad publicity. However, most of his clients are just vulnerable elderly rather than vulnerable teenagers. Earlier this week he conducted a public workshopon Queensland's Sunshine Coast detailing methods of how to kill oneself.
Gennadij Raivich, a professor of perinatal medicine and neuroscience at University College London is the author of publications like “Investigation of cerebral autoregulation in the newborn piglet during anaesthesia and surgery” and “Methyl-isobutyl amiloride reduces brain Lac/NAA, cell death and microglial activation in a perinatal asphyxia mode”. There are 153 of these listed on his website.
Interestingly, 15 satisfied female “customers” from all over the country spoke in his defence, including a police officer, maths teacher and lecturer, some of whom had two and in one case three of his children via what he called “Artificial Insemination Plus”.
The details of Professor Raivich’s extracurricular activities are too seedy to relate here, but the prosecutor’s address to the jury sums up the main issues:
“You have to ask yourselves what kind of woman agrees to meet a complete stranger for AI when they do not even know his real name. Someone who is desperate and is prepared to put up with the potential embarrassment and humiliation and who have kept the details from their friends and families. A perfect victim for sexual assault, someone unlikely to complain.
“Compare the women to this defendant, someone who has traded on the fact he is a doctor and paraded his scientific knowledge, impressing them with his apparent expertise. What kind of man embarks on a breeding programme to have as many children as possible? You will have to ask yourselves if he knows as much as he claims. You may feel there is a high degree of narcissism in what he has done and is sexually motivated in some of these transactions. He provided a one stop shop for women who wanted semen. All were desperate to have a baby.”
The motivations behind assisted reproduction are often mysterious. Atavistic instincts seem to be at work, unconstrained by the social mores associated with the institution of marriage. Perhaps Professor Raivich’s polyphiloprogenitive proclivities will give a clue to future researchers.
The WHO has endorsed the use of untested Ebola interventions on patients infected with the disease.
A 12-member panel of bioethicists convened by telephone on Monday to discuss the issue.
In a press conference following the discussion, Marie-Paule Kieny, assistant director-general of the WHO, said there was consensus about the compassionate use of the drug on those infected with the virus: “[There has been] unanimous agreement among the experts that in the special circumstances of this Ebola outbreak it is ethical to offer unregistered treatments”.
The panel believed that the extent of the outbreak and the high case-fatality rate outweighed concerns about the side effects of untested treatments:
“In the particular circumstances of this outbreak, and provided certain conditions are met, the panel reached consensus that it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention.”
The two American victims of the virus, as well as Spanish victim Rev. Miguel Pajares, received an experimental anti-ebola drug called ZMapp. Pajares has since died, but the American patients are in a stable condition.
An EU investigation into criminal activity during the 1999 Kosovo war has found that a “handful” of Serbian soldiers were killed by Albanian militants for the purposes of organ trafficking.
Special Investigative Task Force chief Cliff Williamson announced the findings at a news conference in Brussels late last month.
Williamson said that “less than ten” soldiers were killed and their bodies smuggled to Albania for organ harvesting.
The fact that there were only a few victims, Williamson remarked, does not diminish the savagery of the crime: “even one person was subjected to such a horrific practice, and we believe a small number were, that is a terrible tragedy”.
He did say, however, that accusations of widespread organ harvesting have caused unnecessary trauma for families of missing soldiers.
The investigative committee does not currently have enough evidence to initiate prosecution but will continue its investigation.
The Festival will feature a range of films and documentaries. If the Walls Could Talk (1996) is a revealing trilogy of stories about unexpected pregnancies set in the same house, but with different occupants spanning over 40 years. In the teenage classic Juno (2007) an adolescent discovers she is pregnant after a one-off event with her best friend. (See trailer below.)
Following each screening there will be a discussion with an expert panel including Dr Trevor Stammers, of St Mary's University, in London, and Professor Gerard Magill of, Duquesne University, in Pittsburgh (US).
The co-ordinator, Dr Calum MacKellar, director of research for the Scottish Council on Human Bioethics, comments:
“Questions around the moral status of human embryos and foetuses have always been important to society including filmmakers. The films screened during the festival will raise important questions about the degree to which embryos should be considered, from a moral perspective, and the ethical implications that result from this.”
The worst-ever Ebola outbreak has prompted bioethical discussion on two fronts. The viral disease has killed about 1,000 people in West Africa, mostly in Guinea, Sierra Leone and Liberia. A few cases have been diagnosed in Nigeria. The chances of dying in this outbreak are about 50%. Newspapers in Western countries like the US, the UK and Australia are highlighting the possibility of their own epidemics. The World Health Organisation has declared it an international public health emergency, although it has not suggested general bans on travel or trade.
The first issue, as bioethicist Arthur Caplan points out, is that developed countries only worry about exotic diseases like Ebola when it threatens them:
“The harsh ethical truth is the Ebola epidemic happened because few people in the wealthy nations of the world cared enough to do anything about it. We do need headlines about Ebola. They should ask how did this incurable plague get out of control in Africa when medicine knows how to contain it? What are we going to do to fund research to find vaccines and treatments for diseases that don’t immediately threaten us, but kill a lot of people in far away lands? A public health policy that ends at our borders is not fair, just or even smart.”
The second is equitable distribution of a vaccine. There is no approved vaccine at the moment. A small American company, Mapp Biopharmaceutical, has been testing a vaccine called ZMapp on animals. But no one knows whether it is safe or effective on humans. Only a handful of doses at the moment and scaling up production to thousands of doses would take months.
However, two white American medical missionaries, Kent Brantly and Nancy Writebol, who contracted the disease in Africa have been given two precious doses of ZMapp and seem to be improving. Why were they chosen instead of Africans? Apparently it is regarded as good practice to treat "first responders" first because of a social responsibility to help those who help others.
"These were people who had volunteered to put themselves in harm's way to help people who were affected by this," bioethicist G. Kevin Donovan, of Georgetown University Medical Center in Washington told USA Today. "It's not unreasonable for them to have the expectation that we would try to help them."
But bioethicists are chary of manufacturing an untested drug to distribute in West Africa. ZMapp is unproven. The partial recovery of the two missionaries may have had nothing to do with the drug. Instead of curing people, it might make them worse.
The WHO has convoked a gathering to discuss the ethics of providing an untested vaccine. “We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,” says Dr Marie-Paule Kieny, of the WHO. "We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”
Some doctors have argued that African governments should make up their own minds on the ethics. Writing in the Wall Street Journal, three doctors contended that “African governments should be allowed to make informed decisions about whether or not to use these products, for example to protect and treat health-care workers who run especially high risks of infection.”
Arthur Caplan takes another tack. He favours boosting public health response in West Africa which so far has been chaotic and underfunded. “Morally, everyone is keenly interested in who should get the drug,” he told the New York Times. “But the most important moral question is, ‘What is the best thing to do to bring that outbreak to a close? And I don’t think it’s drugs.’”
This New York Times video sketches the burgeoning Chinese surrogacy industry. Although it is technically illegal, there are many loopholes and the country now has an estimated 1,000 surrogate mother brokers. The Times interviews the CEO of Baby Plan Medical Technology Company who says that his business has four branches and a track record of 300 babies.
The children are expensive: US$240,000. The Times features a surrogate from the impoverished countryside who hopes to solve her financial problems with the pregnancy. Baby Plan provides her with good medical care but sequesters her in a flat for the duration of her pregnancy. “Our liaison staff tells them every day that the baby in your stomach isn’t your baby,” says the CEO. “A nice way of putting it is emotional comfort; less nice is brainwashing.”
Most social work students probably do not imagine that their career might require them to play the pander. But finding prostitutes for disabled clients is sometimes part of the job description, even though both the legality and morality of this practice are disputed. Another voice was added this week to long-simmering debate in the pages of the Journal of Medical Ethics over this issue.
Back in 2009 Dr Jacob M. Appel, a New York psychiatrist with a flair for controversy, argued that “sexual pleasure as a fundamental right that should be available to all”. Hence, if the disabled were unable to experience this, the government should step in and provide subsidised prostitution. “As a society, we also provide food for those who cannot feed themselves—even delivering it to their homes, when required. Sexual pleasure ought not be viewed any differently.”
Dr Appel acknowledged that he supports neonatal euthanasia for severely disabled infants. However, he contends, if society has erred in allowing these children to life, it is a matter of justice to offer them the possibility of sexual pleasure.
In 2011 Dr Ezio Di Nucci, of the University of Duisburg-Essen weighed in. He agreed that severely disabled individuals should be helped to satisfy their sexual interests. But he questioned whether this should happen at the public expense. He proposed instead that “the sexual interests and needs of the severely disabled be met by charitable non-profit organisations, whose members would voluntarily and freely provide sexual pleasure to the severely disabled”. He thinks that this is superior to Appel’s proposal because, amongst other reasons, it would not require the legalisation of prostitution.
A powerful argument against providing the disabled with sexual services is that it assumes a regime of legalised prostitution – which many feel is demeaning and harmful to women. The most recent contributor to the debate, Dr Frej Klem Thomsen, of Roskilde University, in Denmark, tackles this problem. He says that the issue is complex and unclear, but that there seems to be sufficient justification for allowed a legal exception. In other words, prostitutes could service the disabled, but only the disabled.