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Monday, March 02, 2015

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FROM THE EDITOR

Hi there,

Even writing a short column like this one is a tough job. Those who agree with you expect more gold when the lode is nearly exhausted; those who disagree with you demand minute documentation; those who are merely curious will not return if the punctuation is sloppy. There’s a deadline and it has to be posted quickly. It can make you quite dyspeptic.

Which perhaps explains a post written by the incoming associate editor of the Journal of Medical Ethics, Brian D. Earp. An Oxford theologian, Nigel Biggars, argues in the JME that there is a place for religion in bioethics and medicine. (See below.) Fiddlesticks, says Earp. “Some people will feel a shiver go down their spines—and not only the non-religious.”

I thought for a moment that he must have been referring to the intersection of religion and cardiology documented in The Discovery And Conquest Of Mexico, by Bernal Diaz. (A fabulous read, by the way.)

"The dismal drum of Huichilobos sounded again, accompanied by conches, horns, and trumpet-like instruments. It was a terrifying sound, and when we looked at the tall cue [temple-pyramid] from which it came we saw our comrades who had been captured in Cortés defeat being dragged up the steps to be sacrificed. …Then after they had danced the papas [Aztec priests] laid them down on their backs on some narrow stones of sacrifice and, cutting open their chests, drew out their palpitating hearts which they offered to the idols before them."

But no, Earp was referring to Christianity, whose distinctive contribution to medicine, apparently, is to deny women life-saving abortions. It’s odd that he ignored the Good Samaritan ethic which gave rise to the modern hospital system and the well-documented origin of bioethics in Catholic medical ethics. And, as Biggar points out, notions of human dignity and a preferential option for the poor are grounded in Christian ethics.

If we are looking for a philosophy to animate good medical care, we could do worse than Christianity, quite a bit worse. I think that the jury is still out on whether religion-less, secular medical ethics has really been a big improvement. 

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Michael Cook
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2015-02-23 12:22 AM
More research needed on the Pill-brain nexus
by | Feb 28, 2015 |
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tags: contraceptive pill

If there is one request by patients which is universally spurned by doctors, without fear of being labelled paternalistic, it for steroids as performance-enhancing drugs. Extensive research confirms that anabolic steroids damage the liver and the heart, among other problems.  

If widespread steroid use is discouraged for men, why haven’t the neurological effects of the steroid-based contraceptive pill on women been studied as thoroughly? In a challenging article in the open source journal Frontiers in Neuroscience, three Austrian researchers argue that 50 years after its introduction, it is time to study what the pill does to the brain.

“Changes in brain structure and chemistry cause changes in cognition, emotion and personality and consequently in observable behaviors. If a majority of women use hormonal contraception, such behavioral changes could cause a shift in society dynamics. Since the pill is the major tool for population control, it is time to find out what it does to our brain…

“As the number of women using oral contraceptives constantly increases, while the age of first contraceptive use constantly decreases down to sensitive neuroplastic periods during puberty, the associated changes in personality and social behavior imply significant consequences for society.”

The article does not scaremonger, but simply sets out the state of current research and points out that there are significant gaps. 

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Does religion have a role in bioethics?
by | Feb 28, 2015 |
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tags: bioethics, religion

The notion that religious convictions have no place in medicine or bioethics is widespread and growing. After the Canadian Supreme Court recently found that euthanasia and assisted suicide are constitutional, for instance, there were immediate suggestions that doctors who refused to assist on religious grounds might have to find other employment.

Writing in the Journal of Medical Ethics, Oxford theologian Nigel Biggar argues that this is wrong. First, because it assumes that only secularity is rational. “The ideal of secular medicine as a realm of reason and therefore as untroubled by deep metaphysical and moral disagreements is a fantasy,” he says.

Second, because religion itself, or at least the Christianity which he professes, is not irrational. Respecting other beliefs, it seeks to persuade with rational arguments.

“Positively, if I, a religious believer, am going to succeed in persuading you, an agnostic or atheist or different kind of religious believer, of my moral view, then I will have to show you that your view has weaknesses or problems, that these cannot be adequately repaired in your terms, but that they can be repaired in mine.”

Does Christianity add anything to bioethical discourse? Surprisingly, perhaps for some critics of Christianity in the public square, Biggar says that its first contribution is good manners. Respect for human dignity and love for the truth, both characteristically Christian, support a style of dialogue which is even-tempered, respectful and inquiring.

More importantly, though, its distinctive views of the fatherhood of God and the Incarnation give rise to convictions which underpin much of contemporary bioethics. “One general instance of such content is a high, humanist view of human dignity, which is not an inevitable part of the cosmic furniture and which we cannot afford to take for granted. Other, more specific instances are the notions that individual autonomy is properly bounded by social obligation and a special sensitivity to the plight of the poorer and weaker.”

Stuff and nonsense, fumed Brian D. Earp, an Oxford researcher and an incoming Associate Editor at the JME. Good manners and respectful conversation are the hallmark of philosophy, not religion, and there is no God the Father to ground respect for other humans. And what about Savita*, the woman who died in Ireland because she was denied an abortion on religious grounds? “Some people will feel a shiver go down their spines—and not only the non-religious” at talk of religion having a role in medicine.

* This does not appear to be true. A 2014 inquiry by Ireland’s Health Information and Quality Authority showed that Savita’s death had nothing to do with the abortion law. It was caused by incompetence.

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Getting ahead in life
by | Feb 28, 2015 |
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tags: head transplants

Head transplants are a familiar theme in B-grade sci fi films which lends itself to an infinitude of excruciating puns. But according to an Italian scientist, it could happen within two years. Sergio Canavero of the Turin Advanced Neuromodulation Group want to use the technique to help people with degenerative diseases like ALS or whose bodies are riddled with cancer. He told New Scientist “the major hurdles, such as fusing the spinal cord and preventing the body's immune system from rejecting the head, are surmountable, and the surgery could be ready as early as 2017.”

Other scientists are sceptical. “"I don't believe it will ever work, there are too many problems with the procedure,” one neurosurgeon told NS. However, Dr Canavero plans to present his ideas at the annual conference of the American Academy of Neurological and Orthopaedic Surgeons (AANOS) in Annapolis, Maryland, in June.

The project presents both philosophical and bioethical conundrums. First of all, since the higher cognitive functions which are commonly thought to be “us” take place in the head, it is more accurate to speak of a body transplant. Would people try to extend their life by transplanting their heads onto a younger or more beautiful body? Could it be the ultimate way to lose weight?

Where would the bodies come from? Deceased donors? Euthanased donors? Altruistic donors? And it might be hard to negotiate laws which assume that a decapitated person is a dead person. A transplant might be seen as murder. Even the  optimistic Dr Canavero believes that it would be a year before the patient is walking again. 

The problems are huge, but NS shares Canavero’s optimism. “Every advance in transplantation has seemed outlandish at first, from hearts to hands to faces, but in each case, doubts have given way to appreciation.”

In fact, there have been some promising results from work on mice. According to NS, “ Xiao-Ping Ren of Harbin Medical University in China recently showed that it is possible to perform a basic head transplant in a mouse (CNS Neuroscience & Therapeutics). Ren will attempt to replicate Canavero's protocol in the next few months in mice, and monkeys.” 

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The Ice Age cometh
by Xavier Symons | Feb 28, 2015 |
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tags: cryonics, futurism, transhumanism

Cryonics – or preserving the body or brain by freezing them for resuscitation in a more technologically advanced age --  is generally regarded as science fiction. However, it is a small industry in the US, where an Arizona company, Alcor, has cryo-preserved about 80 people and 30 pets.

One bioethicist has offered a thoughtful defense of the procedure, arguing “that the potential value that it might help realize is very big” and that “there is a non-negligible, even if small, chance for success”.

In a new Journal of Medical Ethics article, ‘The case for cryonics’, University of Oslo philosopher Ole Martin Moen argues that cryonics has been unfairly dismissed as a scientific flight of fancy.

Moen argues that the technology, though perhaps still many decades away, will in principle be available to us eventually. Considering the huge potential it holds, we should invest more resources in the field. He observes:

“reviving cryopreserved persons, though it cannot be done today, does not require the development of radically new technologies; it requires further refinement and convergence of technologies that already exist.”

Moen discusses the various technological precedents that exist in current science, such as the routine freezing and thawing of human sperm, eggs and tissues.

He is cautiously enthusiastic about the possibilities that cyronic revival would open up: 

“[We would have] a non-negligible opportunity to have a significantly longer life”.

At a more confident moment in his article Moen argues that we may have a rational imperative to opt for cryonic preservation:

“It is rational to opt for a small chance of survival when the alternative is no chance at all.”

Indeed, for most people it may sound like a flight of fancy. But by Moen’s cold logic this is something to take very seriously.  

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Thailand outlaws foreign surrogacy
by Xavier Symons | Feb 28, 2015 |
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tags: surrogacy, surrogacy law, Thailand

Thailand has passed a law to outlaw the use of Thai surrogates by foreign couples.

The law, passed by the ruling junta government last week, stipulates that foreigners will be prohibited from using Thai surrogates unless they have been married to a Thai national for at least three years. The violation of the law carries a prison sentence of up to ten years.  Agents for surrogate mothers also face lengthy prison sentences.

"This law aims to stop Thai women's wombs from becoming the world's womb. This law bans foreign couples from coming to Thailand to seek commercial surrogacy services," said Wanlop Tankananurak, a member of Thailand's National Legislative Assembly.

Thailand was rocked by several surrogacy scandals last year, including allegations that an Australian couple abandoned a baby boy with Down syndrome while taking his healthy twin sister.

Another case involved a Japanese man who fathered at least 15 babies using Thai surrogates in what local media called the "baby factory".

Critics of the new law say that making commercial surrogacy illegal could push the industry underground, making it harder for patients to access quality physicians and medical care.

But some are sceptical that the legislation will even be implemented. “Law enforcement in South East Asia is famously lax”, wrote BBC correspondent Jonathan Head.

Thailand's junta, known as the National Council for Peace and Order, disbanded the upper house Senate following a May coup and placed all law-making authority in the hands of an interim parliament hand-picked by the military rulers. 

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Refugees: be vaccinated or be turned away
by Xavier Symons | Feb 28, 2015 |
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tags: consent, Pakistan, polio, public health, vaccination

In the fight to end polio, the Pakistani government has for the past year made safe-haven for internally displaced persons (IDPs) conditional on receiving polio vaccinations.

The country’s ruling party, the Pakistan Muslim League, has made polio drops mandatory for anyone leaving the country’s tribal areas – the regions in which the worst polio outbreaks have occurred. Previous voluntary vaccination programs in these regions have failed to eradicate the polio threat.

As the stakes grow higher, the authorities have chosen to prioritize public health over individual consent. A significant number of refugees refuse the vaccine and are turned back at regional checkpoints. In June last year, for example, nearly 40 trucks carrying internally displaced persons (IDPs) from North Waziristan en route to Afghanistan were turned back by the Pakistan army at the Pakistan-Afghan border. The refugees demanded that they be first provided with food and shelter before the administration of the vaccine.

Refugees often believe Taliban authorities, who claim that vaccination is a ‘Western conspiracy’ and will ‘spoil’ (i.e. render infertile) their children. This is not an entirely unfounded claim. In 2011, the CIA used a hepatitis vaccination program as a front to gather intelligence on the whereabouts of Al Qaeda leader Osama bin Laden.

The new government policy has attracted the attention of Western bioethicists. In an article in this month’s edition of the Journal of Medical Ethics, Art Caplan and David L Curry of the NYU School of Medicine argue that states have a right and a responsibility to require vaccination in instances where serious vaccine-preventable diseases threaten local populations.

“Aid can morally be made contingent on vaccination when there is direct, imminent risk to aid givers and nations from whom aid is being sought.”

Surprisingly, Caplan and Curry do not mention the CIA incident that has provided such strong support for Taliban scaremongering. 

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US states tying psychiatrists’ hands over guns
by | Feb 28, 2015 |
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tags: confidentiality, gun control, psychiatrists

After eight people were shot to death this week in rural Missouri, the debate over psychiatrists’ confidentiality in treating people with mental illness has revived. Coincidentally, the American College of Physicians, seven other national health professional organizations, and the American Bar Association, made several recommendations this week about how to decrease deaths and injuries through guns.

One of them is to “oppose state and federal mandates that interfere with physician free speech and the patient-physician relationship, including physician ‘gag laws’ that forbid physicians to discuss a patient's gun ownership.”

The idea is that even mentally-ill persons have a constitutional right to bear firearms. Several states have passed laws guaranteeing this. Florida’s law, which was passed last year, specifies that “A health care practitioner …  may not discriminate against a patient based solely upon the patient’s exercise of the constitutional right to own and possess firearms or ammunition.” Missouri passed a similar law this year.

Another recommendation is to “oppose blanket reporting laws that require physicians to report patients with mental or substance use disorders, as these laws may stigmatize the patients and inhibit them from seeking treatment.”

"These laws go too far, Steven Weinberger, executive vice president of the American College of Physicians, told New Scientist. "Blanket mental health reporting laws can have unintended consequences," he says. Such laws can discourage people from seeking mental health care, he says. "They can create a tremendous disincentive for people to get the support they need."

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British mum in bid to give birth to child of dead daughter
by Xavier Symons | Feb 28, 2015 |
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tags: ART relationships, informed consent, IVF, new frontiers

A British woman has entered a court battle so that she can give birth via IVF to the child of her dead daughter.

The daughter passed away four years ago from bowel cancer, but not before having her eggs frozen.

The mother, 59, claims that the daughter asked her to bear her baby in the event that she succumbed to cancer. The mother and her husband are now fighting to receive IVF treatment using the girl’s eggs. They claim that in receiving the treatment they will be honouring their daughter’s dying wishes.

Importantly, the objection made by the British authorities is not a matter of deep moral principles, but rather a question about whether the daughter had given express consent to the use of her eggs.

No UK-based clinic has agreed to treat the mother, so the couple have applied to export the eggs to New York – a clinic there have agreed to provide the fertility treatment at an estimated cost of up to £60,000.

The Human Fertility and Embryology Authority (HFEA) refused the couple’s application to export their daughter’s frozen eggs to America, on the grounds that she did not give clear written consent.

The deceased woman completed a form that gave consent for the eggs to be stored for use after her death, but crucially, failed to fill in a separate form that indicated how she wished the eggs to be used. This technically meant her consent became invalid.

They couple have appealed to the High Court. The case will be heard in the Administrative Court (a division of the High Court) at a date to be set.

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Michael Cook
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