The virtuous surgeon

There is a hoary medical joke which runs: “What is the difference between God and a surgeon? God does not think he is a surgeon.” Perhaps there is a bit of truth in the implication that surgeons tend to be brash and bullying. Certainly the disturbing allegations made against Australian surgeons bear it out, as we report in our lead story.

After some appalling reports of sexual harassment by surgeons hit the media, the surgeons’ professional body asked a group of eminent experts to investigate. They found that “discrimination, bullying and sexual harassment are pervasive and serious problems in the practice of surgery in Australia and New Zealand” and called for “a profound shift in the culture of surgery”.

A noble goal, indeed, but how will it be achieved? By creating new lists of standards and writing more reports? The most natural way, surely, is to make character, not just competence, part of medical training. Unless surgeons are virtuous, in the old-fashioned sense of the word, I suspect that it will be impossible to eliminate this seedy behaviour.  

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Is there a “right” to euthanasia?

Milou de Moor committed suicide after her doctor refused to euthanize her.    

When it comes to lawsuits, doctors are extremely gun-shy. Their business is healing people, not lining the pockets of lawyers. That's why the fall-out from a euthanasia case in the Netherlands may be highly significant.

As you can read in this week's BioEdge, a family doctor refused to sign off on the euthanasia of a 19-year-old woman suffering from lupus-related depression, so the teenager committed suicide. Her bereaved family believes that she was denied the right to a peaceful death and has brought the case to a disciplinary tribunal. 

If the doctor is censured, will this effectively lead to euthanasia on demand in the Netherlands? Rather than fight to have their professional judgement respected, I'll bet that most doctors will just rubberstamp every request that passes across their desks. It will be interesting which the Dutch respect more: the informed consent of the patient or the informed consent of the doctor. 

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Euthanasia for unbearable mental suffering in Belgium

Euthanasia in Belgium is an increasingly popular subject for documentaries. The latest comes from Dateline, a program of Australia’s SBS network. (See the video below). Journalist Brett Mason interviews several people who have featured in BioEdge reports over the years. But the main focus is on Simona, an 85-year-old woman whose only reason for requesting death is grief over the sudden death of a beloved daughter.

“It was, without question, the most difficult day I’ve had as a journalist,” he told Daily Mail Australia. “As a foreign correspondent, I’ve seen a lot of people dying. I’ve witnessed a lot of final moments. All of those people, I remember very clearly, didn’t want to die. They had something to live for, something they feared losing.

“What I struggled with most, was that despite being in near perfect physical health, Simona believed she had nothing and no one in her life worth living for,” he said.

Simona is adamant that she wants to die. “I don’t have to justify myself to anyone,” she says defiantly. However, it seems like a pretty miserable way to depart. A doctor, a friend, a nurse, a journalist and a cameraman at her bedside – no relatives. She drinks a lethal dose, asks to put her feet up and dies. It is a scene which will make anyone ask whether Belgian doctors understand what compassion for the vulnerable, the disabled and the elderly means. 

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UK Parliament votes against assisted dying

Too often I have described the deliberations of the British Parliament – most legislatures, really – as an Olympic stadium for windy blatherskite. This is unfair, especially in London, for there are occasions when the honourable members rise to the occasion and deliver excellent speeches. Such was the case on Friday when 85 MPs debated the merits of assisted suicide. The outcome was a resounding defeat for the Yes campaigners; the vote was 330 votes to 118 against a bill presented by Rob Marris, a Labour MP.

However, the quality was outstanding, on both sides of the issue. The former Director of Public Prosecutions, Sir Keir Starmer, revealed his reasons for not prosecuting 79 of the 80 cases of assisted suicide which came before him. This was highly informative, as it could be argued that the guidelines he issued were tantamount to stealth legalisation of helping a loved one to die.  

A number of MPs had accompanied parents or spouses through their last days or were doctors who had rich experience in dealing with dying patients.

I found the speech of Nadine Dorries, a former nurse, particularly interesting, as it confirmed me in my impression that opponents to the right-to-die are not all fuddy-duddies and ideologues. This colourful MP was once described as “a tropical bird in amongst all that dull, grey plumage on the Commons benches”. I particularly relished her cheek in ignoring the dull, grey plumage and participating in a reality TV show called “I'm a Celebrity...Get Me Out of Here!” She was suspended from the Conservative Party for several months over that. 

Anyhow, her speech concluded with a cogent warning about government involvement in assisted dying:

There are people all over the country who do not have a family member or relative as their next of kin. They do not have loved ones. For them, the next of kin is the state. It sends a shiver of fear down my spine to think that such a Bill might be legislated for and approved when so many people who are protected by the law may not have such protection in future because their next of kin is the state. When they feel that they are a burden or they feel under pressure, who will coerce them and who will feel the budgetary constraints involved in looking after them? 

That sums up many of my concerns, as well. 

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The Lancet and assisted dying

At long last, Richard Horton, editor-in-chief of The Lancet, appears to have made up his mind about whether to support “assisted dying” in the United Kingdom.

As he points out in a comment this week, “Careful readers of The Lancet may have noticed that we have had little to say about assisted dying (or physician-assisted suicide) in recent years. Moral cowardice? Perhaps more that we couldn't easily make our minds up.”

A ringing endorsement of a private member’s bill to be introduced this week Dr Horton’s comment is not. But in his carefully worded assessment of its safeguards he rings no alarm bells and he underscores a “growing consensus” on the issue. Altogether, it is a world away from his position in 2006. Back then, commenting on another assisted dying bill, he wrote: “A commitment to life may present troubling dilemmas to the modern physician; but a commitment to death will undermine the very nature of doctoring itself.”

Editors are free to change their minds without explaining why. Unhappily, this is not a courtesy that Dr Horton extended to Baroness Ilora Finlay, whom he describes as “the most high-profile campaigner against assisted dying” in the UK. Baroness Finlay is the immediate past president of the British Medical Association and a leading palliative care physician. She obviously knows more than most of us about death and dying.

Yet Dr Horton slyly suggests that the real reason why she opposes assisted dying is her religious beliefs. “Some of those resisting changes to the law do so by deliberately using speculative and misleading arguments—‘fibbing for God’,” he writes.

Funny about that. In her eloquent essay against assisted dying in The Economist earlier this year, Baroness Finlay put forward powerful arguments. I have no idea what her religious beliefs are, but they weren’t needed to make her case.

If the sharpest arrow in Dr Horton’s quiver is to insinuate that his opponents are insincere and tainted by faith, his others must be blunt indeed. Personally, I can't understand this prurient interest in people's religious lives. Arguments stand or fall on their merits, not on supposed links to extramural activities. One might as well attribute Sartre's atheism to his chain-smoking or Berkeley's idealism to his chronic constipation. 

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Interview with Julian Savulescu

Twitter has just expanded its character limit from 140 to 10,000 for direct messages. Yay Smile. However, this is only for DMs, not for public tweets Frown. Which means that for the foreseeable future, Twitter will not be the ideal medium for debating contentious bioethical issues. In 140 characters there is not much room for nuance or complexity. 

Which means that bioethics journals, which have a much bigger characer limit, still have a role to play. In our lead story today Xavier Symons interviews the editor of the Journal of Medical Ethics, Julian Savulescu, who is also a professor at Oxford. He says that the internet has made his job harder. 

"What I have learnt is that it is not Big Brother who is watching, but everyone. In the current era, everything that is published can be instantly accessed by nearly everyone. Ethicists have to be prepared for titles and one-liners to be pumped around the internet. You have to be prepared to defend what you have written or published against the harshest criticism."

It's a fascinating conversation. Check it out. 

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V is for victory for pink Viagra

This week the FDA approved the controversial drug Addyi, aka "pink Viagra". This wonder drug is supposed to be a treatment for a condition whose latest name is “hypoactive sexual desire disorder”. It has also been dubbed "female sexual dysfunction" and "female sexual arousal disorder". Its manufacturer claims that 1 in 10 women sufffer from HSDD. But critics say that drug companies are exploiting women's anxieties. 

"Approval of Addyi could see widespread overprescribing of a drug with marginal benefits and real safety concerns," says Ray Moynihan, a campaigner against the medicalisation of normal human behaviour. One of the most trenchant critics of the medicalization of women's sexual issues is Leonore Tiefer, a psychologist at New York University School of Medicine. She suspects that demand for the drug has been manufactured: 

"People fed a myth that sex is 'natural'—that is, a matter of automatic and unlearned biological function—at the same time as they expect high levels of performance and enduring pleasure, are likely to look for simple solutions. This sets the stage for disease mongering, a process that encourages the conversion of socially created anxiety into medical diagnoses suitable for pharmacological treatment."

Has the cause of women's rights taken a big step forward, as the manufacturer alleges, or are women going to be drawn even further into the nets of a pharmaceutical company whose sales pitch is that happiness depends on regular consumption of its product? What do you think? 

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Splurging on euthanasia

Apologies! Apologies! Nearly everything in this week's newsletter revolves around euthanasia. It was not planned that way; it just happened. However, some important new data has been published about the Netherlands and Belgium which are of great interest. 

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Remembering Nagasaki

A survivor prays at Nagasaki   

I am afraid that the newsletter is late. I hope that we will return to our normal schedule next week. However, the small delay means that our publication date is August 9, the 70th anniversary of the dropping of the atomic bomb on Nagasaki.

It has always amazed me that the ethical debate over the bomb has not advanced much since 1945. For most people, the moral reasoning was, and is, pretty simple. Hundreds of thousands of American lives were saved, so shut up. As an example, a popular conservative American website published an article last week about Hiroshima and Nagasaki. “Japan deserved to be nuked and it deserved it ten times over,” wrote columnist John Hawkins. “They needed to be stopped by any means necessary, that’s exactly what we did and the world, INCLUDING JAPAN, is a much better place for it.”

This is a fine example of consequentialist reasoning: it is ethical because it worked. But consequentialism is a double-edged sword. If foetal stem cells work, using tissue from aborted foetuses must be ethical, too. I wonder if defenders of the bomb connect the dots.

The Japanese regime was brutal. But so was the United States. The number of Japanese who died in Hiroshima and Nagasaki was about 250,000 – more than twice the number of American soldiers who died in the whole war in the Pacific (106,000). Nearly all of them were civilians, including 3,000 American citizens of Japanese ancestry who had been caught in Japan at the beginning of the war. Nowadays, we call attacks on innocent civilians terrorism.

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Journalistic ethics at work

A team of a team of undercover freelance investigative journalists called the Center for Medical Progress has been making life miserable for abortion provider Planned Parenthood over the past few weeks (while we were on holiday, sorry about the gap in coverage).

In a recent editorial the New York Times accused this unknown group of being, um, journalists. “The Center for Medical Progress video campaign is a dishonest attempt to make legal, voluntary and potentially lifesaving tissue donations appear nefarious and illegal.”

Well, actually, that’s not quite the case. It’s an attempt to see whether the donations are in fact legal and voluntary. Journalists tend to do that sort of thing. Being sceptical about bland reassurances from organisations with budgets of over $1 billion is kind of part of their job description.

This clothespeg-on-the-nose attitude is odd for a newspaper whose motto is “All the News That’s Fit to Print”. And even odder for a newspaper which defied the President of the United States by publishing revelations obtained illegally by whistleblower Edward Snowden. It editorialised at the time:

“Mr. Snowden was clearly justified in believing that the only way to blow the whistle on this kind of intelligence-gathering was to expose it to the public and let the resulting furor do the work his superiors would not.”

Large organisations like the National Security Agency, Phillip Morris or the Galleon Hedge Fund tend to deny that they ever have done, are doing or ever will do anything which is nefarious and illegal. That’s what their public relations staff are paid to say. What is extraordinary is that America’s paper of record has become an unpaid extension of Planned Parenthood’s PR office.

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