Sunday, October 04, 2015

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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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Michael Cook
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This week in BioEdge

2015-09-28 1:34 AM
Harassment “pervasive” among Australian surgeons
by | Oct 03, 2015
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tags: Australia, bullying, sexual harassment

The late Edmund Pellegrino, the chairman of the President's Council on Bioethics under George W. Bush, was a champion of approaching bioethics through the lens of virtue ethics. A virtuous physician must also be a virtuous person, characterised  by the  character traits of courage, honesty, justice, wisdom, temperance and so on.

What would he say about the scandal which has blown up amongst Australian surgeons?

In March, a vascular surgeon, Gabrielle McMullin, made headlines when she complained about widespread sexism amongst her colleagues and about a toothless complaints mechanism. She said that she had advised surgical trainees to provide sexual favours or otherwise their career prospects would be damaged.

But the president of the Royal Australasian College of Surgeons, Professor Michael Grigg, angrily denied that there was a culture of sexual harassment. "The inference is that this is what successful female surgeons and trainees have done in the past and this is deeply insulting," he said. "Unfortunately, instances of sexual harassment and indeed bullying in general occur in society, but encouraging non-reporting serves only to perpetuate it."

However, Dr McMullin’s outburst did prompt an investigation by an “expert advisory group” which was released earlier this week. It was shocked by what it had found -- that “discrimination, bullying and sexual harassment are pervasive and serious problems in the practice of surgery in Australia and New Zealand”. It called for “a profound shift in the culture of surgery”. Although about half of fellows, trainees and international medical graduates surveyed said they had been bullied, they still believed that lodging a complaint was  "career suicide". 

The experts declared firmly that: “The status quo will not serve the future. Individually and collectively, College Fellows must recognise and commit to closing the gap between how it has been, and how it must become.”

Noble words – but this week, leaked documents from the College suggested that they may not be very effective. It turns out that Dr McMullin had made exactly the same complaint to the College seven years ago – and nothing was done. She wrote at the time:

“Granting of sexual services is probably the safest way to play it in that there will be no fuss. I have warned the women however that men have very short memories following sex and are unlikely to follow through with promises of training positions.

“Refusing sexual services is the most palatable option but is likely to lead to some grief in terms of references and reports. I have discussed, with my male colleagues, the possibility of making a complaint to the College and this suggestion has been greeted with horror and an assurance that such a complaint would mean the end of the surgical career of the trainee.

“I am well aware of these sexual politics having been through the situation myself in England. Fortunately because I left London I was able to remove myself from the adverse reaction of refusing sex. I find the situation abhorrent and would like to protect my female trainees against this behaviour. I would be very interested in your response and to how the problem might be tackled.”

Behind the scenes, a lawyer who was also then chairman of the Victorian Equal Opportunities and Human Rights Commission, was consulted about the 2008 letter from Dr McMullin. He recommended better policies, more education, an anti-harassment campaign, surveys and mentoring for victims. Nothing happened. 

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Conscientious objection under fire in Canadian hearing aid case
by | Oct 03, 2015
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tags: Canada, conscientious objection

An FM transmitter   

Most disputes over conscientious objection concern issues like abortion and euthanasia. However, a case from Canada centres on a hearing aid.

William Sears, a third-year history student at Memorial University in Newfoundland, is hearing-impaired. When he attends lectures, he asks professors to wear an FM transmitter which transmits to his hearing aids. However, to his great surprise, Ranee Panjabi, who taught a course on the history of espionage, refused on religious grounds. She is a Hindu.

“I do have certain spiritual beliefs garnered over a lifetime of travel with my diplomat parents, intense study of many religious and spiritual sources," Ms Panjabi said. However, experts on Hinduism contacted by the Canadian media were baffled. They said that there was no Hindu belief which would preclude wearing an FM transmitter.

Apparently this is a long-standing conviction of Ms Panjabi because a similar incident arose in 1996. That ended up with the University giving her an exemption from having to wear such devices.

Memorial University issued a statement acknowledging that it had a duty to accommodate students with disabilities. But in “rare circumstances such as this, where a student’s request for an accommodation engages a competing legal right, the university must determine the validity of the legal rights and seek a balance that fully respects the importance of both sets of rights.”

Commenting on the case in the Impact Ethics blog, Jackie Leach, a hearing-impaired bioethicist at Newcastle University, in the UK, argued that religious beliefs should defer to disability.

Standoffs like these are increasingly common as the claims of oppressed identity groups become more widely recognized. Aside from their direct impact on individuals, these conflicts raise important theoretical questions about rights, responsibilities, practical limits on accommodations, and the risks of exploitation that institutionalized accommodations inevitably offer (like using an oppressed identity as an excuse for behaving selfishly) …

The limits to accommodation must surely be different for an impairment that, with the best will in the world, can’t be changed. We can respect faith-based positions on a variety of issues while still recognizing that, compared to disability, religion really is more of a choice.

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Creating Lexie’s Village
by | Oct 03, 2015
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tags: designer babies, IVF, single motherhood

Natalie Lovett and Lexie / Australian Story   

IVF for single women who never found Mr Right is becoming more popular, even if it is still regarded with some misgivings. A documentary on Australian Story profiles a former Facebook executive, 46-year-old Natalie Lovett, who decided on single motherhood and a designer baby after several failed relationships.

“Have I done it all right? No. I, I’ve made so many mistakes in my life: so many. I’ve walked away from an amazing relationship in my early, late 20s because I chose career over it. Should I be punished for the rest of my life because I didn’t make the right choices at the right time? I love my nieces and nephews so much, but they weren’t my own.”

Her daughter Lexie is now about two years old.

Ms Lovett’s choice involved more work than most IVF mothers. She had to select both a sperm donor and an egg donor. The egg donor was a college student who is using her US$10,000 fee to pay her way through college. Since it is illegal to sell gametes in Australia, she resorted to an Californian clinic. She designed the embryos carefully, specifying that the donors had to have tertiary qualifications and no addictions.

An unusual twist to her story is that she discovered that the clinic had created 25 embryos for her. Reluctant to give them to science or to destroy them, she decided to advertise her “high quality embryos” to prospective mothers. But as a condition of accepting the embryo, the mother has to sign an agreement stipulating that the children and their families have to get together once a year. Her relatives call her scheme Lexie’s Village.

“ … if I can have a say in who I am donating these embryos to and who are going to be adopting these embryos, wouldn’t it be nice, considering they are Lexie’s siblings, for us to stay in touch?”

So far, according to Australian Story, three women have signed the contract.

Kate Bourne, of the Victorian Assisted Reproductive Treatment Authority, commented: “I think baby lust is very strong and very powerful. People desperately want to become parents, so will go to great lengths to travel anywhere to meet that need.”

Single motherhood is an increasingly popular option. According to statistics from the UK’s Human Fertilisation and Embryology Authority, the number of singles using IVF rose 20% between 2012 and 2013 in the UK.

Dr Marilyn Glenville, a popular British commentator on women’s health issues, told the Daily Mail that other issues are at work besides women deferring motherhood to pursue a career. Men are also reluctant to commit and are afraid of expensive divorce settlements:

“There is that feeling from men, worrying that they've built up a good income that they'd end up losing some of it - or a vast majority - should they get married and have children … that forces women to take action alone … In some ways it's sad because I think it falls in line with the feeling that men aren't needed. Obviously you can get a sperm donor - and in a way that is a shame. I can understand that it probably is easier to parent a child on your own, than have disagreements between couples, but I don't know whether it is good for the child.” 

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UK transgender woman wants to be both father and mother
by | Oct 03, 2015
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tags: gender dysphoria, new frontiers, sex reassignment, UK

Another dispatch from the Wild West of assisted reproductive technology. The third place contestant in the UK’s first Miss Transgender beauty competition wants to be the first Briton to be both father and mother of a child.

Fay Purdham, 27 (formerly Kevin McCamley) froze some of her sperm before transitioning to a woman via hormone treatments and surgery. Now she has launched a 100,000 pound crowd-funding appeal to help her engage a surrogate mother. If she is successful, she would be both the biological father and the adoptive mother. “Even before I knew I wanted to become a woman, I wanted to be a mother,” she says.

Ms Purdham first raised the possibility of changing her gender with a doctor when she was 16. At 19 she changed her name by deed poll; at 21 she embarked upon gender reassignment surgery. At the moment she has a career as a performance artist fire-breather, but she would like to be a TV presenter.

She is preparing to marry a childhood friend, Chris Dodd, 24. “It took me some time to get my head around the fact that she used to be my best friend Kevin,” he told the Daily Mail, “but I have never looked at her in any other way other than the fact she is a gorgeous woman.”

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Mexican politician suggests lethal injections for the homeless
by | Oct 03, 2015
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tags: euthanasia, Mexico

This belongs in the “ooops, I really shouldn’t have said that” department rather than serious public policy -- but if some politicians think it, others might actually do it. Olga Gutierrez Machorro, a councillor in the local government of Tecamachalco, not far from Mexico City, has suggested that homeless beggars should be put down with a lethal injection to keep them off the streets.

“Yes they’re a little crazy, but they’re harmless. Which is why I think to myself wouldn’t it be kinder to just give them a lethal injection?”

She said in an interview with the local paper Diario Cambio that this would be an improvement on “wandering around on the roads in danger of being hit or causing an accident.”

Ironically, Ms Gutierrez Machorro is the councillor responsible for the Vulnerable Groups Commission, a group which tries to find ways to help the homeless and disadvantaged. She said that she had offered her own home for the homeless, but this was obviously not a long-term solution.

More ominously, she alleged that vagrants were already being killed -- some mentally ill patients would be dumped onto highways so that they would be hit by vehicles.

The councillor’s remarks were provoked by frustration with a lack of funding for the homeless from the state government. However they caused outrage in Mexico and abroad. She has apologized for her remarks and is working on a new plan for the local government. 

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Do money and mother’s milk mix?
by | Oct 03, 2015
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tags: breast milk, commodification

© Laura Breiling / Mosaic     

Demand for human breast milk is increasing “exponentially”. What are the ethics of creating a market for it?

North America is currently home to 19 milk banks, with nine more opening their doors soon. The Human Milk Banking Association of North America, which helps to run and accredit these banks, has gone from dispensing around 400,000 ounces of pasteurised donor human milk per year in 2000 to 3.8 million ounces in 2014. John Honaman, its Executive Director, says that the rise is due to both an increase in awareness of the health benefits of breast milk and an increase in the number of preterm infants who desperately need donated milk. 

The American Academy for Pediatrics has stated: “all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”

Sharing breast milk is not new. Women have done it for millennia, letting friends’ or relatives’ hungry children nurse at their own breasts. Other times, women would hand-express their milk into pots or jars to give to families in need. And wet nurses, often impoverished or enslaved women, were often used to provide milk for wealthy children, even if it was at the expense of their ability to nurse their own. In the early 1900s, hospitals and charities began freezing and banking breast milk for sick babies.

Some parents are squeamish about giving their children milk from a stranger, but more and more neonatologists are framing it much more simply. “We tell them that this milk is medicine,” says Amy Hair, a neonatologist at Texas Children’s Hospital in Houston.

It all seems very simple. Some babies need breast milk that their mother can’t produce; other mothers are producing more than their babies need; human milk banks take the excess and give it to those in need. But as more parents and hospitals seek to use pasteurised donated milk, HMBANA banks have begun experiencing shortages. For-profit milk banking companies have sprung up, and milk can be bought and sold online, with fewer or no checks on quality or contamination. It’s becoming a lot more complicated than simply sharing.

In 2015, Sarah Keim, an epidemiologist at Ohio State University, published an analysis of 102 samples of breast milk she’d purchased online. Eleven had significant amounts of cow’s milk. “That is a concern,” she says. “We were surprised to find the extent of that problem.” Once money becomes involved, she adds, it becomes more likely that people will adulterate breast milk to make a quick buck.

But more than that, does paying for donated milk change the nature of the relationship between the women involved?

The Oregon-based company Medolac is an example of the passions that commercial milk banks can generate. 

In late 2014, the Oregon-based company had partnered with the Clinton Global Initiative to reach out specifically to low-income Detroit mothers and pay them a dollar an ounce for their breast milk. While these payments were to compensate donating mothers for their time and effort, the idea behind this particular scheme seemed to be that if cash-strapped women could make money from their milk, then more of them might breastfeed their children, if only to keep producing milk.

But Detroit breast-feeding activist Afrykayn Moon  immediately cried foul. The idea that the ability to earn money from breast milk would encourage low-income mothers to breastfeed their children was “absurd” to her.

“If I’m breastfeeding but my electric bill needs to be paid or my rent needs to be paid, or my water bill needs to be paid, and I know I can sell my milk to this company and then I can get my bills paid, well guess what I’m going to do,” she says. “I’m going sell my milk to keep my bills up, and not a drop of that milk is going to go to my child.”

With Detroit’s low rate of breastfeeding and one of the country’s highest rates of infant mortality (15 of every 1,000 children in Detroit die before their first birthday), Moon says that the city needs every last drop of breast milk. The Medolac move also brought back a sinister association to Moon. Enslaved black women were often used as wet nurses for white children, leaving them unable to provide milk for their own children.

“This is the face of slavery coming back,” she says.

Georgetown University philosopher and bioethicist Rebecca Kukla says that, while some tactics used by companies might be perceived as exploitative, there’s nothing inherently unethical about a woman selling her breast milk. “There’s a difference between what someone does out of economic necessity and what they do as a private choice to make their life work,” she says.

Blood and tissue donation work entirely on altruism; many people think breast milk should be no different. John Honaman says the Human Milk Banking Association of North America sees no place for profiting from breast milk, and thinks the system is at its best when mothers who have received donated milk decide to then donate in turn.

“If we were faithful to the needs of a community, we would always want to be in a position whereby the need is associated with the supply because you have a perfect circle,” he says. “Moms need to give, kids need to receive.”

Carrie Arnold is a freelance science writer. This article is based on her feature in Mosaic and has been published under a Creative Commons licence

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What are the bioethics of Mars exploration?
by | Oct 02, 2015
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tags: space exploration

Ridley Scott’s latest film, The Martian, opens this month. Matt Damon plays an astronaut who is left for dead on Mars after a catastrophic accident. His challenge is to survive long enough for a rescue mission to return to the Red Planet. He has to make water and air and grow plants – alone and hundreds of millions of kilometres from home. It’s 93% fresh according to Rotten Tomatoes. “A muscular storytelling masterclass, a giddy audience-pleasing thrill-ride and certainly the most purely entertaining sci-fi movie since 2013's awards-magnet Gravity,” according to the critic for the The Times (London).

It also provoked ethicist Janet D. Stemwedel to discuss in Forbes the bioethics (in a more capacious sense) of space colonisation.

  • The assumption of most science fiction is that space exploration is not simply a good idea but an imperative, and not just to save mankind, but because the urge to explore and acquire new knowledge is irrepressible.
  • Steady on, says Dr Stemwedel. There are a number of issues to be resolved. They need not stop us from going to Mars, but we must at least respond to them.
  • We might harm indigenous life forms on Mars. True, it’s unlikely that these exist in a form that we would recognise. But what if they existed in a form that we don’t recognise? “What is the moral status of life forms different enough from the ones we have on Earth that we might fail to recognize them as ‘life’ in the first place? In the interests of extreme galactic biodiversity, would there be on obligation not to harm anything that might be alive…?”
  • What are the benefits and costs of space exploration for Earthlings? “The ethical issue here is not just the magnitude of the costs of a colonization mission relative to the benefits of establishing a Mars colony. It’s also a matter of how those costs and benefits are distributed — of whether the people who bear the costs will also enjoy the benefits.”
  • Even if Mars is lifeless, should we preserve its pristine environment or can we put billboards on it to finance future expeditions? “Does a lifeless landscape have intrinsic value that places ethical obligations on us? ”
  • Does the notion of terra nullius apply to a distant and airless planet? Are we free to plunder its resources?

The Martian is science fiction at its best. But a private project, Mars One, already exists which purports to establish a colony on Mars by the year 2027 – only a decade away. For the volunteers it will be a one-way trip, so they need to have thought through all the bioethical issues.

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Is it ethical to investigate the genetic component of IQ?
by | Sep 30, 2015
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tags: gene sequencing, genetics, intelligence

With the advent of new genomic sequencing technologies, researchers around the world are working to identify genetic variants that help explain differences in intelligence. Can such findings be used to improve education for all, as some scientists believe? Or are they likely to have a chilling effect on programs meant to improve educational outcomes among disadvantaged populations? These are among the questions explored in "The Genetics of Intelligence: Ethics and the Conduct of Trustworthy Research," a special report of the leading bioethics journal,  Hastings Center Report.

The report assesses the science and explores concerns about the implications of the research and interest in applying it to education. It concludes with recommendations to ensure that the research is done in a way that is trustworthy and avoids the "vortex of classism and racism."

The special report is the product of a workshop on responsible research and the genetics of intelligence, conducted by The Hastings Center and Columbia University's Center for Research on Ethical, Legal & Social Implications of Psychiatric, Neurologic & Behavioral Genetics in collaboration with the Johns Hopkins Center for Talented Youth (CTY) and the Johns Hopkins Berman Institute of Bioethics. The workshop was led by Erik Parens, a senior research scholar at The Hastings Center, and Paul Appelbaum, director of Columbia's center, who also serve as coeditors of the special report.

The workshop and special report came about after the CTY leadership approached some bioethicists, including Parens at Hastings and Gail Geller at Hopkins, for advice on a dilemma it was facing. A research team exploring the genetic underpinnings of high intelligence asked CTY if they could recruit people already participating in an ongoing CTY research project, the "Study of Exceptional Talent." The research team wanted to ask these participants if they would donate DNA samples for genomic analysis, with the ultimate goal of using findings to help improve education for highly intelligent students.

CTY's leadership was unsure how to respond. On the one hand, it respected the research team and its goal. But it also worried about the potentially ugly implications, given that the history of scientific inquiry into the genetics of intelligence is marred by assumptions about the superiority of some groups over others.

Major questions addressed in the special report include:

  • How likely is it that gene variants with significant influence on intelligence will be identified? While research has shown that genetic variation helps to explain why people in the same population perform differently on intelligence tests, newer DNA-based studies have thus far enjoyed little success in discovering which genetic variants produce those observed differences. Some scientists are confident that new whole-genome testing technologies, applied to large numbers of people, will lead to breakthroughs in identifying which genes help to explain those differences. Others think that the needle-in-a-haystack metaphor underestimates the difficulty. They argue that the genetic influence on intelligence involves complex interactions among genes and between genes and the environment -- information that can't be gleaned merely by scanning the genomes of hundreds of thousands of people.
  • Can research into the genetics of intelligence improve education? Some scientists think that understanding which genetic variants influence intelligence can help make possible "personalized education," which would customize educational experiences to children's genomes. Others are skeptical and express concern that such research might exacerbate disparities in education opportunity by promoting the view of inherent differences in intelligence and detracting attention away from pedagogical, social, and political ways to enhance intellectual achievement.
  • Given the scientific and ethical reservations about it, should research on the genetics of intelligence proceed? Despite deep concerns, none of the commentators thought that the research should be halted. "Rather, we heard that the right response to research into the genetics of general cognitive ability was to ensure that the research is done in a way that is 'trustworthy,'" write Parens and Appelbaum in the introduction to the report.

The report makes recommendations for conducting trustworthy research on the genetics of intelligence. One recommendation is that, in the conceptualization of the project, researchers should acquire awareness of and sensitivity to the historical and social context in which they should propose to do their research. Another is that they take steps to ensure that the results are accurately represented to journalists and the public. Given the high interest in the topic of the genetics of intelligence, as well as its history of being misused, Parens and Appelbaum write in the introduction that researchers have an obligation to minimize the chances that their results "are sucked into the vortex of classism and racism."

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Michael Cook
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