Julian Savulescu’s Posts

Pandemic Ethics: Extreme Altruism in a Pandemic

Written by Julian Savulescu and Dominic Wilkinson

Cross-posted with the Journal of Medical Ethics blog

Altruism is one person sacrificing or risking his or her own interests for another’s interests. Humans, like other animals, have a tendency towards altruism. This is usually directed to members of their own group. An example is donating a kidney to a family member. This is quite risky – it involves immediate risk of death from anaesthesia or post-operative complications, and long term risk of kidney failure.

But sometimes people are altruistic towards strangers.

Altruism often involves fairly small personal sacrifices. (For example, most people donate to charity, but in countries like the UK, it is typically only a tiny proportion of their income) Where someone can cause great benefit to another person at little or no personal cost, there is an ethical obligation for them to do so. This is the Duty of Easy Rescue. A whole movement has arisen called Effective Altruism which aims to ensure that altruistic acts do as much good as possible.

Altruism can also be extreme. Some people give up their entire livelihood to work overseas for aid agencies or charities. During a pandemic, health workers may take on significant personal risk to provide front-line medical care. In times of war, people may choose to literally give their life for others of their nation.

We can define extreme altruism as an act taken for the benefit of another that involves making large life-altering or life-threatening sacrifices or personal risks.

Society’s approach to extreme altruism is inconsistent. At times of obvious societal need, it encourages it (for example, clapping on the doorstep for ‘key workers’ is in order to offer our appreciation for their altruistic assumption of great risk) or even requires it by conscription of military personnel. At times of perceived lesser need, it is discouraged or even banned. For example, in normal times people are only allowed to take part in research, even if they do so with full knowledge and for no payment, if the risk of the research is minimal, and not if the risks are similar to everyday life. In some jurisdictions, altruistic kidney donations to strangers are banned.

It is not clear why extreme altruism should be limited to national emergency. If someone is competent, knows all the relevant facts, and is thinking clearly and choosing autonomously, they should be able to sacrifice their interests or even life for others. If someone is permitted to participate in highly risky personal activities for purely personal benefit (e.g. climbing Mount Everest, base jumping, or boxing) they ought to be permitted to at least take equivalent risks for the benefit of someone else (e.g. participating in research). Just as a rational, clear thinking person who is competent should be able to sacrifice their own life through suicide for any reason, they should be able to do this for the benefit of others.

We have argued at various points for extreme altruism in medicine. In one sense, there is a constant national emergency: we are all aging and slowly dying. There is a war against aging and death: we are fighting it with medicine. And people should be able sacrifice their interests or lives in this war. 

Extreme altruism extended to COVID-19

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Pandemic Ethics: Why Lock Down of the Elderly is Not Ageist and Why Levelling Down Equality is Wrong

By Julian Savulescu and James Cameron

Cross-posted with the Journal of Medical Ethics Blog

 

Countries all around the world struggle to develop policies on how to exit the COVID-19 lockdown to restore liberty and prevent economic collapse, while also protecting public health from a resurgence of the pandemic. Hopefully, an effective vaccine or treatment will emerge, but in the meantime the strategy involves continued containment and management of limited resources.

One strategy is a staged relaxation of lockdown. This post explores whether a selective continuation of lockdown on certain groups, in this case the aged, represents unjust discrimination. The arguments extend to any group (co-morbidities, immunosuppressed, etc.) who have significantly increased risk of death.

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Pandemic Ethics: Is it right to cut corners in the search for a coronavirus cure?

By Julian Savulescu

Cross-posted from The Guardian

The race is on to find a treatment for coronavirus. This race is split between two approaches: the trialling of pre-existing drugs used for similar diseases, and the hunt for a vaccine. In both instances, important ethical decisions must be made. Is it OK to reassign a treatment that comes with side-effects? And with thousands dying from coronavirus every day, is it acceptable to cut corners in the search for a vaccine?

Read more: https://www.theguardian.com/commentisfree/2020/mar/25/search-coronavirus-cure-vaccine-pandemic

Pandemic Ethics: Who gets the ventilator in the coronavirus pandemic? These are the ethical approaches to allocating medical care

By Julian Savulescu and Dominic Wilkinson

Cross-posted from ABC Online

Imagine there are two patients with respiratory failure.

Joan is 40, normally employed with two children and no other health conditions or disabilities. Mary is 80, with severe dementia, in a nursing home.

In the Western world, doctors are gearing up for an explosion of cases of COVID-19 and with a massive shortage of medical resources, including life-saving ventilators, they are likely to be presented with dilemmas of exactly this kind.

It is undeniable that people should have an equal chance when there are sufficient resources.

But when there are limited resources, doctors do take various factors into account.

Read more: https://www.abc.net.au/news/2020-03-18/ethics-of-medical-care-ventilator-in-the-coronavirus-pandemic/12063536

Press Release: Tafida Raqeeb: Right Outcome, Wrong Reasons

Written by Professor Julian Savulescu

Dominic Wilkinson describes well the decision to allow a severely brain damaged girl, Tafida Raqeeb, to travel to Italy to continue to be kept alive with artificial ventilation.

This is the right outcome. It appears as if Tafida is insensate or unconscious. If Tafida is vegetative, continuing treatment won’t cause suffering. So it is not harmful for her to be transferred to Italy at her parent’s request. (It would also be permissible to discontinue medical treatment.)

There is some chance she might experience something, in other words that she is minimally conscious. If she is minimally conscious, doctors would have to show she is unrelievably suffering in order to discontinue treatment in her interests. That has not been demonstrated in this case.

Medicine is provided to patients in their best interests. It is not clear, at least to me, whether it is against Tafida’s interests to continue to be kept alive. Italian experts cite a number of reasons to continue to keep Tafida alive, not least to clarify prognosis and to allow parents to come to terms with the situation.

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Puberty-Blocking Drugs: The Difficulties of Conducting Ethical Research

The ethics of research trials for young people with gender dysphoria are complicated.
Billion Photos/Shutterstock

Dominic Wilkinson, University of Oxford and Julian Savulescu, University of Oxford

A recent Newsnight programme reported that a major UK puberty-blocking trial is under investigation. Doctors at a London clinic provided drugs to block the development of puberty in young adolescents with gender dysphoria, a condition where the person experiences discomfort or distress because of a mismatch between their biological sex and gender identity.

The trial began in 2011. A year after starting the drugs, the young people were apparently more likely to report thoughts of wanting to harm themselves. The worry is that perhaps the treatment they received was causing them to have these thoughts of self-harm and suicide.

One of the criticisms of the study, put forward on Newsnight, is the design. The study involved giving the drugs to a group of adolescents and monitoring the effects. However, there was no control group, that is, adolescents who did not receive the drugs. This makes it hard to be sure whether the rates of self-harming thoughts are related to the drugs, would have happened anyway, or perhaps were lower than they would have been without treatment. Continue reading

Four Lessons from the Covert Separation and Study of Triplets

Written by Julian Savulescu

Today, the Journal of the American Medical Association published an article entitled “Three Identical Strangers and The Twinning Reaction— Clarifying History and Lessons for Today From Peter Neubauer’s Twins Study” written by Leon Hoffman and Lois Oppenheim.  It provides background to a documentary, Three Identical Strangers, which gained a lot of attention earlier in the year into “the lives of Edward Galland, David Kellman, and Robert Shafran, triplet brothers who stumbled upon each other in their college years and enjoyed a brief period of celebrity before emotionally confronting the implications of their separation.” One triplet ultimately committed suicide.

The triplets were part of a covert research study by child psychiatrist Peter Neubauer who followed them up for many years to study gene-environment interactions in triplets separated at birth. The article alleges that Neuberger was wrongly blamed by the triplets and film makers for their separation at birth. The authors argue it was “Viola Bernard, then a prominent child psychiatrist from Columbia University and consultant to a now-defunct adoption agency” who was responsible for their separation because she “believed that children born of the same pregnancy and placed for adoption would fare better if they were raised by separate families.” The authors review some evidence from the child development literature at the time that supported the idea that twins or triplets would fare better if adopted, experiencing less sibling rivalry and having greater access to parental resources.

Importantly they argue that Bernard and Neubauer acted independently of each other. Moreover, the secrecy was required by laws at the time. “It was illegal at the time of the study to provide information about biological families to adoptive parents, a practice that did not begin to be modified until the late 1970s and 1980s.”

Hoffman and Oppenheim conclude:

“So the study was ethically defensible by the standards of its time—principles of informed consent and the development of institutional review boards lay in the future.10 However, these documentaries demonstrate how unsatisfactory that defense is to the study’s families who live with its legacy.

The films’ message for today’s child specialists and researchers is thus something other than their surface themes of outrage and restitution. They rather provide an unusually dramatic example of the potential for harm from human participant research, even if only observational.”

I would like to draw four other lessons from this episode.

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Responsibility Over Time And Across Agents

Rebecca Brown and Julian Savulescu

Cross-posted from the Journal of Medical Ethics blog, available here.

There is a rich literature on the philosophy of responsibility: how agents come to be responsible for certain actions or consequences; what conditions excuse people from responsibility; who counts as an ‘apt candidate’ for responsibility; how responsibility links to blameworthiness; what follows from deciding that someone is blameworthy. These questions can be asked of actions relating to health and the diseases people may suffer as a consequence. A familiar debate surrounds the provision of liver transplants (a scarce commodity) to people who suffer liver failure as a result of excessive alcohol consumption. For instance, if they are responsible for suffering liver failure, that could mean they are less deserving of a transplant than someone who suffers liver failure unrelated to alcohol consumption.

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Cross Post: Ten Ethical Flaws in the Caster Semenya Decision on Intersex in Sport

Written by Julian Savulescu, University of Oxford

File 20190508 183103 1eva5jd.jpg?ixlib=rb 1.1
Caster Semenya is legally female, was from birth raised as female and identifies as a female.
Jon Connell on flickr , CC BY-NC

Middle-distance runner Caster Semenya will need to take hormone-lowering agents, or have surgery, if she wishes to continue her career in her chosen athletic events.

The Court of Arbitration in Sport (CAS) decided last week to uphold a rule requiring athletes with certain forms of what they call “disorders of sex development” (DSD) – more commonly called “intersex” conditions – to lower their testosterone levels in order to still be eligible to compete as women in certain elite races.

The case was brought to CAS by Semenya, as she argued discrimination linked to a 2018 decision preventing some women, including herself, from competing in some female events.

This ruling is flawed. On the basis of science and ethical reasoning, there are ten reasons CAS’s decision does not stand up. Continue reading

Press Release: In Defence of Intersex Athletes

Julian Savulescu

The Court of Arbitration for Sport (CAS) has announced that multiple Olympic and World Champion runner Caster Semenya and other athletes with disorders of sex (DSD) conditions will have to take testosterone lowering agents in order to be able to compete in her events.

Reducing the testosterone levels of existing intersex female athletes is unfair and unjust.

The term intersex covers a range of conditions. While intersex athletes have raised levels of testosterone, its effect on individual performance is not clear.  Some disorders which cause intersex change the way the body responds to testosterone. For example, in Androgen Insensitivity syndrome, the testosterone receptor may be functionless or it may be partly functional. In the complete version of the disorder, although there are high levels of testosterone present, it has no effect.

As we don’t know what effect testosterone has for these athletes , setting a maximum level is sketchy because we are largely guessing from physical appearance to what extent it is affecting the body. It is not very scientific. We simply don’t know how much advantage some intersex athletes are getting even from apparently high levels of testosterone. Continue reading

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