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Clinical Ethics

Nudge Drugs: should the social side-effects of medications weigh into public health?

You are a public health official responsible for the purchasing of medications for the hospitals within your catchment area in the NHS. Your policies significantly affect which, out of the serpentine lists of heart disease medications, for example, are available to your patients. Today, you must choose between purchasing one of three heart disease medications: Drug A, Drug B, and Drug C. They are pretty similar in efficacy, and all three have been being used for many years. Drug B is slightly less expensive than Drug A and Drug C, but there is emerging evidence that it increases the likelihood that patients will take “bad bets,” i.e. make large gambles when the chance of winning is low (and thus might contribute to large social costs). Drug C costs a tiny bit more than Drug A, but there is some evidence that Drug C may help decrease implicit racial bias. You have been briefed on the research suggesting that implicit racial bias can lead to people making choices that consistently and unintentionally limit the opportunities of certain groups, even when all the involved parties show explicit commitments to social equality.  Finally, there is emerging evidence that drug A both helps people abstain from alcohol and dissociates negative emotional content from memories.

Which drug should you purchase?

 

Let us begin to think about this question through the lens of the idea of the “Nudge,” which has exploded onto the public sphere (and blogosphere) since Thaler and Sunstein’s published their book, “Nudge: improving decisions about health, wealth, and happiness.”   (see the blog here). I briefly and incompletely introduce nudges here, in hopes that we may soon move on to discuss the kind of “nudge drugs” our thought experiment considers.

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Rick Santorum, birth control, and “playing God”

By Brian Earp

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Rick Santorum, birth control, and “playing God”

Rick Santorum thinks that birth control is immoral. Santorum, a former Senator from Pennsylvania, is one of two human beings – if the polls have it right – likeliest to become the Republication nominee for President of the United States this election cycle.

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Obligatory Ventilation: why Elective Ventilation should not be elective

On the BBC’s Moral Maze this evening, the question of elective ventilation was discussed at some length. (For those who missed it, the program is still available here). There were several striking features of that discussion, but one argument that stood out was the argument against elective ventilation based on the importance of respecting the autonomy of patients, and the absence of consent, This has been the basis of previous ethical concerns about Elective Ventilation.

But actually, it seems to me that the consent/autonomy argument is completely upside down.* Patient autonomy provides one of the strongest arguments in favour of elective ventilation. So strong, in fact, that the proposed form of Elective Ventilation should arguably not be ‘elective’. It is morally obligatory that we embrace Elective Ventilation.Read More »Obligatory Ventilation: why Elective Ventilation should not be elective

Back from the grave: Should we allow Elective Ventilation?

Mary is 62 years old. She is brought to hospital after she collapsed suddenly at home. Her neighbour found her unconscious, and called the ambulance. When they arrived she was deeply unconscious and at risk of choking on her own secretions. They put a breathing tube in her airway, and transported her urgently to hospital.

When Mary arrives she is found to have suffered a massive stroke. A brain scan shows very severe bleeding inside her brain. In fact the picture on the scan and her clinical state is described by the x-ray specialist as ‘devastating’. She is not clinically brain dead, but there is no hope. The emergency department doctors have contacted the neurosurgical team, but they have decided not to proceed with surgery as her chance of recovery is so poor.

In Mary’s situation, the usual course of events is to contact family members urgently, to explain to them that there is nothing more that can be done, and to remove her breathing tube in the emergency department. She would be likely to die within minutes or hours. She would not be admitted to the intensive care unit – if called, the ICU team would be likely to say that she is not a “candidate” for intensive care. However, new guidance from the National Institute of Clinical Effectiveness, released late last year, and endorsed in a new British Medical Association working paper, has proposed a radical change to this usual course of events.Read More »Back from the grave: Should we allow Elective Ventilation?

10-year-old gets a tattoo, mother gets arrested

By Brian Earp

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See Brian’s most recent prior post on this blog here.

See a list of all of Brian’s previous posts here.

 

Inking arms, piercing ears, and removing foreskins: The inconsistency of parental consent laws in the State of Georgia 

Gaquan Napier watched his older brother die in Acworth, Georgia after being hit by a speeding car. He was with him in those numbing final moments. And now Gaquan wants to keep his brother close to his own heart as he picks up the pieces and moves through life: in the form of a tattoo on his upper arm. Malik (that’s his brother’s name) plus the numbers from Malik’s old basketball jersey. Rest in peace. A memorial to his sibling and best friend, whose life was cut tragically short.

Gaquan is ten years old. So he asked his mother, Chuntera Napier, about the tattoo. She was moved by the request, by the sincerity and maturity of her son’s motivations. She assented. She took Gaquan to have the remembrance he wanted etched into his arm in ink.

Now stop the presses. Chuntera was arrested last week under child cruelty laws and for being party to a crime. Someone at Gaquan’s school had seen his tattoo and tattled to the authorities. But what was the offense?

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The cost of living and the cost of dying

X, a patient with reliably diagnosed PVS, lies in a hospital bed for years, fed via a nasogastric tube. He has not, and by definition never will have, any capacity for pain, pleasure or any sort of sensation. Devoted family members come each day to sit by his bedside, but he has no idea that they are devoted, or that they exist.
It is expensive to keep him alive. He occupies a bed and consumes a good deal of nursing time.
The NHS Trust responsible for his care has a limited budget. It decides that the money spent on maintaining his merely biological life would be better spent on dialysis machines. It can, and does, justify its decision in purely utilitarian terms. It writes in the minutes of the relevant committee meeting: ‘For the money we spend keeping X alive, we can save the lives of 10 kidney patients, each of whom will have a good quality of life for many years. The QALY arithmetic makes X’s continued existence nonsensical.’Read More »The cost of living and the cost of dying

The moral case for elective caesarean section

Should a father dive into a flowing stream to aid his daughter, struggling to keep her head above water? Should a mother donate a kidney to her child with renal failure? Is it ethical for a parent to work two or three jobs so that they can pay private health insurance or school fees for their children? In all of these situations most of us would think that it is commendable for a parent to take these actions. We applaud and approve of a parent who decides to take on some personal risk, who sacrifices his or her own wellbeing and health in order to prevent a risk of serious harm to their child. It is one of the duties of a parent to do whatever they reasonably can to avoid risks  and secure benefits to their children. How morally important it is for parents to make these sacrifices depends on the balance between the risks to the child and those to the parent. But it is appropriate for a parent to give greater weight to the risks to their child than to themselves. Indeed we might well be critical of a parent who failed to do so.

What then, of a mother who decides to undergo abdominal surgery in order to reduce the risk of her child suffering brain injury, or being admitted to intensive care? Shouldn’t we also applaud this decision?Read More »The moral case for elective caesarean section

Is a child a blessing?

By Charles Foster

Three years ago Ana Mejia bore a son, Bryan Santana. To her surprise he had no arms and only one leg. I should have been warned about this, she recently told a Florida court. It was negligent not to warn me. Had I been warned, I would have had an abortion. She asked the court for $9 million compensation. The jury gave her $4.5 million.

The disability rights lobby is predictably outraged. Why, they say, should it be presumed (as it clearly is), that a disabled person’s life isn’t worth living?

If that is Ana Mejia’s presumption, then (at least in relation to a child as relatively mildly disabled as Bryan) it is plainly reprehensible. I don’t know her motivation, but I doubt that she saw it that way. Many parents in her situation (and this is a very common issue in medico-legal practice) don’t make their decisions on the basis of their child’s quality of life at all. A much commoner thought is: ‘A disabled child will disrupt my own life. One of the purposes of pre-natal screening is to enable me to decline to bring into the world a child who does not fit with my ideas about how I should be living my life.’ I will call this thought the ‘pre-natal screening default thought’ (PNSD).Read More »Is a child a blessing?

Should one have a tummy tuck?

“Beauty is a greater recommendation than any letter of introduction.”  – Arthur Schopenhauer, Aphorisms on the Wisdom of Life

As our wealth increases, more and more of us undergo cosmetic surgery: From tummy tucks, breast enlargements and nose jobs to hair transplants and face-lifts: You name it—and pay—they fix it.

Even though cosmetic surgery has grown to become a multi billion-dollar industry, it is looked at with some suspicion. Many feel that there is something superficial and, perhaps, slightly desperate about undergoing surgery for aesthetic reasons. In academia, at least, although a hair transplant and a teeth bleaching might pass, chances are that a breast enlargement would raise eyebrows.

It is not be unlikely, however, that the eyebrows in question would be both plucked and colored—for we already do quite a bit to enhance our looks. We work out, try to dress well, shave, and go to the hairdresser. We make sure we get tanned during summer. Some of us are on a diet, wear make up, or dye our hair.

Read More »Should one have a tummy tuck?