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Informed consent in the Googlesphere

Here's an interesting snippet

But there's also the fact that Google is stuffed full of people who just love to experiment on its users. For instance, Google Mail uses a very slightly different blue for links than the main search page. Its engineers wondered: would that change the ratio of clickthroughs? Is there an "ideal" blue that encourages clicks? To find out, incoming users were randomly assigned between 40 different shades of links – from blue-with-green-ish to blue-with-blue-ish. It turned out blue-ness encouraged clicks more than green-ness. Who would have guessed? And who would have cared? Google, of course, which wants to get people clicking around the net.

I take this sort of experimentation as utterly, boringly unproblematic

But on one view – this is surreptitious experimentation without consent including randomisation.

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Oxford Debates Cont’d – Opposer’s Closing Statement

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster
Closing Statement

The criterion 'self-inflicted' is unworkable in practice. One simply does not know in many cases whether a particular disease or injury is self-inflicted. Yes, there is ample evidence to show that smoking can cause lung cancer. But some lung cancers are not caused by smoking. How can medical decision-makers decide in the case of Patient A, a smoker, that her cancer is a result of her smoking?  Such matters of medical causation are notoriously hard to resolve even in the courts, with the luxury of expert evidence, unlimited time and prolonged argument from counsel.
Many illnesses are caused by a (generally mysterious) interaction of genes and environment. How does Dr. Sheehan take account of the genetic contribution? Suppose that Patient B has a familial predisposition to high cholesterol. She only discovered this in her thirties. Until then she ate a diet that would be fine in someone without her predisposition, but is dangerous in her case. She gets atherosclerosis and needs a coronary stent. Should she have one? Is her condition self-inflicted? Would Dr. Sheehan's decision about her treatment depend on whether she should, with the exercise of appropriate care (what's 'appropriate'?), have cut down on the pies earlier than she did? These questions are horrifically difficult. We can multiply them ad nauseam. They are all raised by Dr. Sheehan's purportedly straightforward criterion.

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Oxford Debates Cont’d – Proposer’s Closing Statement

Part of the debate "The NHS should not treat self-inflicted illness"
Proposer: Dr Mark Sheehan

Closing Statement

What is most difficult about topics such as this one is that there are clear intuitions on both sides. These intuitions pull against each other and tempt us to focus on extremes at either end. The solution lies in the middle, where we can respect the desire to care for all those who are suffering as well as taking seriously the network of rights and responsibilities on which society is based.

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Oxford Debates Cont’d – Opposer’s update 2

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster
Update 2

Dr. Sheehan has fairly and inevitably surrendered. The motion as it stands is wholly unarguable.

But he contends that there are still important matters to discuss. I agree. Let's look at the 'subset of extreme examples' he relies on, where it is blindingly obvious that injury has been self-inflicted. The three clearest examples are perhaps attempted suicides, injuries resulting from dangerous sports, and some road traffic accidents.

We need to start by chasing away one red herring: insurance.  Of course bungee jumpers and parachutists should be insured. Insurance is mandatory for drivers. I have no difficulty with the proposition that the NHS should recoup the cost of care from the bungee jumper's insurer. But let's suppose that the insurance company won't pay. There could be many reasons. The jumper's wife might have failed to post a letter; the tour operator, unbeknown to the jumper, might not have been on the insurer's approved list; the insurer might litigate long and hard to avoid liability on a technicality.

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How bad are heatwaves and flu epidemics?

The UK health media is currently focused on two natural threats to public health: one from swine flu, and the other from the heatwave currently affecting the country. Both flu epidemics and heatwaves frequently cause many deaths. For example, the August 2003 heatwave had a death toll in Europe of around 30,000, and a typical seasonal flu epidemic causes hundreds and thousands of deaths. Yet my impression is that, in the majority of the population, flu epidemics and heatwaves are not regarded as particularly great evils (flu pandemics, such as the current one, may be a different story).There's an obvious explanation for why they are regarded as less bad than killers such as road traffic accidents, wars and terrorism: these involve human action – and often human wrongdoing – in a way that flu epidemics and heatwaves do not. But flu epidemics and heatwaves also elicit a weaker reaction than many other natural events that typically kill far fewer people: for example, floods and earthquakes.

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Pandemic ethics: Party to the flu (or vigilante vaccination)

A public health expert has warned yesterday against the idea of swine-flu parties, arguing that it may undermine the fight against the emerging pandemic. But others, including James Delingpole in the Telegraph have embraced the idea, hoping that mild influenza now will protect against more serious illness later. Exposure parties might be thought of as a form of vigilante vaccination against influenza.

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Oxford Debates Cont’d – Opposer’s update 1

Part of the debate "The NHS should not treat self-inflicted injuries"

Opposer: Charles Foster
Update 1

It simply won't do to underplay the practical difficulties posed by this motion. The motion is not 'The NHS should not treat those illnesses which can be shown beyond any doubt to have been self-inflicted', but 'The NHS should not treat self-inflicted illness'.  The world of medical causation is simply not as straightforward as Mark Sheehan suggests. To reiterate: to prove a link in the general population between smoking and lung cancer is a very different thing from proving it in an individual patient.

There are no 'robust' or indeed any systems in the NHS for dealing with this sort of issue. Nor can there be. Questions of individual causation are argued expensively before the courts in clinical negligence cases. They are notoriously nightmarish. The same job can't be done by committees, however enlightened or well meaning.

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Oxford Debates Cont’d – Proposer’s update 1

Part of the debate "The NHS should not treat self-inflicted injuries"

Proposer: Dr Mark Sheehan
Update 1

There is a robust system in place in the NHS that grapples with questions like ours regularly. Far from these being my decisions, or the decisions of 'right-minded people', this system is open, publicly accessible, and accountable. Indeed, given the constraints, it is one of the fairest ways of making the kinds of allocation decisions that must be made.

The questions that confront NHS commissioners involve precisely the sorts of issues that concern us. They are not about whether to kill a particular individual but about how to prioritise services and allocate resources. In Foster's terms these are not decisions about whether to kill or let an individual die but decisions about which individuals to choose between. The situation is more akin to a transplantation decision where there is one liver and two potential recipients. Who should receive the liver, the child or the alcoholic? Alternatively — should the intensive care unit admit a car accident victim or a person who has just narrowly failed in their third attempt at suicide?

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Umbilical cord blood donation: opt out or work on Sundays?

Umbilical
cord blood (UCB) contains haematopoietic stem cells, which can be used for the
treatment of several lethal disorders, including leukaemia
and several types of anaemia. Other sources of haematopoietic stem cells are bone marrow and ordinary peripheral
blood. Unlike bone marrow donation, which requires general anaesthesia, UCB
donation does not cause any inconvenience or significant risks for the donor. Peripheral
blood contains very few stem cells. Another major advantage of using UCB stem
cells is that less genetic similarity is required between donor and recipient.
This increases the chance of finding a ‘match’ and thus of the transplantation
being successful.

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Oxford Debates Cont’d – Opposer’s Opening Statement

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster (Barrister & teacher of medical law and ethics at
Oxford. He is attached to the Ethox Centre and is an Associate Fellow
of Green Templeton College)
Opening Statement

'The NHS has shown the world the way to healthcare, not as a privilege to be paid for, but as a fundamental human right', proclaimed the Department of Health in 2008. 'The values of the NHS – universal, tax-funded and free at the point of need – remain as fundamental today to the NHS as they were when it was launched in 1948.'

These values are important. We abandon or dilute them at our peril.

Mark Sheehan suggests that we have to grow up: to shoulder responsibility for our own actions and omissions. Why, he asks, should society pick up the bill for my stupidity?

There are many answers. Some of them will be ventilated over the next few weeks. But here are a few:

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