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Medical ethics

“The Madness of Normality” – On why the DMS-5 is fundamentally wrong

The DSM (Diagnostic and Statistical Manual of Mental Disorders) is the world widely recognized classificatory system of psychiatric disorders, published by the American Psychiatric Association (APA). It is currently under major revision; the release version DSM-5 is expected in May 2013. The “psychiatrist´s bible“ has overwhelming impact: Inclusion in the DSM carries weight far beyond the psychiatrist’s office. It has major influence on whether insurers will cover therapy for a condition, whether research will be pursued for a specific disease or whether the health technology assessment agencies will approve medications that can be marketed for it.

Many interesting issues in DSM-5 could be discussed: the prevailing categories “substance abuse” and “dependence” will be substituted by “addiction and related disorders”, gender and ethnicity specific distinctions will we introduced and instead of distinguishing different entities like “Autistic disorder” or “Asperger´s disorder”, the manual introduces the term “Autism spectrum disorder”.

In this blog post, I want to focus on one particular innovation: The introduction of so-called risk syndromes. This is a collective term for all those conditions, which do not “yet” meet the “full” clinical diagnostic criteria, e.g. for schizophrenia: In this case, you would suffer from the “attenuated psychotic syndrome”. The aim is obvious: “Young people at risk for later manifestation of a psychotic disorder can be identified“. (http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=412#). This is a clear paradigm shift towards early diagnosis and prediction in psychiatry. Is this shift ethically justified?

Read More »“The Madness of Normality” – On why the DMS-5 is fundamentally wrong

Uterine transplants: applaud, and then shut up

By Charles Foster

It was reported this week that 56 year old Eva Ottosson is planning to give her 25 year old daughter, Sara, the uterus in which Sara herself gestated. Sara suffers from Mayer Rokitanksy Kustner Hauser Syndrome: she was born without a uterus.

Predictably the newspapers loved it. And, equally predictably, clever people from the world’s great universities queued up to be eloquently wise about the ethics of the proposal.

But if ethics are concerned with what we should do, there was really nothing worthwhile to be said about Eva Ottosson’s altruism (bar the usual uninteresting caveats about dangerousness and resource allocation), except: ‘Fantastic’.Read More »Uterine transplants: applaud, and then shut up

Why Wills and Kate must breed

By Charles Foster

As some may have noticed, today there is a wedding.  It has been immensely costly, and while I do not for a moment resent that expenditure, the cost has an important ethical corollary.

The money has been spent primarily to ensure dynastic continuity. By accepting our money for their Bollinger and bobbies, William and Kate are impliedly accepting our commission to use their best endeavours to breed. They have taken the People’s Shilling, and have become, first and foremost, breeding animals. Their gametes are held in trust for the nation, and they should guard them.  Kate must marinate her eggs in the finest organic nutrients that Fortnums has to offer: William must never wear tight underpants, and always wear a box when he plays cricket.Read More »Why Wills and Kate must breed

Knowing is half the battle: preconception screening

In a recently released report the UK Human Genetics Commission said there are “no specific social, ethical or legal principles” against preconception screening. If a couple may benefit from it, testing should be available so they can make informed choices. Information about this kind of testing should also be made widely available in the health system (and in school). The responses in the news have been along predictable lines, with critics warning that this is a modern version of eugenics or that it would lead to some people being stigmatized.

Read More »Knowing is half the battle: preconception screening

The Second Coming of the Placebo Treatment

The German Medical Association has recommended that doctors should sometimes make use of deceptive placebo treatments when those treatments may be more effective than pharmacologically active alternatives. This recommendation stands at odds with the position of nearly every other international medical association, including the British Medical Association and the American Medical Association, which ruled in 2007 that it would always be unethical for doctors to prescribe placebos without informing their patients.

There is a gathering controversy on the placebo issue; for a long time it has been assumed that placebo treatments are both unethical and/or ineffective, and that widespread use of placebo treatments would grievously undermine the trust between doctors and patients. But a series of recent studies has been undermining the orthodox opinion:

Read More »The Second Coming of the Placebo Treatment

Autonomy: amorphous or just impossible?

By Charles Foster

I have just finished writing a book about dignity in bioethics. Much of it was a defence against the allegation that dignity is hopelessly amorphous; feel-good philosophical window-dressing; the name we give to whatever principle gives us the answer to a bioethical conundrum that we think is right.

This allegation usually comes from the thoroughgoing autonomists – people who think that autonomy is the only principle we need. There aren’t many of them in academic ethics, but there are lots of them in the ranks of the professional guideline drafters, (look, for instance, at the GMC’s guidelines on consenting patients) and so they have an unhealthy influence on the zeitgeist.

The allegation is ironic. The idea of autonomy is hardly less amorphous. To give it any sort of backbone you have to adopt an icy, unattractive, Millian, absolutist version of autonomy. I suspect that the widespread adoption of this account is a consequence not of a reasoned conviction that this version is correct, but of a need, rooted in cognitive dissonance, to maintain faith with the fundamentalist notions that there is a single principle in bioethics, and that that principle must keep us safe from the well-documented evils of paternalism. Autonomy-worship is primarily a reaction against paternalism. Reaction is not a good way to philosophise.Read More »Autonomy: amorphous or just impossible?

Suicide for sale in Oregon: a “valuable service”?

Oregon is currently the scene of a controversy about the sale of so-called “suicide kits” or “helium hoods” (see here and here). These kits are sold by mail by a two-person company called The Gladd Group; one of its owners is reported to be a 91-year-old San Diego County woman who has been selling the kits for four years. The device is now receiving increased media attention following the suicide, with the help of the helium hood kit, of 29-year old Nick Klonoski, who had health-related issues that had brought him into depression, but was not terminally ill. His tragic death has now sparked a movement to outlaw the sale of those kits in Oregon. However, the woman selling the kits protests that she is providing a valuable service, and is quoted as saying that “[i]t is not my intention to hurt anybody, but to offer people comfort when they die”. Is the sale of those suicide kits a legitimate form of business, or should it be banned?

Read More »Suicide for sale in Oregon: a “valuable service”?

The patient vanishes

by Dominic Wilkinson

If a patient’s family refuse to allow withdrawal of breathing machines should doctors provide long-term support in an intensive care unit for a patient who is clinically brain dead? Should doctors provide heart-lung bypass (ECMO) for a child with anencephaly? Should doctors perform a tracheostomy and provide a long-term breathing machine for a patient in a documented persistent vegetative state?Read More »The patient vanishes

How to Stop the Medical Killing Spree

According to a recent study, around 350 patients die in Australian hospitals every two weeks. The figure would be expected to be much higher in the UK.

Prof Jeff Richardson, from Monash University, appropriately said, “The issue of adverse events in the Australian health system should dominate all others. However, it would be closer to the truth to describe it as Australia’s best kept secret.”

I have a personal interest in this issue. My father died as a result of a “preventable hospital error.” He was having a routine imaging procedure of his liver and bile ducts and a major artery was hit. The bleeding was not recognised til too late and he bled to death. (The autopsy report claimed he died of a heart attack! The heart eventuyally does stop when there is not enough blood.)

So what is the answer? Current debate is focussed on improving systems. Mandatory reporting of incidents, immunity from prosecution for those who report, etc.

Read More »How to Stop the Medical Killing Spree

Ethical Lessons From Locked-In Syndrome: What Is a Living Hell?

A recent important study by Stephen Laureys and colleagueson what it is like to be to experience severe brain damage has been widely reported. (eg, http://abcnews.go.com/Health/Wellness/locked-patients-life/story?id=12984627). Laureys and colleagues surveyed the views of people with “locked-in” syndrome. This syndrome, which typically occurs after certain kinds of stroke, results in the person unable to move his arms or legs and unable to speak. In some cases, they can move their eyes and communicate through eye movements but in other cases, the eyes are paralysed. They are awake and aware.

Many people would think this is a living hell, imprisoned in one’s own body, with limited if any means of communication. But Laureys et al found differently when they actually asked patients who were in this condition. According to the ABC,

“More than half of patients coping with a form of nearly complete paralysis called locked-in syndrome indicated — through eye blinks in some cases — that they were getting some satisfaction in life, though 8 percent had often thought of suicide.

“Among 65 patients who had developed the syndrome a median of eight years previously, only 18 characterized their lives as “somewhat on the bad side” or worse… Seventeen patients indicated that they felt as well, or almost as well, as in their happiest times before becoming locked-in. Another 21 gave their overall quality of life lesser but still positive marks.”

So what can we learn from this study?Read More »Ethical Lessons From Locked-In Syndrome: What Is a Living Hell?