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Pandemic ethics: Mild flu and Tamiflu – the patient’s dilemma

Pandemic ethics: Mild flu and Tamiflu – the patient’s dilemma

In recent days there have been reports of a jump in the number of cases of H1N1 influenza (swine flu) in the UK. There have been 29 deaths associated with pandemic influenza in the UK, and there are 652 people in hospital in England with the flu. Faced with the prospect of primary health care services becoming overwhelmed, the government has set up a telephone hotline to allow those affected by the flu to access antiviral drugs (for example oseltamivir or Tamiflu) without needing to see a doctor. But there are also suggestions that not all patients with flu-like symptoms should be treated. Patients with mild or vague symptoms of the flu, without other medical conditions that put them at particular risk, may not be given medication.

This sets up a problem for patients who develop mild flu-like symptoms. Although there is only a small chance of them becoming seriously ill or dying from the flu it is possible that early treatment with anti-virals would reduce that risk. (Antivirals were only effective in trials if given in the first 48 hours of illness) Should they demand treatment from their doctor in the hope of avoiding a serious complication of influenza? Should they exaggerate their symptoms? If the doctor refuses, should the patient self-treat with medications that they have obtained privately (for example over the internet)? There is a form of the classic prisoner’s dilemma involved in such questions.

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Arificial sperm: a woman needs a man like a fish needs a bicycle?

Professor Karim Nayernia and his team at Newcastle University produced sperm cells from embryonic stem cells (here and here)
Italian newspapers ( here and here) (English ones were more restrained here) ran articles about this research claiming that  in the next future men will be not necessary in human reproduction because it will be possible to develop sperm cells from women’s somatic cells, like skin cells.  The fact that women may, sooner or later, be able to reproduce without men’s help did not shock me too much. Reproductive human cloning should allow us to do more or less the same thing: Dolly the sheep was born in 1997, so it’s almost 12 years that we have been aware of this. 

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Does self-help make you feel worse?

A study
by Canadian researchers published in the latest issue of the journal Psychological
Science (20:7, July
2009, 860-66), as recently reported by BBC news,
discovered that people with low self-esteem paradoxically happened to feel
worse after repeating a series of positive statements about themselves. The
conclusions of this study are interesting, yet one might regret that the BBC
News headline, “Self-help ‘makes you feel worse’”, though certainly
attention-grabbing, is also rather misleading.

 

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Pandemic Vaccination: Who to Vaccinate?

Fears of the spread of pandemic influenza in the UK continue to grow. Three apparently previously healthy patients have died here. There are now plans for widespread immunisation later in the year – though initially this is likely to be restricted to those at highest risk, and those in 'vital' professions.

Who should be vaccinated? This is a question of distributive justice.

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Refusing Cochlear Implants: Is It Child Neglect?

Australian Graeme Clark developed the cochlear implant, or bionic ear, in the 1970s. It does not amplify sound but directly stimulates any functioning auditory nerves in the inner ear. The Australian Government has promised a screening program of all babies for deafness from 2011. At present, only 70 percent children who might benefit are picked up early. The earlier deafness is detected, the more effective treatment can be.

Lobby group Deaf Australia says the implant "implies that deaf people are ill or incomplete individuals, are lonely and unhappy, cannot communicate effectively with others and are all desperately searching for a cure for their condition. [This] demeans deaf people, belittles their culture and language and makes no acknowledgment of the diversity of lives deaf people lead, or their many achievements."
Some deaf parents have denied their children cochlear implants. Is this right?

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Hunger for long life: the ethics of caloric restriction experiments

This has been a good week for life extension research, with the Nature paper Rapamycin fed late in life extends lifespan in genetically heterogeneous mice by Harrison et al. (free News and Views) showing that the drug boosts lifespan in middle aged mice, and Science countering with Caloric Restriction Delays Disease Onset and Mortality in Rhesus Monkeys by Colman et al. showing that in a 20-year longitudinal study rhesus monkeys do seem to benefit from caloric restriction (CR). CR involves keeping the energy intake low, but not so low that it induces starvation.

Not everybody seems to like the experiment. The Swedish major newspaper Dagens Nyheter had an article by Per Snaprud
that appeared to criticise the monkey experiment on ethical grounds. He
quotes Mats Spångberg, chief veterinarian at the Swedish Institute for
Infectious Disease Control, who doubts the experiment would have been
approved in Sweden. The only use of monkeys in Swedish research is AIDS
vaccine research. The article concludes by stating that the virus kills
2 million people every year, 270,000 of whose are children.

But ageing kills 100,000 people worldwide each day directly or indirectly. 100% of humans and monkeys are "infected".

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Is it Worth Living Longer?

Research recently published in Nature suggests that the drug rapamycin may have the potential to extend human life span by decades: http://news.bbc.co.uk/1/hi/health/8139816.stm

If the life is of ‘positive’ value, it might seem obvious that the drug is worth taking. But not everyone would agree. The Hellenistic philosopher Epicurus famously argued that, since it marks the end of conscious life, ‘death nothing to us’. Fearing death makes as much sense as regretting you weren’t around for all that time before your birth.

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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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