Tuesday, February 28, 2012

Globally embarrassing bioethics

February continues to be a trying month in bioethics circles. This week we have a firestorm concerning an article published a couple of days ago in the Journal of Medical Ethics, entitled After-Birth Abortion: Why Should the Baby Live? The authors Alberto Giubilini and Francesca Minerva argue that as a matter of consistency, if we accept that fetuses can be aborted for certain reasons (severe abnormality, psychological or financial burden on the family) then we must rationally accept that newborns can be put to death for the same reasons, because both fetuses and newborns have the same moral status as non-persons. Reactions from non-fans of infanticide have been swift and ugly, with the usual accusations of Nazism and dire assessments of where the world is headed when intellectual life is not constrained by religious faith. Editors at the JME, laughably, act as if shocked by all the fuss, as if they seriously expected all readers to receive the paper in a spirit of cool, robotic detachment.

What I found surprising about the paper was how old the main arguments are. Check the references: the philosophical papers cited are all between 20 and 30 years old. Peter Singer and Michael Tooley made the same basic arguments with the same basic premises and with the same rationalistic mindset. So it is not clear why what makes this paper especially publishable, unless the publishers were thinking the time was ripe for stirring up the culture wars (yet again) with a big, fat stick.

But the editors at JME are right that it would be good, ultimately, have a reasoned debate about the article's content. There is plenty in the article to question, including the key premises that our attitudes towards persons is based on their possession of mental capacities (especially their ability to plan for the future) and the idea that our moral sentiments (including our feelings towards newborns) ought or can as a general rule be governed solely by logic and consistency. Those outraged by the Giubilini and Minerva article should take some consolation in the fact that those old arguments by Singer and Tooley did not exactly popularize infanticide, even among other academics. To the extent that the new article has a shock value, the old article has had little effect on common morality.

There is another concern, though: how this all looks to those outside North America and Western Europe, the traditional bastions of bioethics. High-minded arguments in favor of dispatching unwanted babies (and other non-persons) setting off a torrent of mud-slinging and breast-beating. Bioethics: so that's how you do it.

Update: the Journal of Medical Ethics Blog has published some further responses to the paper by Giubilini and Minerva in an apparent effort to open reasoned dialogue on the subject. Giubilini and Minerva have published an open letter to clarify their position, interestingly claiming that they only meant their audience to be other bioethicists familiar with abortion/infanticide debates, emphasizing that they were only making an academic argument, without any practical implications for policy, law, or for what people ought to do.

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Saturday, February 25, 2012

Research ethics committees in developing countries: something old, something new

February has been a rough month for bioethics in the USA. Alleged conflicts of interest at the American Journal of Bioethics -- the top ranked bioethics journal -- has lead to a kind of feeding frenzy of accusation, distain and soul-searching in regard to the whole idea of bioethics and how it is practiced in it's most powerful home. Is bioethics a lousy kind of philosophy? Does it just consist in rationalizing the newest biotechnology that comes along, and running intellectual roughshod over whatever traditional values (often religious) might be threatened by that technology? Is that why bioethicists are lured to agencies and institutions that are part of one might call the military-industrial-university-biotech-pharma complex? Is bioethics losing ability to speak truth to power, because they are part of (or eating hors d'oeuvres with) the 1%?

Perhaps on another occasion there will be room for reflection about whether all this should be a cautionary tale for bioethics in other countries in the world, how much of it is true, and how much of it is overblown to serve the interests of other agendas. For my part, I have been lying low, staying away from bioethics news, and looking at what other journals have been putting out. A recent research ethics article in the Journal of Medical Ethics caught my eye, called 'Ethical Approval in Developing Countries is not an Option' (Online First, requiring subscription, goddammit).

What struck me initially was the obviousness of the title: how is that news? It is like having an article called 'Eating people: some arguments against'. And in a certain way, the point of the article is obvious: when there is an appropriate body in developing countries to review human subjects research conducted by anyone (local or from abroad), then it should be reviewed. The authors cite a published article about research conducted in Nepal, which did not have local Nepalese research ethics committee approval. It doesn't sound like a very risky study, but that is not the point. Nepal has an ethics committee that could have reviewed it, and it was not even submitted.

What makes the article publication-worthy are the underlying issues. Central among them is who should have ensured that the study was submitted to local review. Ethics committees are not detective agencies, who scour the community to find out who is doing research on what. Researchers have to volunteer this information; they also have to know that there is a committee to submit their research to. In many developing countries, this is not straightforward: in some settings, research ethics committees may not exist; where they exist, they may only review certain kinds of (biomedical) studies; and even if they do exist and they could review a certain study, getting information about them and their procedures can be unreasonably taxing for scientists. Compounding the problems, some committees may be dysfunctional and intolerably slow, undermining motivations to bother looking for them.

Perhaps if a study is conducted by a developed world institution, their own research ethics committee should ensure that scientists make good faith efforts to get their research reviewed where it will be conducted, or help them get it reviewed. Or journals should not publish articles in which researchers failed to get their research reviewed where it really is human subjects research, and there really is an adequate body that can appropriately assess its ethics. The authors rightly point out that if researchers from Nepal were to do a research study in the UK or USA, but only sought ethics approval for it in Nepal, and published it, this would be considered scandalous -- but when developed world institutions do the same in the developing world, there is far less concern, even when committee members do not know much more about Nepal than Everest expeditions.

So it is not news that local ethics committee review in developing world ought to be reviewed; the news is how this requirement continues to fall through the gaps.

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Wednesday, February 01, 2012

Foreskins, clamps, and stabbings

Part of the interest in getting Google Alerts, at least as far as I am concerned, is that they provide diverse (if not surreally clashing) news items about the same topic. This week, I received a couple of links about male circumcision as HIV prevention strategy in low-resource, high HIV prevalence countries. A few years ago, three randomized controlled trials in Africa indicated that being circumcised significantly reduced risk of female-to-male HIV transmission. Male circumcision was then all the rage for awhile, but soon slipped off the front pages as it passed from 'research innovation' to 'yet another intervention to be implemented.'

Some countries in Africa are making male circumcision part of their HIV prevention strategy, though informing/convincing men to have their foreskins removed for this purpose, and actually getting it done, has proven slow going. There is some movement to change this. The New York Times has an article about new methods to speed the process of circumcision, complete with pictures of what to the untrained eye look (predictably?) like cock rings of a fairly utilitarian sort. The most promising of these devices seems to be the PrePex, which basically involves putting a ring around your Johnson, and cutting off blood circulation to the foreskin, until the latter comes off 'like a fingernail' as one proponent so sensitively put it. Apparently the clinical trials on male circumcision and HIV gave birth to a growing industry in foreskin removing clamps, from China's somewhat sinister sounding Shang Ring to the exoticism of the Turkish Ali's Klamp, to the device that terrorized many a South African penis a few short years ago, the infamous Malaysian Tara KLamp. That is the new story: which plastic gadget most cost-effectively whips off the African foreskin?

The other story on my Google Alert really goes in another direction. The Citizen, a Tanzanian newspaper has an item entitled 'One Hacked to Death in Male Circumcision Confrontation'. Apparently traditionalists in Tanzania are (very) opposed to the idea of medicalizing male circumcision and treating it similarly to an appendectomy; after all, circumcision in Africa is commonly viewed as a rite of passage for males, where the pain of circumcision is part of its meaning, and the act is part of a ritual performed by traditional practitioners. A crowd of those who have this 'old school' view of male circumcision confronted someone who was treating it more as a medical, disease prevention intervention, and things got ugly. Modernity meets tradition. So the clinical trials on HIV and male circumcision have not only given rise to plastic gadgets, but also some measure of inter-tribal conflict.

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