Monday, May 18, 2015

Desperate patients campaigning publicly for living donor organs

Interesting debate in Canada this week. The short version is this: reportedly wealthy, well-liked owner of Ottawa Senators needs urgently a liver transplant. He (well, his friends, but that's beside the point) uses his means (access to mass media) to campaign publicly for a living donor organ donation. Within a few days there's hundreds potential donors, reportedly money isn't changing hands, but who knows. The hospital where he is being prepared for surgery says that he's likely to receive his - hopefully - life preserving transplant some time this week. The transplant success rate is anywhere between 85%-90%.

Naturally the media and the usual-suspect ethicists got all fired up about rich folks 'jumping the queue' of people waiting for transplant organs, and the ethics of it all.

I thought it might be good to sort thru some of the issues here.

The Canadian Liver Foundation published an instructive background report in 2013 that I do recommend to your attention. Reportedly, in Canada, about 5,000 patients die annually while waiting for liver transplants, tendency: numbers rising. About 400 patients receive successful transplants, roughly every third patient waiting for a liver transplant dies because there are insufficient numbers of donors. Importantly, living donor donations (relatives, friends, otherwise altruistic others) don't actually affect people on the mentioned waiting lists directly, because these waiting lists are for people waiting for donations from deceased donors (ie folks who signed up to be organ donors in case of their demise) . If you manage to coax your workmate or a suitable relative into donating bits and pieces of their liver you will likely be able to live, unlike many of those who fail to do so and who keep on languishing on our waiting lists. Living donors regenerate their livers within a few months, the surgery is reportedly a relatively unproblematic, it's a low-risk procedure requiring of you to take a few weeks off work. So, it is a sacrifice, but not a major sacrifice, considering that human lives are at stake.

When you look at the Ottawa club owner's situation, it's not clear that he is guilty of any objectionable behaviour. Those folks who responded to his plea would not have donated to random others, they wanted to help him. Reportedly he is 'well liked'. Nobody stuck on a waiting list was any worse off as a result of his high-profile attempt at getting his hands on a living donor liver.

What is problematic isn't so much this individual's response, what is objectionable is a system that gives rise to such responses. While clinical need is a reasonable prioritisation and triage criterion, 'whoever shouts loudest' or is 'most likeable' are not ethically defensible selection criteria. And yet, if 'whoever shouts loudest' does not affect the existing waiting list negatively, it seems to me that there is no good reason for people not to try to 'shout loudest' given that their survival depends on it.

What ought to be criticised is the lack of available transplant organs that gives rise to such activities. Here much could be done to improve our current status quo, an immediately available strategy could be to switch our donation systems to an opt-out or presumed consent system. This is known to increase available transplant organs significantly. We should investigate the possibility of incentivising potential organ donors financially. There are various questions that need to be answered prior to implementing payments for organs, among them concerns about the exploitation of vulnerable, impoverished people as well as what the actual impact of such incentives would be on the availability of transplant organs.

Tuesday, May 05, 2015

Australian Academics' Confused Responses to Sacking of Medical Journal of Australia Editor

The Board of the Australian Medical Association (AMA) fired yet another Editor in Chief of its flagship publication, the Medical Journal of Australia.  Australian public health icon Stephen Leeder is the latest victim of the AMA's shenanigans. The MJA, like the Canadian Medical Association Journal, is by and large an also-run kind of academic publication. Doctors in those countries get a free copy by virtue of their membership in the association, it's doubtful that they do much more than check job ads and perhaps read the odd editorial during a break. Nobody would seriously expect cutting edge medical research findings of international significance published in these sorts of publication. However, they do serve an important role as regional medical publications.

Often these journals are run in manners that can best be described as unprofessional, by the associations that own them. There are plenty of examples of interference with the editorial independence of editors by these associations, the half-life of editors appointed by them is typically low, too.

For some reason good people continue to apply for these positions, only to be shafted at the next unexpected opportunity. What happened this time around? Apparently the AMA, behind Leeder's back, decided to outsource the production of the journal to international publishing behemoth Elsevier. Elsevier is publisher of illustrious publications among medical journals that you will have actually heard of before, such as for instance The Lancet. Like most international publishing houses Elsevier has a dreadful reputation among academics, mostly for its price gauging (ask your librarian in case you have doubts about this claim), but also for a range of deeply unethical activities such as creating fake medical journals to promote particular drugs for pharmaceutical companies.

It is not at all unreasonable for Leeder to not want to be involved with Elsevier and leave (or get fired by the AMA if he refuses to leave). The same is true for the members of the journal's Editorial Advisory Committee who also resigned bar one (someone looking for an Editor-in-Chief job by any chance?). And yes, Leeder had good reason to question  the decision and should have resigned in a huff over the shenanigans that happened mostly behind his back. Folks are also correct to be upset about the AMA's decision to go to bed with Elsevier, of all commercial publishers that would have been willing to take over the production of the journal. Fair enough criticism.

For some reason in Down Under this is also debated as a threat to editorial independence. Reports the Sydney Morning Herald, 'one of the signatories, Professor Gary Wittert, the head of medicine at Adelaide University, said AMPCo's track record in sacking editors, including Dr Annette Katelaris in 2012, and its commercial arrangements with Elsevier "does not inspire confidence in editorial independence".' This charge clearly doesn't stick. As of today there is no evidence that Elsevier interferes with the editorial independence (ie the published content) of its editors. It is as simple as that.

A bunch of Australian academics that wrote to the AMA Board to criticise the decision also lamented that The Lancet has published a controversial piece about goings-on in Gaza as well as a controversial paper on vaccines and autism that it failed to retract for about a decade. That is about as bizarre a complaint as it gets. Here the publisher is in effect held accountable for non-interference with its journal editor's editorial independence, and that is also held against it by these academics. Medical journal editors in days gone by were crusaders for particular causes (in the current Lancet editor's case it's global health), and they were expected to write and publish sharply worded editorials with a view to changing the world of health. In this instance Australian academics think that's another reason why the AMA called it wrongly, they don't want to see their journal being produced by a publisher that respects its editors doing precisely that. In any case, it is worth repeating that Elsevier wouldn't even have that sort of oversight in the case of the MJA, because it's not that the journal is being sold to the company, only its production is outsourced to it.

The owners of journals are well within their rights to change the production modi of their journals. They can even outsource the production to international publishing houses (eg in bioethics the Hastings Center's Hastings Center Report is these days produced to some extent by Wiley, with zero impact on the publication's editorial independence). Editors are well within their rights to protest such decisions and to resign (or face the chop) if they ultimately do not wish to go along with such commercial decisions. A threat to editorial independence such decisions are not.

One would expect senior academics to appreciate these differences.

Sunday, May 03, 2015

Treatment resistant depression and access to assisted dying

I have long been in favour of offering access to assisted dying to competent people suffering from treatment resistant major depressive disorder. Other than the occasional newspaper column or blog entry I didn't have time to actually write a proper peer reviewed paper on the issue. Well, that's finally rectified. It came out yesterday. I jointly authored it with Suzanne van de Vathorst of Amsterdam University's Medical Centre. Here's the abstract:

Competent patients suffering from treatment-resistant depressive disorder should be treated no different in the context of assisted dying to other patients suffering from chronic conditions that render their lives permanently not worth living to them. Jurisdictions that are considering, or that have, decriminalised assisted dying are discriminating unfairly against patients suffering from treatment-resistant depression if they exclude such patients from the class of citizens entitled to receive assistance in dying.

Sam Harris vs Noam Chomsky - atheist writer in search of a cause?

It was one of those Facebook moments, I saw a link to Sam Harris' website promising an exchange between him and Noam Chomsky. I thought that that would likely be an odd conversation to have. Here's a neuroscientist who essentially wrote one short - but bestselling - atheist polemic that I enjoyed reading a great deal. Then came a dreadful book on how science can determine human values and I didn't bother reading whatever he produced since then. Well, then there's Noam Chomsky. You will know (of) Noam Chomsky. He doesn't need an introduction. Love him or loathe him, unlike Harris he is one of America's foremost intellectuals.

I have come to know Chomsky as an invariably courteous correspondent who takes the time to reply to emails even while being overwhelmed with many other competing demands on his time. I couldn't believe - and I encourage you to read the beginning of Harris' exchange with Chomsky - Harris approach to this exchange. You would have thought that there would have been a mutual interest on both sides to have a public debate with a view to publishing the content of that debate.

Nothing could be further from the truth. Harris tells Chomsky that there are purported millions of followers both have that would just appreciate this debate. Chomsky doesn't clearly care one way or another. I must say, I have never heard such nonsense before. I can't wait for Harris to write to the Pope with a similar declaration, insisting that the Pope just must reply to him, because both men have millions of followers that can't wait to read said exchange.

Anyhow, I wasn't surprised to see Chomsky being too polite to tell Harris to go away and leave him alone (he tried initially, but being the guy he is, he eventually relents and engages Harris). Harris, ever keen on publicity, writes early on that he wants Chomsky to reply in such a way that the exchange can be published. Chomsky says 'no', it's one thing to agree to an informal email forth-n-back with someone harassing you for replies, it's quite another to see that published. Well, to cut a long (email conversation) short, Harris eventually coaxes Chomsky into agreeing to let him publish the exchange on his website.  You can tell, Chomsky mostly wants to end the conversation, so he succumbs to Harris bugging him, in order to move on with his actual work, rather than indulge Harris any longer.

I can't help but wonder what Harris' next publicity stunt will look like. My bet, Harris emails Pope. Dreadul, just dreadful. I finally got the meaning of 'people full of themselves'. It tells you all that you need to know about Harris that he chose to actually publish this exchange.

Tuesday, April 14, 2015

The trouble with international ethics guidelines

In nearly regular intervals arguments flare up among bioethicists as well as political activists about the substantive guidance proffered in international ethics guidance documents such as the World Medical Association’s (WMA’s) Declaration of Helsinki or the Council for International Organisation of Medical Sciences’ (CIOMS’) research ethics guidance documents. Who doesn’t recall the arguments about standards of care in clinical trials undertaken in developing countries, or the post-trial benefits debate?[1] Monographs, anthologies, as well as an endless stream of graduate student theses focused on particular aspects of these debates. There is nothing wrong with these efforts. As someone who spends significant amounts of time vetting other people’s content, as a journal editor, academic supervisor and external examiner of graduate students’ theses I have read a lot of content dedicated to these debates over the years.

What has always struck me as strange is that virtually nobody seems to question the relevance of these documents. They are usually taken as authoritative statements, not dissimilar to consensus statements clinicians might publish in medical journals. And yet, it is far from clear that anyone should accept these declarations and guidelines as relevant documents of that kind.[2] Take the WMA’s Declaration of Helsinki as a case in point: it is interesting in so far as it has been one of the most bitterly fought over international research ethics guidance documents just a few years ago. It is still being revised in fairly frequent intervals, alas the old battle axes in this dispute have by and large moved on to other issues. There is little professional interest in substantive changes to what once were highly sensitive provisions in the Declaration.

At least the WMA has some claim to represent the world’s doctors. Still, the Declaration offers no justifications for its guidance, so it is unclear why anyone who undertakes biomedical research and isn’t a medical doctor should bother about it. It is also doubtful that the national medical associations debated in any meaningful way proposed revisions to the Declaration and instructed their delegates to the WMA’s General Assembly to vote in particular ways that actually represent the views of the members of these national associations. You might also wonder why a local GP’s views and vote ought to matter a great deal in matters research ethics in the first place. CIOMS remains a fairly smallish operator with even less of a claim to represent meaningfully people involved in biomedical research.[3] Its initial claim to fame was that it put itself forward to interpret the WMA Declaration of Helsinki. Once that – kind of - established its legitimacy this interpretation morphed into its own guidance document. At least CIOMS has a habit of trying to justify its guidance, as opposed to engaging merely in ex cathedra declarations like the WMA is wont to do.

The situation doesn’t get any better when one looks at international institutions such as the World Health Organisation (WHO). While undoubtedly United Nations insiders are clued in with regard to the status of myriad WHO documents, the wider public, and indeed policy makers outside the corridors of WHO offices, almost certainly do not. A case in point: After spectacularly failing in its response to the Ebola outbreaks WHO engaged in what can best be described as wild activism to show that it is doing something. It issued eventually an ethical guidance document that declared that it is OK to use unregistered experimental interventions on Ebola virus disease patients.[4] The authors of this document, celebrated as they were as experts on the subject matter, had mostly never published a word on either Ebola virus disease or, indeed, on the difficult subject of emergency access to experimental drugs in case of patients with catastrophic illnesses. The latter topic has been a matter of intense debate over the last few decades in bioethics. I should know, I have been involved in these debates. The WHO’s experts may have been nice people interested in this topic, who were known somehow to WHO people in charge of inviting someone ‘expert’, alas very few of their experts had any demonstrable expertise when they willingly pontificated publicly on WHO letterhead on this subject matter. Much like CIOMS, the authors of this guidance document ought to be commended for having made the effort to provide justifications for their recommendations.

The results of the WHO meeting were eventually reported the world all over as the WHO ‘approving’ the use of experimental drugs in patients with Ebola virus disease.[5] It turns out that the WHO has no jurisdiction to approve anything of that sort, and, equally as importantly, WHO never actually did approve what it was reported to have approved. The WHO documents produced by the people it invited to pontificate on this subject, state actually in small print that they merely reflect the views of the people who wrote them down, and that they are not the official view of WHO. Their views, in other words, ought to carry no more weight than the views of any other groups of academics who hang out together at conferences and draft papers in their spare time. This hasn’t stopped academics writing about this subject to mention the WHO documents as if they carried any meaningful regulatory or other weight.[6]

WHO is at the time of writing in the process of developing procedures for the selection and use of such experimental agents in Ebola virus disease patients.[7]  I suspect the status of these documents won’t be of more significant regulatory weight than that of any of its other Ebola crisis triggered documents. That is not to say that they will be bad documents. It appears to be the case that these documents will be an amalgam of best practice guidelines from nations that have many decades of regulatory experience with emergency access to investigational agents in patients with catastrophic illnesses. However, if, for instance, Liberia and the USA decided to establish an emergency access program for a particular therapeutic experimental agent, and they chose to ignore WHO (who is apparently keen to inject itself into these bilateral processes) what exactly would WHO be able to do about that? Nothing that I can think of.

What is the value of these sorts of guidance documents then? I think they are valuable as documents that drive debate among interested parties about the substantive controversial issues that they address. They might also be of value to organisations such as the International Committee of the Red Cross, Doctors without Borders, and others, who want guidelines for their own emergency access plans without spending too much time thinking about ethically defensible operational frameworks themselves. Last but not least, they might be useful to developing nations without the capacity to develop their own regulatory frameworks and who decide to resort to WHO guidance documents and protocols.

However, given these questions about the status and the legitimacy of these documents, if the old adage caveat emptor ever applied anywhere, it should apply to these guidelines, declarations and policies. Anyone choosing to adopt them ought to adopt them because they consider them ethically defensible, and not because they happen to come from WMA, CIOMS or indeed the WHO.

[1] Schuklenk, U. 1998. Unethical Perinatal HIV Transmission Trials Establish Bad Precedent. Bioethics 12: 311-318.
[2] Schuklenk U. 2004. The Standard of Care Debate: Against the Myth of an ‘International Consensus Opinion’. Journal of Medical Ethics 30: 194-197.
[3] Schuklenk U. 2004. Ibid.
[4] WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva, August 12, 2014. [Accessed March 16, 2015.] See also WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva: Report of an advisory panel to WHO. Geneva, n.d. [Accessed March 17, 2015.]
[5] Eg Anonymous. 2015. WHO approves experimental treatment for Ebola. AlJazeera August 12, 2014., McKay B, Loftus, P. 2014. Ebola Virus: Experimental Drugs Approved for Use in Fighting Outbreak in West Africa. Wall Street Journal August 13, 2014. [Accessed March 17, 2015]
[6] Hayden EC, Reardon S. 2014. Should experimental drugs be used in the Ebola outbreak? Nature August 12 doi:10.1038/nature.2014.15698.
[7] WHO. 2015. Public consultation on emergency use assessment and listings procedures for medical products during public health emergencies. [Accessed March 18, 2015.]

Monday, April 06, 2015

GoodLife's straight members only competion -2-

I have since received a written reply from GoodLife in response to my complaint.

Tara McLain from the chain's marketing department sends this in her response:

Thank you very much for bringing this to our attention. We were not aware that this legislation exists in Jamaica.
A part of the rules and regulations for this contest include the ability to substitute, modify etc. trips for any reason. Should you win this trip, we would be happy to award you with a trip of equal value to another destination.
We have connected with Tourism Jamaica and they provided us with the following information:
Jamaica welcomes visitors from all over the world and from all segments of society equally with the warmth and courtesy they expect and deserve. We recognize that there are diverse communities and cultures interested in Jamaica as a travel destination, and we embrace that diversity with respect.
In Jamaica, we are committed to the safety of all travelers. We respect the right of all visitors to Jamaica to express their own beliefs and to satisfy their own vacation experiences while staying with us.
We respect the choices of adults and responsible adult activities. In keeping with travel to any destination in the world, we encourage visitors to respect Jamaican laws and community standards, and to take reasonable  measures to enhance their travel experience. 
Please know that we welcome everyone with open arms and look forward to sharing the beauty that is Jamaica with them.
Thank you,
Tara McLain
Public Relations Specialist
Marketing & Public Relations Department

My response:

Dear Tara,

thanks for your prompt response. I trust that you appreciate that the Jamaican marketing person essentially confirmed what I said on my blog. Gay male winners of your competition who might innocently hold hands or show affection in public in Jamaica will likely be attacked in public places and face up to ten years in jail should they engage in sexual intercourse. 

Nowhere on your posters do you warn your gay members of your gym of this risk, nowhere on your posters do you even mention that gay people who might win this competition would be able to choose an alternative location. Do you plan to issue warnings to your winners, just in case they happen to be gay?

I am a bit surprised that you think this should be the end of it!

A colleague of mine has since written about this issue here:

May I suggest that you should take the concerns expressed in my blog a little bit more seriously and take action to address the concerns raised.

udo Schuklenk

I am also delighted that fellow fitness friend, philosophy professor and blogger Samantha Brennan has taken up the issue on her own blog.

Wednesday, April 01, 2015

Goodlife's straight members only competition - Open Letter to its CEO

Dear Mr Patchell-Evans,

I am writing this Open Letter today to you, because I have been inundated in my local gym with advertisements linked to your gym chain's 36th anniversary. You run a competition among members offering a vacation in Jamaica to the winning member.

My partner and I have been members of your gym chain for many years. We happen to be gay. Your competition misleads members into thinking that Jamaica is a tourist destination like any other, sun, beach and a good time. Nothing good be further from the truth.

Jamaica is a militantly homophobic society, religious fundamentalists have written anti-gay provision into the country's constitution. Here is a helpful link to a 2014 report by the respected human rights organisation Human Rights Watch on anti-gay violence in Jamaica.

My husband and I would be up 'eligible' for an up-to ten year jail term should we choose to engage in sexual intercourse during a vacation we might win if we took part in your competition.

Local civil rights groups lament, 'serious human rights abuses, including assault with deadly weapons, of women accused
of being lesbians, arbitrary detention, mob attacks, stabbings, harassment of gay and lesbian patients by hospital and prison staff, and targeted shootings of such persons.'

Given the current attention to laws permitting the active discriminations against gay customers in Indiana, I cannot help but wonder what drove your company to offer a competition that would subject your gay and lesbian members to serious risk of bodily harm, not to say long jail terms, should they win your competition and decide to actually go to Jamaica.

I am writing to you today to ask that you cancel the ongoing competition and replace the 'Jamaica' labelled posters with posters that offer a vacation price, but a vacation of the winner's choosing. Otherwise, you really are telling your gay and lesbian members that our well-being and safety is of no concern to you, and that the current competition celebrating the chain's 36th anniversary is really addressed to the club's straight members only.

I am looking forward to your timely response.

Thursday, March 26, 2015

Conscientious objection in medicine: Private ideological convictions must not supersede public service obligations

Canada’s Supreme Court decided that Canadians’ constitutional rights are violated by the criminalisation of assisted dying. Canada’s politicians are currently scrambling to come up with an assisted dying regime within the 12 month period that the Supreme Court gave them to fix the problem.

Since then the Canadian Medical Association, the country’s doctors’ lobby organisation, has insisted not only that doctors must not be forced to provide assisted dying, but also that doctors must not be required to transfer patients asking for assisted dying on to a colleague who they know will oblige these patients.(1) 

In many countries, including Canada, conscientious objection clauses protect – mostly - health care professionals from being forced to act against their individual ideological convictions. I suspect it isn’t unfair to note that these protections in the real world are nothing other than protections for Christian doctors who are unwilling to deliver services they would be obliged to deliver to patients who are legally entitled to receive these services, were it not for their religiously motivated objections.(2) Secular health care professionals could arguably avail themselves of conscience clauses, but in a liberal democracy, what reasonable conscience based cause could they have to refuse the provision of health care services to patients? Conscience clauses today are by and large a concession of special rights to Christian health care professionals, at least in secular Western democracies.

An uneasy compromise is often struck that stipulates that conscientious objectors must not be forced to deliver the health care services that they object to, but that they must ensure that patients will be transferred to a health care professional willing to provide the requested service. Typically they are prohibited from engaging in activities aimed at persuading the patient to see the errors of their ways. Typically they must also transfer the patient in an expeditious manner to their more obliging colleague.

Looked at from a conscientious objector’s perspective, this compromise is anything but a compromise. If I object to abortion because I believe that abortion is akin to murder, as Christian objectors happen to believe, surely my moral responsibility is barely smaller if I knowingly pass a pregnant woman looking for an abortion on to a colleague who will commit the act rather than if I do it myself. Christians are not typically known to see these issues through a consequentialist analytical lense, but even from their perspective, moral responsibility is barely reduced by the compromise. I sympathise with their objections to the compromise, because it is not a compromise. A compromise under the circumstances arguably is not feasible to begin with.  

Patients are entitled to receive uniform service delivery from health care professionals. They ought not to be subjected to today’s conscientious objection lottery. The Canadian Medical Association proposes that Canada ought to establish a website where patients can ascertain where the nearest non-objecting doctor is located.(3) One difficulty with this proposition is that in many rural areas there might be only one doctor and the next – more obliging - health care professional might actually be a flight away. Nothing would stop us from taking this proposal to its absurd logical conclusion: why not establish comprehensive websites where patients can find out whether their doctor objects on grounds of conscience to treating sexually active gay patients, or perhaps whether their conscience prohibits them from treating patients of a particular objectionable ethnicity. Consequentialists might well decide not to treat Ebola Virus Disease patients because of the risk involved, call it their consequentialist conscience. Health care service delivery would soon become a random event, entirely based on the vagaries of conscientious objections. Incidentally, Canadian doctors’ legal conscience protections do not actually cover these kinds of objections, because really these protections are designed to protect Christian doctors’ convictions, despite feeble attempts at giving them a lick of neutrality paint. The odd thing about conscientious objections is that there is no way to find out whether they are genuine or just a matter of convenience. Even if they were genuinely held beliefs, why should that constitute a sound reason for refusing service delivery?

The very idea that we ought to countenance conscientious objection in any profession is objectionable.(4) Nobody forces anyone to become a professional. It is a voluntary choice. A conscientious objector in medicine is not dissimilar to a taxi driver who joins a taxi company that runs a fleet of mostly combustion engine cars and who objects on grounds of conscience to drive those cars due to environmental concerns. Why did she become a taxi driver in the first place? Perhaps she should have opened a bicycle taxi company instead. I recall well, during an extended teaching stint in a dental school, that in every intake there were a fair number of dental students mentioning that they settled on going to dental school rather than medical school because of their objections to abortion. That seems a much more reasonable decision than to join a medical school and cause throughout one’s working life problems for patients seeking medical care for health issues that they are legally entitled to receive medical care for and that one objects to for one reason or another. Societies ought not to prioritise individual ideological commitments of some health care professionals over patients’ rights to receive professional care in a timely and hassle free fashion. Dying patients living in rural areas should not be subjected to an access-to-assisted-dying-lottery caused by conscientious objectors. Doctors are first and foremost providers of health care services. Society has every right to determine what kinds of services they ought to deliver.

That a doctors’ lobby organisation such as the Canadian Medical Association should aim to prioritise its members’ interests over patient access to care is not terribly surprising, albeit disappointing. Canadian legislators would do well to ignore its plea on this occasion.








[1] Sharon K. 2015. Unacceptable to force doctors to participate in assisted dying against their conscience: CMA. National Post March 05. [Accessed March 26, 2015.]
[2] Leiter B. 2013. Why Tolerate Religion? Princeton, NJ: Princeton University Press.
[3] Kirkey S. Op.cit.
[4] Savulescu J. 2006. Conscientious objection in medicine. bmj 332: 294