Thursday, January 24, 2019

Certainty is not a defensible standard for policy making in the context of assisted dying

Image result for certaintyI mentioned in a Bioethics editorial a while ago that new frontiers are opening in the assisted dying debate. As an increasing number of jurisdictions decriminalize assisted dying in some shape or form, ethical arguments against all models of assisted dying are seen increasingly as settled in favour of this practice. I suggested in said editorial that the focus of the academic debate has shifted toward a new set of questions: the scope of assisted dying (i.e., who should be eligible), the status of advance directives, and the issue of conscientious refuser accommodation.[1] It seems my prediction wasn't far off the mark. The Canadian Academies have produced a voluminous expert panel report focusing extensively on scope (mature minors, mental illness) as well as the issue of advance directives. I highly recommend it to your attention.[2]

Unfortunately, as is so often the case with these sorts of panels, it is unclear how its members were appointed: Why was a particular member appointed and not someone else? What criteria were used to determine who would and who would not be chosen? And, indeed, did the funder of the report, the Government of Canada, have a veto right on particular potential expert members? All of this matters if the sponsor of the report, in this case the Canadian Academies, wants to meet basic standards of public reasonableness and accountability. After all, the Government of Canada is currently defending its restrictive assisted dying legislation in the Supreme Court of Canada. The expert panel was tasked with summarizing the state of knowledge, but not with providing policy guidance to the government. It is not inconceivable that the government hopes to use evidence from these ostensibly authoritative reports in the Court. For that reason alone, transparency about the procedures guiding the appointment of experts drafting reports financed by that same government is important.

The chairperson of the group drafting the report on mental illness and assisted dying, Kwame McKenzie, made a statement to Canadian news media in support of current government policy that excludes competent people who suffer from refractory mental illness from access to assisted dying. He reportedly cautioned that ‘no one can be completely certain that a mentally ill patient is never going to get better’.[3] Which takes me to the actual topic of this blogpost: certainty as a standard for health policy making. Complete certainty, if that were ever possible in the context of health and disease, where most decision making is based on probability as opposed to certainty, might be a defensible threshold if nobody were harmed by the implementation of such a high standard. If the setting of a high standard were cost neutral, there would be no good reason not to have such a standard.

Of course, in the real world, such an elevated standard comes at a cost. A high price is paid by those patients who have decisional capacity and live with refractory mental illness that renders their lives not worth living to them, who would avail themselves of assisted dying if it were available to them.[4] Regulatory attempts influenced by Dr McKenzie's demand for certainty would result in a restrictive eligibility policy harming precisely those patients who will, in reality, never get better. It is uncontroversially true that that is the case for many patients, particularly those suffering from refractory depression. Dr McKenzie's take is identical to the policy favoured by the government sponsor of this report. High suicide rates among this particular group of patients suggest that many of these patients vote with their feet while well intentioned experts and policy makers implement policies that are detrimental to what is arguably in their best interest.[5]

Ultimately, policy makers implement legislation aimed at overriding competent patients’ choices simply because they disagree with their choices. The justification for such strong paternalistic action rested so far on vacuous labels, such as ‘vulnerability’, under the cover of which individual agency was removed wholesale from a whole class of patients with legal capacity. This is now apparently complemented by demands for certainty. If medical practice and health policy depend on certainty as a conditio sine qua non, going forward, no further regulatory action can be taken on any subject. In fact, the current assisted dying legislation, as it requires that death of the assistance‐seeking person is ‘reasonably foreseeable’, would have to be reconsidered, given that we can never be certain that death would actually be forthcoming. The decriminalization of the possession and use of cannabis in Canada, that was recently legislated by the Government of Canada, would have to be reconsidered, because we cannot be certain what the consequences of that will be for a whole range of issues. 

The lesson to be taken from the demand for certainty is this: mentally ill people with legal capacity are treated unjustifiably as special cases by mental health experts and policy makers. They are being stigmatized in the name of protecting them. Strong paternalism is inflicted on them in ways that would not be considered acceptable in a liberal, modern 21st century society if it affected others who
have legal capacity, but are not afflicted by the mental illness label.

[1] Schuklenk, U. (2017). New frontiers in end‐of‐life ethics (and policy): Scope, advance directives and conscientious objection. Bioethics, 31, 422–423.
[2] Canadian Academies. (2018). Medical assistance in dying: Expert panel on medical assistance in dying. Ottawa. Available at:‐assistance‐in‐dying/ [Accessed Jan 6, 2019].
[3] Harris, K. (2019, Jan 3). The next frontier in the right to die: advance requests, minors and the mentally ill. CBC News. Available at:‐assisted‐death‐minors‐mental‐illness‐1.4956388 [Accessed Jan 6, 2019].
[4] Rooney, W., Schuklenk, U., & van de Vathorst, S. (2018). Are concerns about irremediableness, vulnerability, or competence sufficient to justify excluding all psychiatric patients from medical aid in dying? Health Care Analysis, 26, 326–343.
[5] Schuklenk, U., & van de Vathorst, S. (2015). Treatment‐resistant major depressive disorder and assisted dying. Journal of Medical Ethics, 41, 577–583.

Monday, October 08, 2018

Sokal on steroids: Why hoax papers submitted successfully to academic journals proves nothing (ok, little)

A trio of authors has, during a 12 months period, submitted - by their own account - 20 manuscripts to academic journals they broadly identify as being in disciplines or fields of study associated with 'academic grievance studies'. From what I gather they are not too terribly fond of social constructionist colleagues in their own academic disciplines, and presumably other disciplines. Let me say at the outset that I am sympathetic to some of their concerns. They rightly lament that what they broadly label as 'academic grievance studies' has led to thought crimes prosecutions of sorts (just think about the Hypatia controversy involving an article by Rebecca Tuvel - mob justice might be one way to describe what happened to Tuvel). Ironically, Hypatia is again among the offending journals, which is interesting in so far as it isn't a journal entirely dedicated to publishing social constructivist content, another bugbear of the initiators of the Sokal-on-steroids hoax.

In any case, they apparently spend their while producing 20 hoax articles that they planned to submit to top journals in different disciplines or areas of study that they find disagreeable. I am genuinely curious whether this research project was submitted to their institution's ethical review committee, because it uncontroversially involved involuntary human research participants (identifiable journal editors, reviewers).

Here's the result of their efforts: Of these 20 papers 7 were accepted, 6 were rejected outright, and the rest were somewhat in-play, including a number that received a revise and resubmit verdict. The hoax initiators claim that two papers received a verdict of 'revise and resubmit' that they took to mean 'usually results in publication.' For what it's worth, at the journals I co-edit this verdict means renewed external review with the possibility of an outright rejection. So, no, not 'usually results in publication.' I wonder whether this interpretation is self-serving in so far as they needed to, of course, bolster their case as good as they could.

At the end of the day, they had 20 submissions, 7 acceptances.

I agree with the team of hoaxters that this constitutes egg on the faces of the editors of those journals, and more so, on their reviewers' faces. It's embarrassing.

I read a few comments on this project along the lines that in STEM subjects journals also face large numbers of retractions each year, and so it's not surprising that terrible content also passes peer review in humanities' areas. While that is true, it shouldn't distract from the fact that well-established, influential journals were coaxed here into accepting garbage. Of course, that matters!

My problems really lie elsewhere. One is that a study where n=20 doesn't demonstrate that a particular discipline has methodological problems. It simply means that - when all is said and done -  7 crappy papers were accepted by non-specialist journal editors based on their reviewers' recommendations. Big whoop! Frankly, this shows us that on this occasion reviewers failed. On 7(!) occasions. We do not know whether the same would have transpired if hundreds of such papers had been submitted to the same journals. It's one such paper per journal. Talking anecdotal, this is as anecdotal as it gets.

Let me be honest here, as an editor of journals that rarely if ever publish social constructionist papers, I could also be accepting papers that succeeded in fooling our peer reviewers. I don't have the subject expertise to be confident in evaluating all the manuscripts that are submitted to my journals. I rely on - these days - mostly reluctant reviewers who hopefully provide me with good (sometimes excellent, detailed) comments and recommendations. I rely on competent reviewers being diligent. I rely on colleagues I ask to review a manuscript to come back to me if they do not consider themselves competent. I rely on unpaid reviewers spending a considerable amount of time doing their job, when they could spend that time writing their own papers, or on a grant application, or a job application, or they could simply spend time with their loved ones. Not all of them, all the time, deliver a reliable review. Big whoop. If a faulty paper gets published (and it hasn't happened to us yet), I'm confident, over time responses to such a paper would eventually show where the paper we published went wrong, and why. A case in point is this Editorial I wrote. One of the articles flagged there was making false empirical claims, it has since been retracted. The article in question passed external peer review, but it is clear that the reviewers took the empirical claims made by the authors to be true, referenced as they were. It turns out that that was a mistake. 

All of that happens without hoaxters wasting my time and that of our reviewers.

The hoaxter trio takes these 7 accepted manuscripts as evidence for the methodological failings of what they refer to as 'social constructivism'or 'radical constructivism'. They apparently 'corrupt' scholarship.

The thing is, that might well be true, and social constructivism scholarship is truly a naked emperor. Unfortunately, pointing to 7 anecdotal papers as evidence that that is the case, is plain ludicrous. As far as I can see, there wasn't even a control group (say, 20 manuscripts submitted to analytical journals, 20 manuscripts submitted to STEM subjects).

To my mind, if you wish to criticize social constructivism (and much critical that I wholeheartedly agree with has been published over the last few decades) don't avail yourself of childish activities like these kinds of hoaxes. Show by means of analysis and argument that, and why, the social constructivism emperor is naked.

The process of producing and publishing peer reviewed academic content relies on an assumption of good intent and genuineness among authors. Obviously, this is not justified in all cases, that's where critical responses and retractions come in handy. The last thing needed is a cottage industry of 'gotcha authors' like our hoaxter trio. They could and should have spend their time producing one sound academic paper taking on social constructivism, placing it in a top-notch journal, and subsequently enjoying the fireworks of rebuttal and response. That's how progress in the academy is facilitated.

I have sat on this for a good week, because I wasn't sure whether I should bother writing a response. On the one hand I share many of their concerns, on the other hand, this was such a time wasting pointless exercise, it boggles the mind smart people would have resorted to that sort of thing.

Ethics Violations: Canadian Medical Association exits World Medical Association

The Canadian Medical Association (CMA) has left the World Medical Association (WMA) because of ethics failings of its new President, Dr Leonid Eidelman. Apparently Eidelman's inaugural speech was in parts plagiarised from content produced, among others, by Dr Christopher Simpson, a former President of the Canadian Medical Association. As far as Eidelman is concerned, he says his speech was written by speech writers, and he was unaware of the plagiarism.

Let me just say that Eidelman ought to resign, whether or not his speech was written by others. He delivered plagiarized content as if it was his own, so the fact that he used speech writers is irrelevant, he remains responsible for what he says. The WMA did not force Eidelman to resign, it did not fire him.

The thing with the WMA is this: ethics failings are kind of power for the cause. That's what it does. It is a morally bankrupt organization, and it has been a morally bankrupt organization for a long time.  Its plagiarizing current President, by comparison, nearly falls into the category of 'good guy'.

In 1992 it wisely chose to elect a Nazi war criminal as its President, Dr Hans Sewering. Sewering was reportedly a member of the SS and the Nazi party. He signed death warrants for some 900 children with disabilities who were then murdered in a Nazi extermination centre.

In 2010 the WMA elected Ketan Desai to is President. He was found guilty by the High Court of Delhi of corruption and abuse of power in 2001.  The High Court ordered his removal from his job as President of the Medical Council of India. Investigators had charged him with seeking a massive bribe from a private medical college in return for approving admissions of students for the 2010-2011 academic year.

So, the WMA has a knack for picking the wrong people. The only thing that is odd about the CMA's timing is that they chose to resign their membership from the WMA over a comparably trifling matter, namely a vanity speech giving by its incoming President. Desai's failings were apparently of no concern at the time to the CMA.

The CMA's President, Dr Gigi Osler is quoted in the Toronto Star newspaper, '“We must continue to hold ourselves to a high standard of professionalism and ethical behaviour,” said Osler. “We are going to strive to uphold honesty, humility, integrity and prudence.”

This, of course, is the same medical association whose views on professionalism are akin to that of a trade union rather than that of a proud professional association. Dr Jeff Blackmer, the Director of the Canadian Medical Association’s Ethics Office wrote on behalf of the association that medical doctors are neither obliged to provide abortion services, nor are they obliged to transfer patients on to doctors they know will provide abortions to women seeking one. He holds the same view on medical aid in dying, and - one wonders - on what other medical services. Of course, doctors are monopoly providers of this service, abortion is legal in Canada, and pregnant women are entitled to receive that service free of charge (ie publicly funded) from said monopoly providers. The CMA's take is that the refusal to provide or transfer is perfectly compatible with professional conduct, when, by definition, that isn't the case.

Apparently Eidelman and Blackmer got into a bit of a bunfight over Eidelman lecturing the CMA over its support for medical aid in dying. Blackmer rightly criticises Eidelman for claiming that the CMA thought assisted dying is comparable in terms of its seriousness to prescribing antibiotics.

It appears to be the case that the WMA has again managed to appoint a reactionary doctor with questionable ethics as its President. One does wonder why anyone would take too seriously any longer its pronouncements on matters medical ethics. In its conduct it really is not dissimilar to the Roman Catholic Church. There is a lot of hand waving and posturing, but when it comes to actual conduct, it disqualifies itself as an arbiter of matters ethics.

So, kudos to the CMA for leaving the WMA; even though the point in time is ill-chosen, it was a long overdue decision.

Tuesday, August 14, 2018

2018 Google Scholar Metrics for Bioethics Journals

Quite possibly the below table will be displayed in odd ways on your screen. 

Usual CoI blurb applies. I co-edit two of the journals in this list. List up-dated August 2018. Any mistakes are my own, please alert me if you discover discrepancies between what I am reporting and what you're able to find on google scholar.

                                                                                                                           h5               h5-median

  1. Nursing Ethics                                                                              37          51
  2. Journal of Medical Ethics                                                             33          40
  3. Journal of Law, Medicine and Ethics                                             32          40
  4. Science and Engineering Ethics                                                        30           45
  5. The American Journal of Bioethics                                              30         41
  6. bmc medical ethics                                                                       28           38
  7. Bioethics                                                                                       26         37       
  8. Medicine, Health Care and Philosophy                                        24         28
  9. Neuroethics                                                                                   22         37
  10. Hastings Center Report                                                                 22          30
  11. Journal of Bioethical Inquiry                                                                   19        22
  12.  American Journal of Bioethics Neuroscience                              18            26
  13.  Journal of Medicine and Philosophy                                            18          25
  14. Journal of Empirical Research on Human Research Ethics         18          21
  15. Developing World Bioethics                                                                  16          21
  16. Nursing Philosophy                                                                        16      18
  17. Health Care Analysis                                                                     15       22
  18. Cambridge Quarterly of Healthcare Ethics                                            15          20
  19. Public Health Ethics                                                                               14          17
  20. Theoretical Medicine and Bioethics                                                       13          21
  21. NanoEthics                                                                                             13         18
  22. Indian Journal of Medical Ethics                                                     13       17
  23. Kennedy Institute of Ethics Journal                                                13          17
  24. The Journal of Clinical Ethics                                                        12          19
  25. Journal of Medical Ethics and History of Medicine                         12         19 
  26. Perspectives in Biology and Medicine                                                12        15
  27. Narrative Inquiry in Bioethics                                                                11              15
  28. HEC Forum                                                                                     10         17
  29. Ethik in der Medizin                                                                         10           13
  30. American Journal of Bioethics Empirical Bioethics                                8          10
  31. International Journal of Feminist Approaches to Bioethics              8         10
  32. Monash Bioethics Review                                                                7            12
  33. South African Journal of Bioethics and Law                                         7             9
  34. JAHR - European Journal of Bioethics                                             5           9
  35. Asian Bioethics Review                                                                   5           7
  36. The New Bioethics                                                                           5            7
  37. Christian Bioethics                                                                            5           6
  38. National Catholic Bioethics Quarterly                                              4             6
  39. Journal international de bioethique                                                         4             5

*h5-index is the h-index for articles published in the last 5 complete years. It is the largest number h such that h articles published in 2013-2017 have at least h citations each
**h5-median for a publication is the median number of citations for the articles that make up its h5-index

Certainty is not a defensible standard for policy making in the context of assisted dying

I mentioned in a Bioethics editorial a while ago that new frontiers are opening in the assisted dying debate. As an increasing number of...