Monday, October 29, 2007

Should skincolour manipulating products be developed and sold?

Nice article today on the CBC news website. Some students from Carleton University have developed yet another cream capable of whitening the skin color of darker skinned people. It's kinda old news, due to continuing racist ideologies insisting that a lighter skin coloration is kinda better than a darker skin coloration, skin lightening products have been on the market for a very long time. You'll find them in most drug stores in places where larger numbers of darker skinned folks live. In many parts of India it is common knowledge that the darker a young woman is, the more difficult it will be for her to find a husband (or her family for her - don't ask). Now, the question is, of course, whether one should aid such skin color related prejudices by means of developing products that permit folks to lighten their skin color. We should never develop any kind of technologies that serve such purposes. They will only prolong the existence of such prejudices over time, because the cremes in question will be seen as an easy way out of the dilemma by many, while really they help cementing views about the inferiority of particular skin colors.

The inventors of the concoction in question insist that they're no racists (a claim likely to be true), and that in fact their creme could also be utilized by folks wanting to darken their skin color.

At first this seems an innocent enough idea then, as the technology kind of cuts both ways. It stops being innocent when we ask ourselves why some light skinned people like to look a bit darker (but not really dark, of course). The reason is that to many pink skinned folks a slightly darker look translates into ideas of vacation (you know, beach, sun and tequilas) and health. Of course, darker skinned folks will not have this kind of motive in mind. They are more likely to think that they might move up in societal status if they're lighter skinned. Equating then the two possible utilisations of the technology seems remarkably naive. Interestingly, one of the students is from India and should be painfully aware why such products are so popular in that country, yet clearly it doesn't seem to have hit home that, big as that market might be, it's nonetheless a market created by racist interpretations of skin color.

So, in the same way that I would not want a prenatal genetic test predictive for homosexuality in a homophobic society (even if it could be also used by homosexuals to detect heterosexual etc etc), I would not want to see products on the market that support racist societies' take on skin coloration.

Saturday, October 27, 2007

Lives not worth living and voluntary euthanasia

Most of the voluntary euthanasia crowd argue that we should permit competent folks who are suffering from a terminal illness, and who consider their lives not worth living access to death with dignity if they so wish. Death with dignity here is meant to include access to voluntary euthanasia and/or physician assisted suicide. The main reasons have both to do with the idea that we should respect competent people's choices particularly when it comes to how they wish to end their lives, and also with the view that there is little point in sticking around when you suffer from a terminal illness, and there is no prospect that you'd be able to enjoy your life sufficiently again that you yourself consider it worth living. So, it's not about a Nazi declaring your life not worth living, but that you yourself say that you wish to die, because you yourself do not consider your life worth living any longer.

I find this argument by and large persuasive, but it strikes me as mostly strategically motivated. Opponents of voluntary euthanasia have long been arguing that accepting this argument, and translating it into policy would lead us down a slippery slope to non-voluntary euthanasia (say folks get killed a) against their express wishes [there doesn't seem to be any evidence whatsoever to support this claim, at least with regard to countries that have since legalised voluntary euthanasia], and b] that incompetent folks get killed). The latter point is quite dicey obviously. If you've someone who meets the other criteria (terminal illness, overwhelming impact on that patient's quality of life), and you know that competent people under such circumstances often (but not always!) demand voluntary euthanasia or physician assisted suicide, how are you to go about someone unable to express an autonomous choice?

Anyway, my main question today is somewhat different, but also somewhat related to the incompetent patient. As you may or may not know, very many people suffer from clinical depressions. It's truly a debilitating disease that renders the quality of life not worth living for many of those affected. Some of the anti-depressants that are on the market work for some of those affected, but for many patients these drugs do not work, or do not work reliably over time, or do not work sufficiently well to permit them to enjoy their lives again. It goes without saying that depressive people have suicidal thoughts that are usually caused by their depression.

But, here is the question: If a given depressive patient has tried and tested the available anti- depressants over reasonable periods of time, and they fail to do the trick for her, would it be unethical if a doctor complied with her request for an overdose of some drug cocktail or other that would permit her to end her life? If the legitimacy of decisions on voluntary euthanasia or physician assisted suicide rests on a patient's evaluation of her experienced quality of life over time, who are we to say that a depressed patient 'because she is depressed' should not be respected in her wish to end her life?

My view would be that we should acknowledge that depression might be the major factor triggering her demand to die with dignity, but equally that unless we're able to do something successfully (in her judgment, not our's) about her depressions, we should respect her choice. At the end of the day, whether or not we consider our lives worth living should be the decisive factor with regard to society respecting patients' end-of-life decision making. The question surely is not whether their condition is terminal but whether there is a reasonable likelihood that the condition that renders their life not worth living (in their judgment!) can be fixed in the foreseeable future. If the answer to this question is 'no', or 'most likely not', it does not matter whether the condition we are concerned about is of a terminal nature. It does not help a great deal to go on about depressed people being not competent to evaluate exactly how they feel about their lives. The fact of the matter is that they know perfectly well how it is to live with depressions, they understand that it is their depression that stuffs up their lives, but also that nothing that they tried worked to bring their lives back to reasonably livable normality. To use that experience to declare them incompetent to make choices about ending their lives seems absurd to me.

Am I missing something?

Friday, October 26, 2007

African Vaccine Trials Ethics Problems Continue

A few weeks ago much propagated microbicide trials designed to test the efficacy of a microbicide aimed at reducing or preventing HIV transmission during sexual intercourse ended in failure. It turned out that the microbicide actually increased the risk of HIV infection. All sorts of ethical questions arose, of course, including whether an infection acquired during the course of the trial should count as a trial related injury that ought to be subject to compensation.

Well, much better resourced preventive HIV vaccine trials also crashed in a spectacular way today. Again, it turned out that the trials left those who were injected with the vaccine candidate more susceptible to HIV infection than those who were in the placebo arm. In all fairness to those who undertook this trial, the plug was pulled quickly when these results came to light. Equally, how would one ever find out whether a vaccine candidate works other than by means of undertaking such trials. So, the problem with both the microbicide trials, and the preventive vaccine trials isn't that they took place at all. The problem is to do with the question of what is owed to those who became already infected during the course of the prevention trial, and to those who are now at greater risk of catching an infection. There were also clear failings in the informed consent process.

I think these quotes from two of the participants are revealing in important ways. I found them in an article in the Washington Post:

"It's quite shocking," said Nelly Nonoise, 26, who had received three injections of the vaccine in her left shoulder. She added, "I probably wouldn't have joined the study knowing there's a risk." Another participant, Nonhlanhla Nqakala, 22, said she thought the text message urging her to visit the vaccine test site meant she had tested positive for HIV. Her brother and a close friend had the disease and died, she said. Nqakala said she was relieved when a doctor explained that she was not infected, but the news of a possible problem with the vaccine -- she had received three doses, not placebos -- left her distressed. "I thought the trial would help us find a cure for HIV," she said."

Now, here is a problem obviously! Two people are being interviewed by the journalist, and both indicate that they didn't understand properly the nature of the trial. This does not reflect well on the investigators' professed best practice standards in their informed consent process. It seems obvious that they happily accepted participants into their trial who did not actually comprehend the nature of the trial.

Again, the question is what is owed to the trial participants by the trial sponsors and / or the investigators. Surely if you accept people into your trial that end up being worse off when the trial is stopped, you have some responsibility for these folks, particularly so when obviously you took participants into the trial that didn't understand what was going on in the first place.

And yes, this smug ethicist can claim without embarrassment that 'I told you so' prior to the start of the trial. I argued that trial participants' competence and level of information / comprehension needed to be tested in order to rule out that people would end up in the trial that do not understand its nature. This was rejected at the time with arguments such as 'we would never be able to recruit enough participants then'. So the public health and research imperative was prioritised over individual participants' well being.

Lessons to be learned: Well, to be frank, the warnings were there prior to the trial and they were ignored. That one should not do this isn't exactly a new lesson, so, if anything we should probably consider erring on the side of caution on the odd occasion in future.

The Washington Post cites the Principal Investigator with these remarks:

"This is my worst nightmare," said Glenda Gray, the lead South Africa investigator for the vaccine study. "I haven't slept for days. I have a headache. I'm ready to resign from trials for the rest of my life."

Of course, while I have no doubt about Glenda Gray's integrity as a researcher, and while I have no doubt that her current qualms are genuine, much of this could have been avoided if sensible procedures in terms of the informed consent process had been put in place, including knowledge and comprehension evaluation of the prospective participants. The failure to do so puts the moral responsibility for this trial's failure squarely on the shoulders of the trial sponsors and investigators. It's not about resigning from clinical trials, it's about avoiding ethical short cuts (for instance in the informed consent process).

Wednesday, October 24, 2007

UNAIDS goes head-to-head with Catholic Church

Reuters reported this story yesterday:

Global Challenges | Catholic Church's Opposition to Condom Use Contributes to Spread of HIV in Latin America, UNAIDS Official Says
[Oct 24, 2007]

The Roman Catholic Church's opposition to condom use is contributing to the spread of HIV in Latin America, Alberto Stella -- UNAIDS coordinator for Honduras, Nicaragua and Costa Rica -- said on Monday, Reuters reports.

"In Latin America, the use of condoms has been demonized, but if they were used in every relation, I guarantee the epidemic would be resolved in the region," Stella said. He added that youth "start to be sexually active between 15 and 19 without sex education" -- a factor that contributes to the spread of HIV. In addition, evidence indicates that promoting abstinence is "not working," according to Stella.

About half of the 1.1 billion Catholics worldwide live in Latin America, and the Roman Catholic Church "holds sway" in the region, Reuters reports. About 1.7 million people in Latin America are living with HIV/AIDS. The number of new HIV cases in the region increased to 410,000 in 2006 from 320,000 in 2004, according to UNAIDS (Reuters, 10/23).

Singapore being funny again

Singapore's legislators reportedly changed legislation that until recently threatened to punish perverse (in the non-reproductive sex act sense) sexual activity with jail of up to two years. So, a married couple enjoying oral-genital intercourse, if caught (somehow...) could end up in the slammer. Well, I'm sure that was just those Singaporeans being funny (different, 'Asian values' and all) again. You know, it's the same crowd that prohibited the sale of chewing gum because it messed up their subway. Reportedly Singaporeans are conservative - as if conservatives didn't do such things, but hey, I suppose they don't talk about it.

Anyway, Singapore, with this move came frighteningly close to the civil rights type legislations we take for granted in other democracies. To me it seems as if Singaporeans are kind of keen to continue to be sniggered about behind their backs, much like in the chewing gum case. So they decided that oral-genital is cool whenever it's male to female, but that it's totally unacceptable (and must be punished with jail of up to two years), when, you guessed it, two blokes engage in the same conduct. They even managed to legislate the same spiel for anal intercourse. So, if you're married and you engage in anal intercourse Singapore's legislators don't think any longer two years jail is a sensible response, but if you're a guy doing it with another guy, hey presto, Singapore's jail is waiting for you. One of its psychiatrists discussed in a local medical journal a couple of years back the question of whether one should offer a genetic test (prenatal) for homosexuality if one came about, in 'the absence of treatment'. At the time homosexuality had long been eliminated from any known classification of diseases, but then, he probably didn't know, being conservative and all.

In the real world, of course, nobody is likely to ever go to jail because of this legislation. How would any policewoman ever find out what's happening in any of a zillion flats in Singapore's high-rises? No, this really is a means to say straight sex that isn't reproductive is cool, while gay sex that isn't reproductive isn't.

Inequitably treating like things not alike? Sure thing. Unjust? Sure thing. Bit silly? Sure thing. But hey, what's new about Singapore? One the one hand the city state professes its version of Asian family values. These seem to require that homosexual activities (ie a victimless activity conducted among consenting adults) be criminalised. On the other hand, the professed Asian respect for conservative moral values doesn't seem to prevent the place from being one of Burma's dictators' favorite trading partners. Hypocrisy - I think so.

Monday, October 22, 2007

Conscientious objection to gay adoption

There's a lot of irony in this. Much to the chagrin of some of my gay friends I have always maintained that arguably gay people have a moral obligation to contribute to the welfare of children (often gay couples have the resources and the time to do so, frequently more so than heterosexual couples). In view of large numbers of orphans both in developed as well as in developing countries I think it would be only sensible if more gay people who find themselves in the fortunate situation to be able to resource the upbringing of such orphans should do so (eg adopt them). So, rather than thinking about gay adoption as a right that needs to be fought for, I believe it is a moral obligation that sufficiently resourced gay people have toward orphans. While I was saying 'duty' and 'obligation' as opposed to 'right' ('gay' preferably) my gay compatriots were not exactly taken by my views.
Well, thankfully there's always a religious person around working hard to stuff these matters up. You know, some bloke who had a chat with his 'God' the other day, and who then 'feels' strongly enough about it to campaign against gay adoption (the 'right' and, weirdly the 'duty'). The fascinating bit to me isn't that sort of conduct in itself, as to my mind organised monotheistic religions are about little other than this kind of activity. No, it all comes full circle to my other favorite topic, 'conscientious objection'.
63 year old Andrew McClintock is some kind of professional. His job as a Magistrate in Sheffield is to get kids into adoption. Well, you guessed it, Mr McClintock is part of God's squad, so he knows that it's 'wrong' to place orphans with adoptive gay parents. He wants that the place where he works excuses him from having to give orphaned children to gay adoptive parents. Conscientious objection as an idea holds much sway in health care professions. There members of God's earthly team also want a special exemption when it comes to certain types of medical services. The weird bit about the conscientious objection stance is, of course, that it's not about any kind of actual truth of the belief held by the objectors. So, it's not at all about whether they can show that their God exists and that the views they ascribe to their God are truly God's views, basic stuff like that. Rather, it's about the fact that they feel so very strongly about the issue. Well, what if Mr McClintock had joined an Aryan Nation type religion that would prevent him from given orphans to families from an ethnic group that he doesn't like, because his God etc etc, would that also fly as a reason for racial discrimination?
Given that conscientious objection, as we have seen, is not about the truth or otherwise of the God related claims, to me at least it seems that accepting a right to conscientious objection is close to saying 'anything goes' as long as the objector feels strongly enough about it. This absurdity is truly incompatible with professional conduct, and for that reason alone we should do away with any supposed right to conscientious objection.
You don't want to deliver services that we as society can reasonably expect of you by virtue of your professional status ... frankly, then take a hike and get yourself some other job that you're able to fulfill.

Friday, October 19, 2007

Brits are not selfish post-Thatcherites after all

One could be forgiven for thinking that the post-Thatcherite Brits, having elected the warmongerer and privatisation fanatic Mr Blair (also better known as US President's Busch's poodle) to be PM a few times, would be a fairly selfish bunch showing little concern for those in need. After all, if even the Labour Party in that country gets into the business of privatising public education and hospital care one would not expect a great deal of civic mindedness among the citizens that elect such governments.

Well, if you thought like this, you could not be more mistaken! The British Medical Association (a doctors' trade union) conducted a survey of patients' views on organ donation. The UK system, much like the Canadian system, requires people to opt-in so that their organs may be utilised in case of their death. The problem with this system is, essentially, that because many of us are too lazy or too forgetful, we forget to sign the relevant forms and as a result when unexpected death hits us, for instance on the road, our organs cannot be utilised to preserve the lives of people in need of transplant organs. Thousands of lives are lost each year, simply because we are phlegmatic, lazy or ignorant about this important issue. It has long been suggested that we have a moral obligation toward out fellow citizens in need. For that reason it makes more sense to operate a system where we presume that a given dying accident victim, for instance, is presumed to be ok with the organ extraction instead of saying that if there's no signature saying 'you may use my organs' we may not use them. In other words, instead of actively opting in you must actively opt out to selfishly (yes, I mean it!) take your complete set of organs to your grave (so they may be eaten by worms instead...). The same phlegmatism, laziness and ignorance that is the root cause of today's insufficient supply of transplant organs would be utilised to save lives.

2/3 of 2,000 Brits interviewed in the above mentioned survey confirmed that they support the presumed consent idea. That's a strong democratic majority if this was true across the country and the survey was representative. This contrasts with only 1 in 4 Brits being on the organ donation register.

Of course, waiting for politicians to act on this, is probably as futile as waiting for them to legalise voluntary euthanasia. They have long understood that such decisions are no vote winners, so they stay clear of making them. What's new?

Thursday, October 18, 2007

Why give famous jerks a platform?

James Watson (Jim to his mates, I presume) is a famous man. Jointly with Francis Crick he discovered the structure of the DNA. That's pretty cool as far as their contribution to scientific progress goes. The thing is, Watson was always kind of known to be a jerk, but people went out of their way to pretend that he wasn't, because of his contribution etc. Why a jerk? Well, Watson has the habit of using his fame to speak out on other issues outside his area of expertise, such as arguing that if a test capable of forecasting the sexual orientation of people came about, pregnant women should be permitted to abort fetuses likely to evolve into homosexuals. This comment, he says, was designed to demonstrate his support for women's right to choose to have abortions for any reasons and none. The question remains, tho, why did he pick 'gay' fetuses to make his point? He also made quite clear that he thinks the reasons for the problems in Africa have kinda to do with the lower intelligence of African peoples. It goes without saying that he since came to realise that he actually has been misunderstood. It's always a misunderstanding, of course it is. Here is the wording of the quote in the context of the interview. Your guess is as good as mine how there could be a misunderstanding... - So, the question is why one should give famous ageing jerks (he's 78 at the time of writing) a public platform to express their prejudices, particularly so when these prejudices are not even in areas of their scientific expertise.

So, I am very pleased that the British Science Museum recently withdrew an invitation to Dr Watson to speak there, on the grounds that 'Dr Watson has gone beyond the point of acceptable debate and we are, as a result, cancelling his talk'. Thumbs up to the Brits for not caving into Jim-co-discoverer-of-the-DNA fame, and for asking him to take a hike, and take his prejudices with him. What a shame that he lost the opportunity to promote his latest book to a British audience...

Addendum 19 Oct 2007
: More good news. Cold Spring Harbor Labs, the international temple of genetics research has announced that it has suspended Dr Watson. Makes me wonder what they're going to do about the 'Watson School of Biological Sciences', tho. Incidentally, the School, of which Dr Watson is the Chancellor, hasn't yet graduated a single black student. You know, my thing was always that you better honour folks posthumously, just in case they lose the plot on the way.

Wednesday, October 17, 2007

Swearing is healthy!

Hey, there's some good news today! For me! I like to swear. I even enjoy peppering lectures occasionally with swear words. Most universities these days are heavens of political correctness, politeness and ensuing eternal boredom. I was once even told that it would be inappropriate for me 'as an ethics professor' to swear. I'm sure you get the drift, swearing is unethical. Well, there's now some empirical evidence that swearing can be good for the atmosphere at the workplace! Imagine that, the occupational health benefits of swearing. Goes without saying, I love it. To me, swearing has always been a most cathartic experience, much like lap swimming does for me, too.

On pedophilia

The world's media and the world's cops (aka Interpol) are currently hunting a high-profile pedophile suspect. Paul Neil, a 32 year old Canadian English language teacher is currently hiding somewhere in Southeast Asia. Bizarrely local Canadian media outlets published the photo of a house where the suspect's mother and brother are currently renting a flat. So, in case I steal a car tomorrow, they'd probably also publish a photo of my parents' house, just so that you know where they are, so they may be punished for my alleged deed. Beats me ...

Anyway, pedophilia: I am almost certain this is one of those blogs I will regret to have ever written, but then, that hasn't stopped me in the past. So, some disclaimers first: Kids don't do it for me, never have, never will. I think legislation outlawing pedophile sexual activity (ie between adults and prebubescent children) is a desireable thing. It's probably also sensible that modern psychiatry has decided that pedophilia is some kind of mental illness, though, just like with other calls they made in terms of DSM inclusion, their coin flipping activitiy could have ended with a different call just as easily.

Having said all that, it gets more difficult to get one's head around the question of what it is that is bad about pedophilia. Fair enough, most of us, myself included, think it's kinda 'yuck'. Beyond that though, what are the main ethical reason against pedophilia (not in the sense of sexual orientation but in the sense of action)? It seems to me that we should reject pedophilia as a reasonable (as in: acceptable) sexual orientation, because children are unable to give informed, voluntary consent (the famous autonomous choice in other words) to sexual interactions with adults. The meaning they'd give to such acts are different to the meanings we ascribe to them (regardless of whether the actual action includes painful penetrative sex or not), and given the power differential between them and us, they're probably not really in a situation to say 'no'. So, this probably is sufficient to outlaw pedophile sex acts.

Still, I have some nagging doubts ultimately about the intellectual integrity of either of these arguments. If the first part of the argument constituted a correct interpretation of the situation, could that not also be read as a case against putting it on the 'shameful' list? Subject to no bodily harm occurring, I wonder whether the real harm doesn't occur when the kids learn from us how badly they have been abused. There is evidence that (some) kids actually enjoy the sexual activity with adults, and that how badly they have been abused only dawns on them much later in life. Well, this makes me wonder, of course, how this pleasurable activity was turned into a horrific experience of abuse retrospectively many years later. I wonder how much of our cultural bias against such activities is actually contributing to this re-interpretation of the initial pleasant experience. Prior that that some kids didn't even think of their experience in terms of abuse. Would they not be better off then not to find out? I wonder how harm minimisation could be most efficiently executed under the circumstances.

The second half of the argument seems even weaker. It is self-evident that there is a substantial power differential between an adult and a child. This power differential renders probably much of what goes on between the adult and the child involuntary. No doubt, prima facie that makes it a bad thing. The thing is, tough, that that is also true for relationships between adults. Power differentials exist in all relationships. Economic, psychological and other dependencies exist in the real world. They can be strong enough to render consent involuntary. We have no laws to protect weak willed adults, financially impoverished adults and the like from exploitation (sexual or otherwise) by other adults. It seems to me that if the second half of the argument rests on the non-voluntariness, to be consistent, we would have to cast our legislative web wider to include many relationships between adults, too.

I kind of hope that some readers of this blog might rise to the challenge and deliver deadly blows to these two counter arguments.

It has been argued that pedophile sex tourists roaming developing countries are particularly despicable characters. The argument goes that in addition to the already mentioned two arguments, they abuse the particular vulnerabilities of impoverished peoples for their own purposes. It has also been reported that dire poverty drives parents in some developing countries to sell their kids off to pedophile networks. - I do think the exploitation argument is sound and there can be little said in defense of such kinds of sex tourism. That's the easy one. It's an argument that has also been deployed in the context of child labour. Except that in the child labour scenario quite a few people (many of whom no doubt well-intentioned) defended child labour by pointing out that, yes, these kids are being exploited (and that's undoubtedly bad!); BUT, they go on to argue, what's the alternative? Surely most parents wouldn't sell their kids as workers to some company if they had a viable alternative. So, here's the conundrum, while the companies exploiting such dire need arguably behave unethical, those trying to make the best of out it (eg the parents) under the circumstances, quite possibly did the ethically right thing.

I still recall as if it happened yesterday, oodles of years ago, when I was a student at Monash I had a shouting match type conversation with a guy who admitted to going to Southeast Asian countries as a sex tourist targetting 'young people' as he called them. I went on and on about how terrible his behaviour is and and that he should not be doing this etc. Then he came with the argument that if he, and many other white males like him, didn't go and didn't buy 'young people' for sex, nobody would be any better off (he implied that they might starve) and arguably some would be worse off. He railed against us do-gooders who didn't understand the dependence of many many people on characters like him. I can't say that I like him much more now, just thinking back about this episode, but it seems to me that those campaigning against sex tourism need to do better than they do currently, in terms of offering viable alternatives to those in dire need. Otherwise there will always be an obliging response to market driven demand, no matter how hard we politically correct folks waive our hands. I know that some NGOs offer such programs, BUT surely if there were sufficient alternative out there, the needs of sex tourists would not be met any longer in developing countries. As we all know, this isn't exactly what's happening in the real world.

Tuesday, October 16, 2007

African AIDS treatment programs lose 40% of patients within 2 years

A very important meta-analysis of patient retention rates in HAART programs in subsaharan Africa was published today in PLOS. Information about these retention rates are of utmost importance. Burried underneath all the rhetoric of human rights to health (and as a corollary access to health care), there's a serious public health issue. It is known that, for instance among people with chronic serious illnesses in developed countries, adherence to strict treatment regimes is only around 50%. So, the mentioned meta-analysis notes that in the average about 40% of patients with HIV infection enrolled in subsaharan AIDS treatment programs cannot be retained. Many are lost due to death (for instance because they got started on treatments too late), others are lost for other reasons. A positive spin on this would probably note that at least in some subsaharan AIDS treatment programs adherence to treatment regimes is better than in some developed countries (while, predictably, it's worse in others).

The negative spin would say that the findings of this meta-analysis are significant, because many of these people, while they will eventually die on AIDS, will have enough time to do two things: 1) develop drug resistant mutations of the AIDS virus, and 2) infect others with their drug resistant variant of the AIDS virus. In short: treatment programs of this sort run the very serious risk of contributing to a public health threat that is larger than the magnitude of the problem it tries to tackle.

Quite an ethical challenge for health policy makers in subsahara Africa, be they government, NGOs or civil society.

Sunday, October 14, 2007

Good Intentions... On First World Do Gooders and the Third World

I had never seen this speech by Ivan Illich before, and came across it on some mostly angry African blog ( Check it out. It's about well intentioned First World do gooders invading Third World countries to do good.

To Hell with Good Intentions
by Ivan Illich

An address by Monsignor Ivan Illich to the Conference on InterAmerican Student Projects (CIASP) in Cuernavaca, Mexico, on April 20, 1968. In his usual biting and sometimes sarcastic style, Illich goes to the heart of the deep dangers of paternalism inherent in any voluntary service activity, but especially in any international service “mission.” Parts of the speech are outdated and must be viewed in the historical context of 1968 when it was delivered, but the entire speech is retained for the full impact of his point and at Ivan Illich’s request.

IN THE CONVERSATIONS WHICH I HAVE HAD TODAY, I was impressed by two things, and I want to state them before I launch into my prepared talk.

I was impressed by your insight that the motivation of U.S. volunteers overseas springs mostly from very alienated feelings and concepts. I was equally impressed, by what I interpret as a step forward among would-be volunteers like you: openness to the idea that the only thing you can legitimately volunteer for in Latin America might be voluntary powerlessness, voluntary presence as receivers, as such, as hopefully beloved or adopted ones without any way of returning the gift.

I was equally impressed by the hypocrisy of most of you: by the hypocrisy of the atmosphere prevailing here. I say this as a brother speaking to brothers and sisters. I say it against many resistances within me; but it must be said. Your very insight, your very openness to evaluations of past programs make you hypocrites because you - or at least most of you - have decided to spend this next summer in Mexico, and therefore, you are unwilling to go far enough in your reappraisal of your program. You close your eyes because you want to go ahead and could not do so if you looked at some facts.

It is quite possible that this hypocrisy is unconscious in most of you. Intellectually, you are ready to see that the motivations which could legitimate volunteer action overseas in 1963 cannot be invoked for the same action in 1968. “Mission-vacations” among poor Mexicans were “the thing” to do for well-off U.S. students earlier in this decade: sentimental concern for newly-discovered. poverty south of the border combined with total blindness to much worse poverty at home justified such benevolent excursions. Intellectual insight into the difficulties of fruitful volunteer action had not sobered the spirit of Peace Corps Papal-and-Self-Styled Volunteers.

Today, the existence of organizations like yours is offensive to Mexico. I wanted to make this statement in order to explain why I feel sick about it all and in order to make you aware that good intentions have not much to do with what we are discussing here. To hell with good intentions. This is a theological statement. You will not help anybody by your good intentions. There is an Irish saying that the road to hell is paved with good intentions; this sums up the same theological insight.

The very frustration which participation in CIASP programs might mean for you, could lead you to new awareness: the awareness that even North Americans can receive the gift of hospitality without the slightest ability to pay for it; the awareness that for some gifts one cannot even say “thank you.”

Now to my prepared statement.
For the past six years I have become known for my increasing opposition to the presence of any and all North American “dogooders” in Latin America. I am sure you know of my present efforts to obtain the voluntary withdrawal of all North American volunteer armies from Latin America - missionaries, Peace Corps members and groups like yours, a “division” organized for the benevolent invasion of Mexico. You were aware of these things when you invited me- of all people - to be the main speaker at your annual convention. This is amazing! I can only conclude that your invitation means one of at least three things:
Some among you might have reached the conclusion that CIASP should either dissolve altogether, or take the promotion of voluntary aid to the Mexican poor out of its institutional purpose. Therefore you might have invited me here to help others reach this same decision.

You might also have invited me because you want to learn how to deal with people who think the way I do - how to dispute them successfully. It has now become quite common to invite Black Power spokesmen to address Lions Clubs. A “dove” must always be included in a public dispute organized to increase U.S. belligerence.

And finally, you might have invited me here hoping that you would be able to agree with most of what I say, and then go ahead in good faith and work this summer in Mexican villages. This last possibility is only open to those who do not listen, or who cannot understand me.

I did not come here to argue. I am here to tell you, if possible to convince you, and hopefully, to stop you, from pretentiously imposing yourselves on Mexicans.

I do have deep faith in the enormous good will of the U.S. volunteer. However, his good faith can usually be explained only by an abysmal lack of intuitive delicacy. By definition, you cannot help being ultimately vacationing salesmen for the middle-class “American Way of Life,” since that is really the only life you know. A group like this could not have developed unless a mood in the United States had supported it - the belief that any true American must share God’s blessings with his poorer fellow men. The idea that every American has something to give, and at all times may, can and should give it, explains why it occurred to students that they could help Mexican peasants “develop” by spending a few months in their villages.

Of course, this surprising conviction was supported by members of a missionary order, who would have no reason to exist unless they had the same conviction - except a much stronger one. It is now high time to cure yourselves of this. You, like the values you carry, are the products of an American society of achievers and consumers, with its two-party system, its universal schooling, and its family-car affluence. You are ultimately-consciously or unconsciously - “salesmen” for a delusive ballet in the ideas of democracy, equal opportunity and free enterprise among people who haven’t the possibility of profiting from these.

Next to money and guns, the third largest North American export is the U.S. idealist, who turns up in every theater of the world: the teacher, the volunteer, the missionary, the community organizer, the economic developer, and the vacationing do-gooders. Ideally, these people define their role as service. Actually, they frequently wind up alleviating the damage done by money and weapons, or “seducing” the “underdeveloped” to the benefits of the world of affluence and achievement. Perhaps this is the moment to instead bring home to the people of the U.S. the knowledge that the way of life they have chosen simply is not alive enough to be shared.

By now it should be evident to all America that the U.S. is engaged in a tremendous struggle to survive. The U.S. cannot survive if the rest of the world is not convinced that here we have Heaven-on-Earth. The survival of the U.S. depends on the acceptance by all so-called “free” men that the U.S. middle class has “made it.” The U.S. way of life has become a religion which must be accepted by all those who do not want to die by the sword – or napalm. All over the globe the U.S. is fighting to protect and develop at least a minority who consume what the U.S. majority can afford. Such is the purpose of the Alliance for Progress of the middle-classes which the U.S. signed with Latin America some years ago. But increasingly this commercial alliance must be protected by weapons which allow the minority who can “make it” to protect their acquisitions and achievements.

But weapons are not enough to permit minority rule. The marginal masses become rambunctious unless they are given a “Creed,” or belief which explains the status quo. This task is given to the U.S. volunteer - whether he be a member of CLASP or a worker in the so-called “Pacification Programs” in Viet Nam.

The United States is currently engaged in a three-front struggle to affirm its ideals of acquisitive and achievement-oriented “Democracy.” I say “three” fronts, because three great areas of the world are challenging the validity of a political and social system which makes the rich ever richer, and the poor increasingly marginal to that system.

In Asia, the U.S. is threatened by an established power -China. The U.S. opposes China with three weapons: the tiny Asian elites who could not have it any better than in an alliance with the United States; a huge war machine to stop the Chinese from “taking over” as it is usually put in this country, and; forcible re-education of the so-called “Pacified” peoples. All three of these efforts seem to be failing.

In Chicago, poverty funds, the police force and preachers seem to be no more successful in their efforts to check the unwillingness of the black community to wait for graceful integration into the system.

And finally, in Latin America the Alliance for Progress has been quite successful in increasing the number of people who could not be better off - meaning the tiny, middle-class elites - and has created ideal conditions for military dictatorships. The dictators were formerly at the service of the plantation owners, but now they protect the new industrial complexes. And finally, you come to help the underdog accept his destiny within this process!

All you will do in a Mexican village is create disorder. At best, you can try to convince Mexican girls that they should marry a young man who is self-made, rich, a consumer, and as disrespectful of tradition as one of you. At worst, in your “community development” spirit you might create just enough problems to get someone shot after your vacation ends_ and you rush back to your middleclass neighborhoods where your friends make jokes about “spits” and “wetbacks.”

You start on your task without any training. Even the Peace Corps spends around $10,000 on each corps member to help him adapt to his new environment and to guard him against culture shock. How odd that nobody ever thought about spending money to educate poor Mexicans in order to prevent them from the culture shock of meeting you?
In fact, you cannot even meet the majority which you pretend to serve in Latin America - even if you could speak their language, which most of you cannot. You can only dialogue with those like you - Latin American imitations of the North American middle class. There is no way for you to really meet with the underprivileged, since there is no common ground whatsoever for you to meet on.

Let me explain this statement, and also let me explain why most Latin Americans with whom you might be able to communicate would disagree with me.

Suppose you went to a U.S. ghetto this summer and tried to help the poor there “help themselves.” Very soon you would be either spit upon or laughed at. People offended by your pretentiousness would hit or spit. People who understand that your own bad consciences push you to this gesture would laugh condescendingly. Soon you would be made aware of your irrelevance among the poor, of your status as middle-class college students on a summer assignment. You would be roundly rejected, no matter if your skin is white-as most of your faces here are-or brown or black, as a few exceptions who got in here somehow.

Your reports about your work in Mexico, which you so kindly sent me, exude self-complacency. Your reports on past summers prove that you are not even capable of understanding that your dogooding in a Mexican village is even less relevant than it would be in a U.S. ghetto. Not only is there a gulf between what you have and what others have which is much greater than the one existing between you and the poor in your own country, but there is also a gulf between what you feel and what the Mexican people feel that is incomparably greater. This gulf is so great that in a Mexican village you, as White Americans (or cultural white Americans) can imagine yourselves exactly the way a white preacher saw himself when he offered his life preaching to the black slaves on a plantation in Alabama. The fact that you live in huts and eat tortillas for a few weeks renders your well-intentioned group only a bit more picturesque.

The only people with whom you can hope to communicate with are some members of the middle class. And here please remember that I said “some” -by which I mean a tiny elite in Latin America

You come from a country which industrialized early and which succeeded in incorporating the great majority of its citizens into the middle classes. It is no social distinction in the U.S. to have graduated from the second year of college. Indeed, most Americans now do. Anybody in this country who did not finish high school is considered underprivileged.

In Latin America the situation is quite different: 75% of all people drop out of school before they reach the sixth grade. Thus, people who have finished high school are members of a tiny minority. Then, a minority of that minority goes on for university training. It is only among these people that you will find your educational equals.

At the same time, a middle class in the United States is the majority. In Mexico, it is a tiny elite. Seven years ago your country began and financed a so-called “Alliance for Progress.” This was an “Alliance” for the “Progress” of the middle class elites. Now. it is among the members of this middle class that you will find a few people who are willing to send their time with you_ And they are overwhelmingly those “nice kids” who would also like to soothe their troubled consciences by “doing something nice for the promotion of the poor Indians.” Of course, when you and your middleclass Mexican counterparts meet, you will be told that you are doing something valuable, that you are “sacrificing” to help others.
And it will be the foreign priest who will especially confirm your self-image for you. After all, his livelihood and sense of purpose depends on his firm belief in a year-round mission which is of the same type as your summer vacation-mission.

There exists the argument that some returned volunteers have gained insight into the damage they have done to others - and thus become more mature people. Yet it is less frequently stated that most of them are ridiculously proud of their “summer sacrifices.”

Perhaps there is also something to the argument that young men should be promiscuous for awhile in order to find out that sexual love is most beautiful in a monogamous relationship. Or that the best way to leave LSD alone is to try it for awhile -or even that the best way of understanding that your help in the ghetto is neither needed nor wanted is to try, and fail. I do not agree with this argument. The damage which volunteers do willy-nilly is too high a price for the belated insight that they shouldn’t have been volunteers in the first place.

If you have any sense of responsibility at all, stay with your riots here at home. Work for the coming elections: You will know what you are doing, why you are doing it, and how to communicate with those to whom you speak. And you will know when you fail. If you insist on working with the poor, if this is your vocation, then at least work among the poor who can tell you to go to hell. It is incredibly unfair for you to impose yourselves on a village where you are so linguistically deaf and dumb that you don’t even understand what you are doing, or what people think of you. And it is profoundly damaging to yourselves when you define something that you want to do as “good,” a “sacrifice” and “help.”

I am here to suggest that you voluntarily renounce exercising the power which being an American gives you. I am here to entreat you to freely, consciously and humbly give up the legal right you have to impose your benevolence on Mexico. I am here to challenge you to recognize your inability, your powerlessness and your incapacity to do the “good” which you intended to do.

I am here to entreat you to use your money, your status and your education to travel in Latin America. Come to look, come to climb our mountains, to enjoy our flowers. Come to study. But do not come to help.

More news from the world's largest gay male organisation, the Vatican

The German Jesuit priest Hermann Kugler labelled the Roman Catholic Church the largest transnational gay organisation that he is aware of, and criticised the organisation's continuing hypocrisy when it comes to the matter of homosexuality.

So without further ado, as my weekend entertainment contribution, here's a cool undercover stint Italy's La 7 TV channel has undertaken. They followed a male teenager's travails in gay internet chatrooms. He successfully managed to pick up a whole bunch of Catholic priests, including a character belonging to the Vatican's senior management, some Monsignore Tommaso Stenico. He meets the boy in his office and tries to pick him up. So he asks the teenager whether he likes him etc. Anyway, true to Catholic form he got fired, and true to Catholic form he denies being gay. He claims he only dated the boy to counsel him (hence presumably the question of whether or not the boy finds him attractive...).

If this all wasn't so sad, it probably would be funny. The ethical question, of course, arises, whether it's acceptable to publicly 'out' closeted gay men such as Mr Stenico. I do subscribe to the view that such men become fair game when they publicly engage in homophobia promoting activities. This is something Mr Stenico would routinely do as part of his job in the Roman Catholic Church's senior management structures. So, in a sense, outing a hypocrite is probably a legitimate kind of activity.

From Biko to Guantanamo - Doctors' involvement in torture

This Letter to the Editor was published in THE LANCET in September 2007. It was also reported on the Canadian Medicine Editors' blog. They note that only one Canadian signature was amongst the signatories of the Letter. The Letter draws parallels between the conduct of doctors in the case of the torture and eventual murder of South African anti- apartheid activist Steve Biko and the treatment of prisoners on Guantanamo.

The irony of the letter, of which I am a signatory, is that its instigators (David Nicholl, Trefor Jenkins and Steve Miles) chose THE LANCET as the outlet for the Letter. THE LANCET, of course, is at the receiving end of an international boycott aiming at its owner, Elsevier. Elsevier is heavily involved in facilitating international arms trade, a profit driven mission that doesn't gel too well with its academic publishing activities.

From Steve Biko to Guantanamo - 30 years of medical involvement in torture

This week marks the 30th anniversary of the death of anti-apartheid activist Steve Biko while being detained by security police. Initially, the South African Minister of Justice suggested Biko had died of a hunger strike. The inquest revealed that he had died of the consequences of head injuries sustained during police interrogation, and identified gross inadequacies in the medical treatment from the two doctors responsible for his care including the falsification of records. The regulatory authorities failed to take firm action, and it was only grass-roots action by doctors that led, almost 8 years later to Dr Benjamin Tucker being found guilty of improper and disgraceful conduct and being struck off, whilst Dr Ivor Lang was found guilty of improper conduct and was given a caution and a reprimand1.

There are strong parallels with the Biko case and the ongoing role of US military doctors in Guantanamo and the War on Terror. Last year, we suggested that the physicians in Guantanamo force-feeding hunger strikers should be referred to their professional bodies for breaching internationally accepted ethical guidelines2. One of us (DJN) lodged formal complaints with the Medical Boards for Georgia and California as well as pointing out to the American Medical Association (AMA) that the former hospital commander at Guantanamo, Dr John Edmondson, was a member3. After eighteen months, there has still been no reply from the AMA, the Californian authorities have stated that “they do not have the jurisdiction to investigate incidents that occurred on a federal facility/military base”, the Georgian authorities stated that the “complaint was thoroughly investigated” but “the Board concluded that there was not sufficient evidence to support prosecution”, yet an analysis of the same affidavit by the Royal College of Physicians concluded that “in England, this would be a criminal act” (Personal communications to DJN).

The UK government has refused a request from the British Medical Association for a group of independent doctors to assess the detainees4 and, to date, there has been no formal report on the 3 alleged suicides in Guantanamo that took place in June 2006.

The resolution of the Biko case was instrumental in the rehabilitation of the South African Medical and Dental Council and the Medical Association of South Africa which had been subject to boycotts during the apartheid years. The failure of the US regulatory authorities to act is quite simply damaging the reputation of US military medicine. No healthcare worker in the War on Terror has been charged or convicted of any significant offence despite numerous instances documented including fraudulent record keeping in detainees who have died as result of failed interrogations5. We suspect that the doctors in Guantanamo and elsewhere have made the same mistake as Dr Tucker who in 1991, in expressing remorse and seeking re-instatement said “I had gradually lost the fearless independence …and become too closely identified with the organs of the State, especially the Police force…I have come to realise that a medical practitioner’s first responsibility is the well-being of his patient, and that a medical practitioner cannot subordinate his patient’s interest to extraneous considerations.” (cited in1)
The attitude of the US medical establishment appears to be one of ‘See no evil, hear no evil, speak no evil’.


1. Jenkins T McLean GR. The Steve Biko affair: a case study in Medical Ethics. Developing World Bioethics 2003; 3(1): 77-102.
2. Nicholl DJ and 262 other doctors. Forcefeeding and restraint of Guantanamo Bay hunger strikers. Lancet 2006; 367:811.
3. Nicholl DJ. Guantanamo- a call for action. Good men need to do something. BMJ 2006; 332:854-855.
4. Nicholl DJ and 119 other doctors. Doctors at Guantanamo. The Times 18th September, 2006.
5. Miles, SH (2006) Oath Betrayed: Torture, Medical Complicity and the War on Terror. Random House, New York

Friday, October 12, 2007

Catholic Priest convicted torturer

It has been known for some time that the Roman Catholic Church has been a haven for pedophile priests in many countries. Well, it turns out that 'Gods' dress wearing representatives on our lil planet also enjoy other kinds of kicks. Christian Frederico von Wernich, a police chaplain no less, couldn't resist laying hands on allegedly left-wing guerillas during the years in which Argentina suffered under a fascist military dictatorship. Von Wernich was convicted of having undertaken multiple acts of torture of prisoners and was sentenced this week by an Argentinian court to lifelong imprisonment.

The Church hierarchy initially denounced the prosecution as an attack on Catholicism itself. The trouble for our dress wearing 'God' rep began when eye witnesses confirmed beyond reasonable doubt that von Wernich participated actively in the kidnapping, torture and murder of left-wing opponents of the dictatorship. Von Wernich, in the past, busily defended torture as a legitimate means to protect the fascist regime against its critics. Naturally the Church hierarchy didn't see it necessary to reign in his activities when it should have.

The one question that remains, given the criminal history of the Roman Catholic Church, is why anyone would still want to give credence to any Church pronouncement on matters ethics. What's kinda puzzling is also why their good, all powerful, and all knowing 'God' didn't think it might be a good idea to put a stop at least to his rep behaving like ... well, a torturer... but that really brings us full circle to the question of why folks continue to believe that there is such a being to begin with.

Sunday, October 07, 2007

Weekend ranting: On being 'invited'

I don't know how many of you find yourselves in the - sometimes - fortunate situation of getting invited by university departments to give presentations, or to attend conferences. I have been lucky in that regard and hope that whatever I offer is worth the hosts time and money. There's something slightly odd about how many universities work, in this context, however. So, to let you in on how they use their guests as their private banking facilities, here are two recent examples, a good one and a pretty terrible one.

Let me perhaps start with a good experience: Cheryl Cox at St George's University on Grenada invited me over for a couple of lectures and a few other things. While everything was short notice, the university was truly superbly organized. Its travel agent booked the air tickets, and nothing had to be advanced by me other than a taxifare to my local airport. Very sensibly the organization appreciated that there is something odd about a university inviting a visitor and expecting them to advance substantial amounts of money to get there.

Contrast this with Subrata Saha from SUNY Downstate in Brooklyn. He invited me (from Europe at the time) to present a talk during a conference he was organizing in April this year. I was expected to purchase the ticket to get there (I did, in February 2007 ), and am still awaiting (in October 2007) the reimbursement. Indeed, both Dr Saha and the person reportedly responsible for organizing the reimbursement have stopped since replying altogether to queries as to when the reimbursement can reasonably be expected. Professional conduct of these organizers of - of all things - an ethics conference? Hardly. I mean, if there had been internal problems they could have kept me abreast of the developments to indicate that they're working on it. One wonders whether there is any intention at all to repay the credit (interest free) that their organization has taken from me...

So, I guess this is one of those let the buyer beware type situations. Each time one agrees to advance travel expenses one has to rely on the decency of those requesting the same, and hope that they will reasonably speedily reimburse what they promised to reimburse. I wonder, though, whether we academics should establish some kind of public blacklist of particularly despicable institutions so that the buyer (ie the next person invited to speak there) can make an informed choice as to whether or not he or she is likely to see his or her money back in a timely fashion. SUNY Downstate, certainly would feature prominently on my blacklist. I won't be seen there again.