Back to blogging - stuff is happening :)

I have been pretty quiet on the blogging frontiers during the last few months. I have been juggling various manuscripts, including a book manuscript, as well as teaching, so basically I was too tired to blog much (well, too tired to blog at all).

Anyhow, so here's an update:

Ruth Chadwick and I managed to send a first rough draft of our textbook to Wiley to have it externally reviewed. It will need quite a bit more work, but we hope to get this done during the summer months.

I have a lengthy review article on the ethics of Conscientious Objection accommodation in the British Medical Journal. You can find it here. 

The title is: Conscientious objection in medicine: accommodation versus professionalism and the public good.


I also, jointly with Justine Dembo and Jonathan Reggler have an Open Access paper in the Canadian Journal of Psychiatry on medical aid in dying and depression. You can find it here.

The title is: 'For their own good': A Response to Popular Arguments Against Permitting Medical Aid in Dying (MAID) where Mental Illness Is the Sole Underlying Condition.


There is also a completed book chapter to report in a Palgrave MacMillan handbook on, I think, political philosophy. I did that jointly with an undergraduate student at Queen's, Benjamin Zolf.

And there are various Editorial type papers, including (in German) this one on the use of ethical deliberation in the decision-making on public health policy.

Bioethics and the Ebola Crisis

As I write this the global north’s media hype about the Ebola outbreak in various West African nations is at its peak. Amidst wild speculations about the number of infected people there are also confirmed facts, such as about 3700 confirmed cases and about 1800 deaths.[1] No doubt numbers will increase. These cases occurred overwhelmingly in Liberia, Sierra Leone, Guinea and most recently Nigeria. It goes without saying that many more people have died of other preventable or treatable diseases in that same period of time in those same countries, yet the world’s gaze was transfixed on Ebola. Just for a reality check, in Nigeria about 215.000 people die per year entirely preventable deaths related to HIV/AIDS and another 300.000 die of Malaria.[2] Having said that, Ebola is a pretty terrible disease, even by the usual unpleasant standards of life-threatening diseases.

As can be expected of some mysterious disease emanating from the ‘dark continent’, a lot of attention seeking theatre accompanies the deadly performance of the actual virus. The actors are a mixed bunch of Christian missionaries busily trying to get their hands on the last available experimental agents while on private medical jet flights out of West Africa. As you would expect, toward the end of their performance they thanked their respective gods for their survival as opposed to state of the art medical care. Who else performed in the mass media’s bright lights? International organisations tried to grab the limelight. There were serious performers such as Doctors without Borders. They have treated patients in Ebola outbreaks for many years, without ever losing personnel in the process. Doctors without Borders provided us with sensible explanations for the ‘why now’ of the outbreak and the ‘why here’ with regard to where the outbreak is occurring. Essentially the outbreak is occurring in failing states with barely existing health care systems. Patients and their families – often with good reason – do not trust foreign or local medical staff. Quite understandably they are suspicious because mostly body bags leave government and other facilities tasked with attending to Ebola patients. Many of these people also don’t quite buy into the idea of viral causes of disease. Doctors without Borders asked for urgently needed specialist personnel from countries of the global north, staff able to undertake the necessary laboratory work, health care personnel for treatment, portable medical equipment necessary to isolate patients, and so on and so forth. That, of course, is so obvious, that it’s nearly boring. Theatre must be entertaining, and Doctors without Borders isn’t quite delivering on that front.

Steps in the WHO. After missing the outbreak for a fairly extensive period of time the world organisation responsible for global health decided that its first act after declaring this outbreak a pandemic, should be to host an expert meeting on experimental treatments and experimental preventative vaccines. It goes without saying that this haphazard meeting, convened within a week by WHO, and not really staffed by people who are experts on access to experimental agents, provided the necessary entertainment required by the media circuit. Endless media interviews were scheduled on the ethics of access to experimental agents all throughout August 2014, and it is here where the stage opened – finally – for bioethicists.

How did we perform? Did we stress that WHO’s choice of topic and the supposed urgency of its recommendation to provide access to experimental agents in Ebola regions amounted to pointless grandstanding in the face of a pandemic that requires a public health response, and not the tinkering with experimental agents? Some of us did, but it didn’t stop most of us from entertaining questions on the ethics of who should get experimental agents, whether it was ok that white religious activists with a health care background were prioritized over local dying health workers, and other reportedly important questions. In the rush to be seen to do something the WHO managed to convene said meeting without a single representative from a country affected directly by Ebola.

None of that mattered on the main stage of a pandemic veering out of control. Predictably riots broke out, patients ran away from hospitals or were violently freed out of isolation units by their worried families. Such on the ground mayhem would have also made for reasonably nice media theatre, alas, bioethicists decided to bring the full armament of analytical ethics to bear on crucial questions such as who should receive an experimental vaccine first. It is not that they were wrong in their concerns about the fact that these vaccines aren’t quite vaccines, they are chemicals that prevented infections in some monkeys. Even the drugs’ toxicity profiles were not established. So, in fairness there were ethical issues, but they were not the most pressing ethical issues. They were not particularly pressing because these vaccine candidates, even if they turned out to work, would not make a dent in the current pandemic. Did these issues occupy most of the mass media – bioethics collaborative performances? Sadly they did.

In supporting roles appeared health care professionals assembled by various nations, tasked with providing health care and laboratory services. They were doing the kind of work that Doctors without Borders has successfully undertaken for many years. Turns out our supporting actors are at the time of writing not quite ready for prime time, so as quickly as they drop in to West Africa, they are being airlifted due to some real or imaginary risk to them. The obvious point to be made here is perhaps this: Don’t send staff not up to the task, because the endless kerosene burned in private medical jets flying them forth and back is using up resources that could probably be put to better use. For instance, it could be used toward a down-payment for the creation of functioning primary care health care systems in the countries in question. Turns out, this allocation decision is an ethical decision, alas one not addressed by anyone currently pontificating on Ebola ethics.

What then are other relevant ethical questions to be addressed in the context of this pandemic? Here are a few that come to mind: What are the ethical obligations of citizens (and their representative governments) in the global north toward those affected now by this pandemic? Should they send health care personnel, possibly even military personnel, as the US President suggested in an interview? Or would it be sufficient to send a couple of experimental agents and wash their hands of the pandemic, as Canadian bioethicist Peter A. Singer seems to suggest in an interview. [3] Assuming that military or police force could assist in curbing the spread of the pandemic, under what circumstances and within which parameters should such deployments occur? What obligations of care do agencies have toward their staff? Do specialist technical public health workers in the global north have professional responsibilities to participate in Ebola related missions, given that they didn’t quite sign on for that sort of risk when they joined governmental agencies in the UK, Australia, Japan or elsewhere. What personal risks – if any – can they reasonably be expected to accept for themselves, both in terms of infection risk, but also in terms of violence that could occur if the local situation spins further out of control. Given that the existing health care infrastructure in the affected countries is disintegrating in front of our eyes, should others consider stepping in to provide the basic health services the local system was able to provide until – however insufficiently - the Ebola crisis hit?

There you go bioethics. Think of Ebola as primarily a public health challenge not a research ethics phenomenon and you might just be addressing questions that actually matter, ethically.

Udo Schuklenk

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[1] Centers for Disease Control (U.S.). 2014. 2014 Ebola Outbreak in West Africa. http://www.cdc.gov/vhf/ebola/outbreaks/guinea/ (Accessed September 8, 2014)

[2] United States Embassy in Nigeria. Nigeria Malaria Fact Sheet. http://photos.state.gov/libraries/nigeria/231771/Public/December-MalariaFactSheet2.pdf

[3] Hildebrandt, Amber. 2014. Why Canada must approach the Ebola outbreak as a natural disaster. CBC News Sept. 05. http://www.cbc.ca/news/canada/why-canada-must-approach-ebola-outbreak-like-a-natural-disaster-1.2754828 [Accessed September 8, 2014]

Compulsory child vaccination and the conscientious objection business

Ontario’s health minister Deb Matthews announced this week that she is adding three further diseases to the list of illnesses against which children in the province must be vaccinated. It’s mandatory. Her move has been widely lauded by public health experts and medical ethicists. We have seen in recent months outbreaks of preventable illnesses in communities with unusually low vaccination rates. You might recall the most recent outbreak of measles in BC’s Fraser Valley where more than 200 children came down with the measles. The situation seems directly linked to a community objecting to vaccines on religious grounds. Don’t think of measles as a harmless kind of infection. More than 100.000 children die each year worldwide of this entirely preventable disease.

Why on earth would parents not wish to protect their children against a serious infectious but preventable disease? Well, some parents likely will simply forget, or think that it’s not that important. After all, if we have herd immunity you can with reasonable confidence become a non-vaccinated free-rider on your responsibly vaccinated fellow citizens. However, if lots of us choose to become such free-riders the risk of a disease outbreak increases quite dramatically. It’s simple maths really. In any case, it is probably fair to say that not getting your children vaccinated simply because you were too lazy or too selfish, aren’t terribly good ethical justifications for your omission to get your kids vaccinated.

Another possibility is that you belong to those misguided parents out there who have decided, typically based on conspiracy websites that I won’t even be mentioning here, that vaccines do all kinds of evil things and really you mean to protect your child from these evils. No doubt you’ll mention autism as an example of the evils caused by vaccines. Well, let me just tell you that the only peer reviewed research output supporting these claims has since been withdrawn by the journal that published it initially. The researcher who wrote the piece was found guilty of misconduct by a statutory medical council. Shown to be a fraudster he was barred from ever practicing medicine again in Britain. He still remains the posterboy of current-day anti-vaccine activists. What better hero than a medical researcher ‘censored’ by the ‘establishment’. In light of this, to my mind, it makes perfect sense for governments to protect children from parents prone to listening to conspiracy theorists. This is so because if you choose to run with the views of one convicted fraudster against the rest of the biomedical and public health research establishment you haven’t quite done your due diligence. It is that simple.

Let’s assume you’re neither too lazy to have your kids vaccinated nor prone to buying into, however ludicrous, conspiracy theories. What’s left? Funny enough, there is a reason left to you that our health minister (no doubt based on good legal advice) thinks is an acceptable reason. Deb Matthews notes that it could be acceptable for you to object on grounds of conscience, or, as she describes it: religious or philosophical reasons. Fair enough, you need to make your case and apply for an exemption. But, what kind of religious reason could that be? That your god kind of had it in for your kids and that if they catch the measles (and pass them on), it’s ‘God’s will’? Or is the idea that because your imaginary friend in the sky is defined as ‘perfect’ by you, and that that perfect being would not create us as anything other than perfect. So, why bother with vaccines then? Is that it?

I’m flabbergasted about the tolerance we show toward folks objecting – against all the available evidence – to the compulsory vaccination of their children on religious grounds. They are not only risking their children’s health, they are also risking other people’s children’s health. There are always kids who suffer from a weakened immune system or who suffer from illnesses (such as cancer) that do not permit us to vaccinate them. They are put at grave risk by conscientiously objecting anti-vaccine parents.

What’s bothersome here is that, as a society, we ultimately prioritize the value of the parents’ religious convictions over their children’s well-being. I cannot see how that could possibly be ethically defended. Are we really saying that people’s clearly mistaken views about the universe matter more than the well-being of their children – and, indeed, that of other children? That’s what Minister Matthews’ religious and philosophical exemption clause ultimately boils down to. It is one thing to permit legally competent adults to make such choices for themselves, provided they are the only ones seriously affected by the consequences of their actions. Adult Jehovah’s Witnesses come to mind. If they wish to refuse life-preserving blood transfusions and bet on their imaginary friend in the sky, we should respect their choices, however, if they wish to place that bet for their vulnerable children, then surely society needs to step in and protect those children. The same holds true for children whose health is gambled with by their anti-vaccine parents. We should not tolerate religious cop-outs anymore than we tolerate parental convictions based on nonsensical conspiracy theories. Irresponsible parental conduct that is putting their children’s well-being at risk does not deserve societal accommodation.

Udo Schuklenk teaches bioethics at Queen’s University, he tweets @schuklenk.

Poverty and Health

Here was an interesting piece of research that is being reported on the website of the Canadian Broadcasting Corporation. It links into debates on the social determinants of health. It has been argued (and shown) on many occasions that folks lower down the socio-economic pecking order are more likely to suffer from a whole host of chronic (as well as sometimes even infectious) diseases. It turns out, they're more likely to suffer from ' increased rates of death and illness including diabetes, mental illness, stroke, cardiovascular disease, gastrointestinal disease, central nervous system disease and injuries.' Indeed, kids brought up in situation subjecting them to what professionals refer to as 'toxic stress', that includes substandard housing, living with adults who are also stressed due to their socioeconomic circumstances, experience stunted brain development according to a technical report published in 2013 in the journal Pediatrics. The American Academy of Pediatrics issued a large-scale technical report in the end of 2012 that reaches similar conclusions.

No wonder a family medicine specialist in Toronto, Gary Bloch, is quoted in the CBC article as follows, 'Treating people at low income with a higher income will have at least as big an impact on their health as any other drugs that I could prescribe them.'

Such findings must have an impact on ongoing ethics debates among public health ethics experts on how to deal with illnesses such as obesity. Would nudging or stigmatising people who have already lost out on much of what constitutes a good life due to the poverty they experiencing be truly fair? Or would it place additional unfair burdens on those already struggling to live a decent life? Perhaps campaigning for better education and jobs for all would be a better placed priority than figuring out what drugs best control obesity? Difficult one.

Table of Contents Bioethics 2013; 27(2)

Bioethics © Blackwell Publishing Ltd Volume 27, Issue 2 Pages ii - ii, 59 - 116, February 2013 The latest issue of Bioethics is available on Wiley Online Library EDITORIAL Saving Lives (page ii) Ruth Chadwick DOI: 10.1111/bioe.12014 ARTICLES USE OR REFUSE REPRODUCTIVE GENETIC TECHNOLOGIES: WHICH WOULD A ‘GOOD PARENT’ DO? (pages 59–64) JANET MALEK DOI: 10.1111/j.1467-8519.2011.01890.x THE ETHICS OF UTERUS TRANSPLANTATION (pages 65–73) RUBY CATSANOS, WENDY ROGERS and MIANNA LOTZ DOI: 10.1111/j.1467-8519.2011.01897.x STIGMATIZATION AND PUBLIC HEALTH ETHICS (pages 74–80) ANDREW COURTWRIGHT DOI: 10.1111/j.1467-8519.2011.01904.x WELLBEING, SCHIZOPHRENIA AND EXPERIENCE MACHINES (pages 81–88) DAVID RHYS BIRKS DOI: 10.1111/j.1467-8519.2011.01894.x UNCERTAIN TRANSLATION, UNCERTAIN BENEFIT AND UNCERTAIN RISK: ETHICAL CHALLENGES FACING FIRST-IN-HUMAN TRIALS OF INDUCED PLURIPOTENT STEM (IPS) CELLS (pages 89–96) RONALD K.F. FUNG and IAN H. KERRIDGE DOI: 10.1111/j.1467-8519.2011.01896.x OVERSTATING VALUES: MEDICAL FACTS, DIVERSE VALUES, BIOETHICS AND VALUES-BASED MEDICINE (pages 97–104) MALCOLM PARKER DOI: 10.1111/j.1467-8519.2011.01902.x IS PAYMENT A BENEFIT? (pages 105–116) ALAN WERTHEIMER DOI: 10.1111/j.1467-8519.2011.01892.x