2014 JCR Impact Factor for Bioethics and Medical Ethics Journals

Caution: this list does not reflect 'quality', or 'best' unless you assume that a lot of people citing and criticising obviously flawed content published in a journal would demonstrate that that journal is a high quality outlet. All it does is indicate how frequently articles in that journal were cited over a predetermined period of time. It doesn't tell us anything about the reasons for the citations. I included journals I found in JCR's medical ethics as well as its ethics list. - Not that it should matter, but for the sake of it, I co-edit 2 and 6 on this list.

Abbreviated Journal Title	{2014}            Total Cites	Impact Factor
AM J BIOETHICS	1363	5.288
DEV WORLD BIOETH	238	2.054
HASTINGS CENT REP	988	1.684
J MED ETHICS	2845	1.511
BMC MED ETHICS	404	1.495
BIOETHICS	982	1.483
NEUROETHICS-NETH	205	1.311
J EMPIR RES HUM RES	365	1.25
PUBLIC HEALTH ETH-UK	190	1.182
J LAW MED ETHICS	1189	1.097
HEALTH CARE ANAL	357	0.958
KENNEDY INST ETHIC J	285	0.867
J MED PHILOS	675	0.851
ACCOUNT RES	173	0.826
J BIOETHIC INQ	165	0.747
NANOETHICS	146	0.703
MED HEALTH CARE PHIL	448	0.7
CAMB Q HEALTHC ETHIC	344	0.682
MED LAW REV	153	0.65
THEOR MED BIOETH	325	0.537
INT J FEM APPROACHES	48	0.486
REV ROM BIOET	112	0.462
ETHIK MED	56	0.326
ACTA BIOETH	45	0.074

The dangers of assisted suicide – making a mountain out of a mole hill

I recently came across this piece by an Australian psychiatrist, John Buchanan, published in Australia's only quality broadsheets, Melbourne's The Age and Sydney's Sydney Morning Herald. Much as I am flattered by being described in Australia as an influential bioethicist, he got it badly wrong in his commentary. Here's a reply to Buchanan's analysis (I did, of course, send it to the paper's OpEd editor but didn't receive so much as an acknowledgment that they received it, much less do they apparently want to publish this response - so far for the influential bioethicist thing :-).

John Buchanan argued in this paper (May 27) that Victoria’s Parliament should reject a motion by the Greens to review the state’s assisted dying prohibitions. His main concern is that assisted dying legislation could not protect against abuse. Buchanan is primarily worried about assisted dying legislation’s impact on disabled patients, the mentally ill, and other vulnerable people.  

As an Australian making a living as an academic in Canada I have been privileged to chair on behalf of the Royal Society of Canada an international expert panel drafting a report on end-of-life decision-making. Among our recommendations was that Canada ought to decriminalise assisted dying. In a unanimous decision the country’s Supreme Court came recently to the same conclusion. On the face of it, it is quite unlikely that the expert panel that I chaired as well as the honourable Supreme Court justices would have missed existing evidence of the abuse of vulnerable people in jurisdictions that have decriminalised.

This perhaps is a good indication as any, that doomsday sayers such as Buchanan have got it wrong on this issue. His arguments are all too familiar to those of us who have been involved in these debates. Let me address some of them.

Among his evidence is a reference to a Dutch ‘medical ethicist’ who changed his mind on euthanasia. Said ethicist’s views are presented as a quote from a notorious British newspaper not known to feature quality content. It turns out, this ‘medical ethicist’ is Theo Boer, a Christian theologian employed at a Dutch Protestant university. Boer cuts a pretty lonely figure on this issue in the Netherlands. The existing assisted dying regime is overwhelmingly supported both by Dutch clinicians as well as the Dutch people. Clutching at straws is a familiar theme when it comes to anti-choice activism.

Buchanan serves another staple of anti-choice campaigners, personal anecdotes. He mentions hospital administrators getting all fired up about assisted dying so that they can empty hospital beds. There’s naturally also a fair bunch of greedy relatives and whatnot else. It is odd indeed that we must take his word for it. In a case currently windings its way thru the courts in New Zealand, similar anecdotes have been presented by the handful of clinicians travelling the globe to prevent legal assisted dying from coming about. Unsurprisingly, actual peer reviewed scientific literature does not support these claims. Perhaps anti-choice campaigners are drawn in strange ways to abusive hospital administrators and greedy relatives. A recent survey of permissive jurisdictions concluded that the average patient requesting assistance in dying is a late-stage middle-class male cancer patient. At no time has it been demonstrably shown that in permissive jurisdictions vulnerable disabled or mentally ill patients have been disproportionately affected by assisted dying. If anything, the existing evidence could be interpreted as showing that they have trouble accessing assisted dying.

There is something deeply troubling about the trope of alleged abuse meted out against disabled people, beyond the mere absence of credible evidence to support it. Disabled people have often been at the forefront of attempts to decriminalised assisted dying, because they often are least able to end their lives on their own accord, precisely due to their disability. A case in point is Canadian Steven Fletcher, a quadriplegic Conservative Member of Parliament. Paralysed from his neck down, a result of a car accident involving a moose in 1996, it was Fletcher who introduced assisted dying legislation in the Canadian House of Commons. 

Buchanan also claims darkly that Belgium and the Netherlands have widened access criteria. For that to be of concern we would already need to have concluded that there is something wrong about assisted dying. That, however, is what is in dispute. If I lived in a jurisdiction that had decriminalised assisted dying, I would want my government to monitor carefully how the existing regime works out and to adjust it in response to societal need. That might well entail changes to access criteria. Any such change as such is not evidence of something gone awry. 

Buchanan further makes the suggestion that we should improve the quality and availability of palliative care. He is right, we suggested that much in our Canadian report. He is wrong to assume that this is an either-or type situation. We know that even with the best palliative care there will be a fair number of patients who want an assisted death regardless. Study after study produced by palliative care specialists opposed to assisted dying comes to this very same conclusion. Palliative care will never be a panacea to resolve everyone’s suffering to their satisfaction.

Buchanan ends with the conclusion that ‘the risks of assisted suicide legislation are too great.’ His whole piece provides no evidence to support that conclusion. The problem for Buchanan and others like him is that we do not live in the 1970s any longer. We actually know what happened over many years in jurisdictions that have introduced assisted dying. Precisely the lack of evidence of abuse is the reason for why an increasing number of jurisdictions are decriminalising assisted dying. It is time for Australia to follow suit. Leaving things as they are condemns many of us to a death that is disrespectful of our final considered choices.

Desperate patients campaigning publicly for living donor organs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One would expect senior academics to appreciate these differences.

Treatment resistant depression and access to assisted dying

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

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

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

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

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

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

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

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

The trouble with international ethics guidelines

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

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

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

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

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

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

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

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

---

[1] Schuklenk, U. 1998. Unethical Perinatal HIV Transmission Trials Establish Bad Precedent. Bioethics 12: 311-318.

 

[2] Schuklenk U. 2004. The Standard of Care Debate: Against the Myth of an ‘International Consensus Opinion’. Journal of Medical Ethics 30: 194-197.

[3] Schuklenk U. 2004. Ibid.

[4] WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva, August 12, 2014. http://www.who.int/mediacentre/news/statements/2014/ebola-ethical-review-summary/en/ [Accessed March 16, 2015.] See also WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva: Report of an advisory panel to WHO. Geneva, n.d. http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf [Accessed March 17, 2015.]

[5] Eg Anonymous. 2015. WHO approves experimental treatment for Ebola. AlJazeera August 12, 2014. http://www.aljazeera.com/news/africa/2014/08/who-approves-experimental-treatment-ebola-2014812122023925143.html, McKay B, Loftus, P. 2014. Ebola Virus: Experimental Drugs Approved for Use in Fighting Outbreak in West Africa. Wall Street Journal August 13, 2014.   http://www.wsj.com/articles/experimental-drugs-are-approved-for-use-in-fighting-ebola-in-west-africa-1407884538 [Accessed March 17, 2015]

 

[6] Hayden EC, Reardon S. 2014. Should experimental drugs be used in the Ebola outbreak? Nature August 12 doi:10.1038/nature.2014.15698.

[7] WHO. 2015. Public consultation on emergency use assessment and listings procedures for medical products during public health emergencies. http://www.who.int/medicines/news/public_consult_med_prods/en/ [Accessed March 18, 2015.]

GoodLife's straight members only competion -2-

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

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

Thank you very much for bringing this to our attention. We were not aware that this legislation exists in Jamaica.

 

A part of the rules and regulations for this contest include the ability to substitute, modify etc. trips for any reason. Should you win this trip, we would be happy to award you with a trip of equal value to another destination.

 

We have connected with Tourism Jamaica and they provided us with the following information:

Jamaica welcomes visitors from all over the world and from all segments of society equally with the warmth and courtesy they expect and deserve. We recognize that there are diverse communities and cultures interested in Jamaica as a travel destination, and we embrace that diversity with respect.

 

In Jamaica, we are committed to the safety of all travelers. We respect the right of all visitors to Jamaica to express their own beliefs and to satisfy their own vacation experiences while staying with us.

 

We respect the choices of adults and responsible adult activities. In keeping with travel to any destination in the world, we encourage visitors to respect Jamaican laws and community standards, and to take reasonable  measures to enhance their travel experience. 

 

Please know that we welcome everyone with open arms and look forward to sharing the beauty that is Jamaica with them.

 

Thank you,

Tara

 

 

 

Tara McLain
Public Relations Specialist
Marketing & Public Relations Department

My response:

Dear Tara,

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

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

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

A colleague of mine has since written about this issue here: http://fitisafeministissue.com/2015/04/06/goodlife-competition-for-straights-only/

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

Sincerely,

udo Schuklenk

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

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

Dear Mr Patchell-Evans,

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

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

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

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

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

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

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

I am looking forward to your timely response.

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

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

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

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

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

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

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

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

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

 

UDO SCHUKLENK

 

 

 

 

 

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[1] Sharon K. 2015. Unacceptable to force doctors to participate in assisted dying against their conscience: CMA. National Post March 05. http://news.nationalpost.com/2015/03/05/unacceptable-to-force-doctors-to-participate-in-assisted-dying-against-their-conscience-cma-head/ [Accessed March 26, 2015.]

[2] Leiter B. 2013. Why Tolerate Religion? Princeton, NJ: Princeton University Press.

[3] Kirkey S. Op.cit.

[4] Savulescu J. 2006. Conscientious objection in medicine. bmj 332: 294

Assisted Dying coming to Canada

What a week this past week has been. While I was away on a business trip to Europe the Supreme Court of Canada (SCC) let it be known that it would release on Friday this week its decision on the so-called Carter case, that is, it would pronounce on the constitutionality of the bits and pieces in our Criminal Code that criminalise assisted dying.

Unless you have lived under a rock during these last few years you will know that I spent a significant amount of my time arguing in favour of the decriminalisation of assisted dying in the country, no least in a report of an expert panel the Royal Society of Canada asked me to chair, on end-of-life decision-making in Canada. In addition I wrote a large number of newspaper columns on the issue and gave oodles of TV interviews and what-not to advance that cause.

So, there I was holed up in hotel rooms in Brussels and Geneva trying to respond to media inquiries. Fearlessly I predicted that the court would come to a unanimous decision and that it would decriminalise assisted dying. I couldn't see, given what we know from jurisdictions that have decriminalised, that the Justices would fall for the slippery-slope clap-trap rolled out by religious opponents of assisted dying, and, of course, their biggest ally, the current Attorney General of this country. I also couldn't see that the Justices would wilfully ignore consistent opinion polls suggesting that overwhelming (I mean: more than 80%) majorities of Canadians are in favour of a change toward making assisted dying available.

It turns out, I was right. The SCC came down with this unanimous decision, defining thus who would be able to receive assistance in dying: a 'competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.'

This is pretty much what we recommended in our report. What I find particularly important about these criteria is that the Justices rejected a threshold requiring that patients must be in a terminal condition, or near the end of life. The current legislation, on this count, in Quebec, will have to be re-written. At the last minute opponents of Quebec's legislation added this threshold, and, thanks to the SCC decision, it will have to be taken out of Quebec's legislation again as it would unjustly deprive people of access to assisted dying who are not close to the end of their lives.

I think, among the important lessons to be learned from all this, is this one: Opponents of assisted dying should reconsider their campaign strategies. They decided that telling anecdotes from jurisdictions that have decriminalised, making up a lot of stuff about things that allegedly happened in such jurisdictions and telling half-truths about what allegedly happened in jurisdictions that have decriminalized worked in their religious echo chamber of pro-life websites, as well as with allied newspaper columnists like the National Post's Barbara Kay and the Toronto Star's Rosie DiManno, and so it would probably work with Supreme Court Justices, too. Turns out, Supreme Court Justices are a bit smarter than DiManno and Kay, who have shown themselves clueless about the issue at hand throughout their years of campaigning in their newspaper columns against assisted dying. The judges looked at the actual evidence and 'rejected the argument that adoption of a regulatory regime would initiate a descent down a slippery slope into homicide.'

The other vacuous agitprop campaign tool deployed by this camp was their ever-growing concern for 'the vulnerable'. Given that they didn't want assisted dying available to anyone, they were careful never to define 'vulnerable'. Turns out, they and their government ally, the Attorney General, really meant everyone. Vulnerability ceases then to be a useful threshold criterion for anything. The Attorney General eventually said, on the Court record, that 'every person is potentially vulnerable.' The Supreme Court called curtains on this rhetoric, too. It states point blank, 'We do not agree.' - 

Aggressive lying and fudging of the issues apparently takes you only that far when it comes to Canada's Supreme Court Justices.

I wonder whether one analysis in the judgment (paragraphs 64-66) could be interpreted as rejecting the Catholic acts and omissions doctrine. Check that one out yourself. Worth a read.

Restorative justice Dalhousie University style

5 Jan 2015 Update on the post below. Dalhousie University announced today that the dental students in question have been suspended from participation in clinics. Apparently they would still be able to attend classes with the fellow female classmates that were the subject of their rape fantasies. Mind boggling. -----

Quite remarkable events are occurring currently at Dalhousie University's Dental School. They take place against the backdrop of an ongoing international outcry about alleged or real rape cultures on university campuses across North America.

 

What happened at Dalhousie is that a bunch of male dentistry students made on a private Facebook page statements celebrating the rape of female fellow students, they reportedly ranked these women for 'hate sex', fantasized about chloroforming them, then raping them, the list goes on.

 

Invariably there has been talk about boys will be boys, immaturity and whatnot. The truth, however, is that these men are adults. They have just about completed a graduate program in dentistry. Here are a bunch of screenshots from their little FB horror show. Misogyny is apparently not a phenomenon limited to student conduct at Dalhousie's School of Dentistry.

 

If the reported facts are correct, I cannot see how any of these students could possibly be permitted to complete their studies and graduate. I also cannot see how anyone could provide them in good conscience with a license to practice dentistry. These students are clearly unfit to become health care professionals. It is that simple. Vulnerable patients should be wary of any regulatory body that saw fit to provide such people with a license to practice dentistry.

 

Given that these students are at the end of the 4th year, one also has to wonder how effective the Dental School's professional ethics education has been.

 

Well, you'd expect that a professional school would simply eject students that demonstrably committed such offences. Not so at Dalhousie. Its President decided to embark on a restorative justice course of action. He is supported by an unsigned letter purportedly from a Dalhousie Feminist Legal Association. The anonymous authors of the letter clearly love restorative justice. Thing is, Dalhousie, prior to engaging in its restorative justice activity, didn't even bother checking with all of the women named in the Facebook group posts whether they thought that that would be an appropriate course of action. At least one of the women named in the Facebook group's messages is explicitly opposed to the informal restorative justice process. She calls the whole idea 'shocking'. It is clear today that there was no consensus among these women about this approach. That alone calls into question its appropriateness.

 

I am not sure where I stand with regard to restorative justice activities. I find the whole idea to subject the victims of violence or abuse to the need to talk to their abusers, make the latter understand and whatnot pretty silly stuff. I can see that it might work in terms of rehabilitating someone, but really, why should that be a victim's job to begin with? In South Africa the Truth and Reconciliation Commission seems to have been a bit of a failure. Many of those whose loved-ones were murdered by the apartheid regime weren't quite happy that everyone was forgiven by the TRC, provided they showed enough contrition - fake or otherwise. You talk to Black South Africans in the streets of, say, Johannesburg today and you'll hear that very many of them think that they were robbed of justice by the activities of the TRC.

 

For the men involved in the Facebook group this restoration exercise provides a shot at walking away scotch-free provided they show enough contrition and reach some consensus with their victims. The fact of the matter is that there will never be a realistic chance of telling whether they have shown genuine insight or whether they were focused on becoming dentists, no matter what. They have been told that they might still be expelled from University, so they have every incentive to grovel as sincerely as they can, no matter what their actual views on the subject. Here is some indication regarding their capacity to show insight and remorse.

 

Meanwhile, come Monday morning, the women subjected to rape fantasies by their male classmates will be lucky enough to face them again in class and dental clinics while the restoration show gets on the road. Is this mind boggling? Not just a little bit. One wonders what's going on in the minds of senior management at Dalhousie.

 

In any case, the university remains responsible for disciplining students that violate its codes of conduct. Several faculty members of the university have lodged a formal complaint that should have triggered a formal investigation (quite distinct from the informal and ultimately toothless restoration exercise). They wrote this letter on December 21, 2014 to Dalhousie's Acting Vice Provost for Student Affairs. The faculty members have not heard back since then. Keep in mind, on Monday these students will be back in class.

 

These faculty members called it right. They asked for a formal disciplinary investigation and a suspension of the students while the investigation is under way. They realised that permitting these men to continue attending classes will not be a cost neutral activity to many of their female classmates. Apparently even this insight is lost on the Dalhousie administration. 

 

While there is nothing per se wrong with following the informal process of restorative justice, it clearly is insufficient to address the problem at hand. A formal disciplinary investigation is called for, independent of the restorative justice exercise. The men involved and identified in the Facebook postings should be suspended until that formal investigation has run its course.