Tuesday, 25 October 2011

Petition Against the Participation of Psychologists in Torture

A Call for Annulment of APA’s PENS Report
Over the decade since the horrendous attacks of 9/11, the world has been shocked by the specter of abusive interrogations and the torture of national security prisoners by agents of the United States government. Although psychologists in the U.S. have made significant contributions to societal welfare on many fronts during this period, the profession tragically has also witnessed psychologists acting as planners, consultants, researchers, and overseers to these abusive interrogations. Moreover, in the guise of keeping interrogations “safe, legal, ethical and effective," psychologists were used to provide legal protection for otherwise illegal treatment of prisoners.
The American Psychological Association’s (APA) 2005 Report of the Presidential Task Force on Psychological Ethics and National Security (the PENS Report) is the defining document endorsing psychologists’ engagement in detainee interrogations. Despite evidence that psychologists were involved in abusive interrogations, the PENS Task Force concluded that psychologists play a critical role in keeping interrogations “safe, legal, ethical and effective.” With this stance, the APA, the largest association of psychologists worldwide, became the sole major professional healthcare organization to support practices contrary to the international human rights standards that ought to be the benchmark against which professional codes of ethics are judged.
The PENS Report remains highly influential today. Negating efforts by APA members to limit the damages – including passage of an unprecedented member-initiated referendum in 2008 – the Department of Defense continues to disseminate the PENS Report in its instructions to psychologists involved in intelligence operations. The Report also has been adopted, at least informally, as the foundational ethics document for “operational psychology” as an area of specialization involving psychologists in counterintelligence and counterterrorism operations. And the PENS Report is repeatedly cited as a resource for ethical decision-making in the APA Ethics Committee’s new National Security Commentary, a “casebook” for which the APA is currently soliciting feedback.
Equally troubling, the PENS Report was the result of institutional processes that were illegitimate, inconsistent with APA’s own standards, and far outside the norms of transparency, independence, diversity, and deliberation for similar task forces established by professional associations. Deeply problematic aspects include the inherent bias in the Task Force membership (e.g., six of the nine voting members were on the payroll of the U.S. military and/or intelligence agencies, with five having served in chains of command accused of prisoner abuses); significant conflicts of interest (e.g., unacknowledged participants included the spouse of a Guantánamo intelligence psychologist and several high-level lobbyists for Department of Defense and CIA funding for psychologists); irregularities in the report approval process (e.g., the Board’s use of emergency powers that preempted standard review mechanisms); and unwarranted secrecy associated with the Report (e.g., unusual prohibitions on Task Force members’ freedom to discuss the Report). These realities point to the impossibility and inadequacy of merely updating or correcting deficiencies in the PENS Report.
We the undersigned organizations and individuals – health professionals, social scientists, social justice and human rights scholars and activists, and concerned military and intelligence professionals – therefore declare that the PENS Report is illegitimate. We call upon the American Psychological Association to take immediate steps to annul the PENS Report.  At the same time, in our own efforts, we aim to make the illegitimacy of the PENS Report more broadly known within our communities.
(Visit www.ethicalpsychology.org/pens to add your signature)

Saturday, 22 October 2011

Update on the European Court Ban on Patenting Embryonic Stem Cell Lines

Alas, I haven't had the time or energy yet to carefully read the entire decision of the European Court to ban the patenting on human embryonic stem cell (hESC) lines, that I posted about the other day. However, some of my colleagues have indeed made more extensive comments:

Julian Savulescu (Uheiro Centre for Practical Ethics, University of Oxford). I made some input in the commentary thread there as well.

Kenan Malik (writer, lecturer, broadcaster, a presenter of Analysis, on BBC Radio 4, and a panelist on The Moral Maze, also on Radio 4).

Other commentators so far make more predictable and less reflective responses, such as those of hESC scientists and overt or covert pro-life campaign organisations. To me, these are of less interest since they mainly repeat dogmatic stances that were set in stone decades back.

Hopefully, I'll be back with my own analysis and comments not too soon.

Friday, 21 October 2011

Court Acquits Swedish Neonatal Doc Charged with Murdering Newborn Baby in Controversial Case

Today, the verdict was announced in a very controversial case in my country regarding a neonatal intensive care doctor, who has been charged with murdering a newborn baby by administrating high doses of sedatives (here, here, here, here, here, here, here, here). The doctor is acquitted of the charges of manslaughter. It remains to be seen if the prosecutor decides to take the case further to appellate court.

The case has sparked heated discussions and not so little confusion in the medical, political and ethics expert community. Leading voices of medicine have somewhat lost their marbles and made megalomaniac claims about doctors being immune from prosecution whatever they do to their patients in the name of best practice. There has also been rather peculiar criticism about the prosecutor taking a long time bringing the case to court, where the unspoken message seems to be that medical doctors should somehow be treated differently than other people in criminal proceedings - reminding a bit about how Julian Assange or Mr. Strauss-Kahn have been reasoning around their own persons in relation to the rape charges they are or have been facing.

All of this has, to my mind, been sheer nonsense. Of course, it is immensely burdensome for anyone to face serious criminal charges. Even more so if your own view is that you have made nothing wrong, but rather the best you can. It is also completely understandable and justifiable that the legal defense and friends of those charged do their best to have the person charged described as innocent in media. However, the principle of equality before the law stands far above any such individual consideration. Take a deep breath and think about for a moment how society would look like if we let that principle slide and this should be crystal clear to anyone.

Now, there have been several attempts to make a spin on the case settled today according to which it is not about a real legal issue, but rather about a more hazy underlying problem of an ethical nature. The idea has been that the critical issue is whether doctors are allowed to take risks in order to achieve effective pain reduction in dying patients. However, albeit indeed being an interesting issue in its own right, that has never been the centre of discussion in the present case. Doctors are allowed to take such risks according to Swedish law, end of story. But they are not allowed to murder people as this is defined in criminal law. It is the latter that has been the base for the prosecutor's claim in the case decided today. 

Instead of making my own explanations of how I read the court's decision, I have made a quick translation of the court's own press summary. The Swedish original is here. Read for yourself and make up your mind!
Solna District Court today acquitted the doctor who was prosecuted for manslaughter or attempted manslaughter of an infant at Astrid Lindgren's hospital in Solna fall of 2008. The district court has not found it proven that a crime has been committed. The district court has not found it proven that the doctor has done something that was not be medically justified.
The district court has not found the evidence sufficient for showing beyond reasonable doubt that a crime has been committed. The prosecutor's claim is based on an analysis of forensic evidence, which has demonstrated an exceptionally high concentration of thiopental in the blood from the deceased child. The district court has not considered this result to be sufficiently reliable to fully serve as the basis of a conviction. The district court does not believe that one can draw any more far-reaching conclusion of the analysis results than the one that thiopental, although observed in a high concentration, it is unclear how high the concentration was. Given this uncertainty about how high the concentration was, it is conceivable that the occurrence can be explained by the fact that the child had received thiopental on previous occasions during hospitalisation. This means that there is no evidence that a crime has been committed and the doctor is already on this ground freed of the charges made.
The district court has not considered that the prosecutor with sufficient certainty has proven that the doctor has acted in any way that was not medically justified when the child died.
In the debate related to this case, it has been claimed that the case concerns the distinction between what a doctor can and cannot do when it comes to relieving pain and anxiety in end of life care. This is not correct. The prosecutor's contention is rather that the child has been poisoned, that the child has been receiving a very high lethal dose of thiopental administered in order to effect that the child would die, not in order to relieve pain or distress. There is no doubt that such conduct, if it had occurred, is punishable as manslaughter under Swedish law, whether or not it had been prompted by reasons of compassion and whether or not the child would have died anyway within a very short time. As has just been said, however, the district court did not consider it proven that such a criminal act had in fact taken place.

Wednesday, 19 October 2011

European Court Rules Against (almost all) Patenting of Embryonic Stem Cells

Yesterday, the European Court publicized its ruling on the controversial case of the patentability of human emryonic stem cell lines (hESC) in European law. I have discussed this issue in two former posts: here and here. The complete ruling can be found here and is quite long, but the conclusions are clear:

On those grounds, the Court (Grand Chamber) hereby rules:
1.      Article 6(2)(c) of Directive 98/44/EC of the European Parliament and of the Council of 6 July 1998 on the legal protection of biotechnological inventions must be interpreted as meaning that:
–        any human ovum after fertilisation, any non-fertilised human ovum into which the cell nucleus from a mature human cell has been transplanted, and any non-fertilised human ovum whose division and further development have been stimulated by parthenogenesis constitute a ‘human embryo’;
–        it is for the referring court to ascertain, in the light of scientific developments, whether a stem cell obtained from a human embryo at the blastocyst stage constitutes a ‘human embryo’ within the meaning of Article 6(2)(c) of Directive 98/44.
2.      The exclusion from patentability concerning the use of human embryos for industrial or commercial purposes set out in Article 6(2)(c) of Directive 98/44 also covers the use of human embryos for purposes of scientific research, only use for therapeutic or diagnostic purposes which are applied to the human embryo and are useful to it being patentable.
3.      Article 6(2)(c) of Directive 98/44 excludes an invention from patentability where the technical teaching which is the subject-matter of the patent application requires the prior destruction of human embryos or their use as base material, whatever the stage at which that takes place and even if the description of the technical teaching claimed does not refer to the use of human embryos.
In short, hESC lines can indeed be patented, but as part of a procedure for "for therapeutic or diagnostic purposes which are applied to the human embryo and are useful to it". In other words, patenting of hESC lines for the purpose of regenerative medical purposes or research is ruled out within the jurisdiction of European patent law.

Saturday, 8 October 2011

The Seductive Power of Nationism: from Revocable Citizenship to Abolishment of the Citizenship Idea

This week, a development that I predicted in a series of posts on the ideology of the new European racism (here, here, here) has occurred for real in Swedish politics. Often controversial local labour leader in Malmö, Ilmar Reepalu, suggested that criminals who have attained their Swedish citizenship recently, should be expelled from the country after having served their sentence (here, here, here, here, here, here, here). It is rather unclear if the idea of Reepalu is that (a) citizenship should be revocable for some time (how long?), or that (b) citizens should be possible to expel from the country for some time (how long?) after having attained the citizenship. In any case, his suggestion has been applauded by Sweden's own new-racist party, the Sweden Democrats, who quite rightly point out that the idea is a central one in their political program. With a few exceptions, the suggestion has met with massive criticism from within the Swedish labour party, as well as from other parties across the political scale.

Nevertheless, I am not surprised that this sort of suggestion is being picked up by politicians outside of the new racist movement. As described in my first post on this subject, this movement has devised a clever ideological trap that is very easy to be seduced by, and it appears that it is this very trap that Reepalu has fallen right into. However, the sort of suggestion he makes is, as I pointed out in my second post, vulnerable to, what I called, the nationism - ethno-racism paradox. When it comes to the idea about revocable citizenship, this paradox leads to the logic that, as a matter of fact, all citizenships should be revocable all of the time (or, alternatively, that it should be possible to expel all citizens). Here's the line of reasoning:

The idea about revocable citizenship (or a citizenship consistent with being expelled from the country) is motivated by the idea that if you commit (sufficient or sufficiently serious) crime, you demonstrate that you do not have a required allegiance to your country, its culture and its shared values (never mind the haziness of these notions at this point). But if that is the case, obviously, this applies to everyone, also those that have their citizenship due to having been born by (or having a lineage to) a citizen. In effect, logic seems to dictate that it should be possible to expel anyone who commits crime (to a sufficiently serious extent) – citizen or not.

Effectively, this means that the whole idea about citizenship is abolished. 

Now, there is – as I noted in my third post – one way to avoid this conclusion, and that is to go down the pure nationist route. Reepalu would then have to argue that there is a fundamental difference between those criminals who have Swedish citizenship due to birthright (these are the vast majority of criminals) and those who have attained it later in their lives. Reepalu would then need to make probable that labour party ideology supports the notion that the value of a person is (partly) determined by who happened to be his or her parents.

Good luck with that one!

Thursday, 6 October 2011

Call for Retraction of Article Claiming Abortion to Cause Mental Health Problems

The controversy grows regarding an article published in the British Journal of Psychiatry some weeks back by Priscilla K. Coleman, presenting a meta-analysis that purports to demonstrate that having an abortion is a causal factor for subsequent mental health problems. It is important to understand that this claim is not only about there being a statistical correlation between having an abortion and suffering from subsequent mental health problems. The presence of such a correlation is well-established in research around abortion since a long time, and is not doubted by anyone. However, many closer analyses have revealed that the correlation is not due to the having of an abortion giving rise to mental ill-health. This since, among other things, there is an over-representation of mental health problems among abortion seeking women. Indeed, in a recent very ambitious study, published in the very prestigious journal New England Journal of Medicine, it is shown that probably mental health problems is a causal factor of establishing of an unwanted pregnancy. So, in fact, it would seem that the causal link goes the opposite way of what Coleman is claiming. I raised these concern already in my first posting on this subject.

Now, the distinction between a statistical correlation and a causal link is elementary to scientific inquiry - it is, one might say, to research as knowing the alphabet is to writing. In my original posting, I therefore assumed that Coleman had probably controlled for the presence of pre-pregnancy mental health problems, as well as other possible explanatory factors (so-called confounders) in her analysis – reserving my critical comments mainly to biased news reporting of her results. However, subsequent harsh criticism from leading researchers in the field, reported about in another posting, revealed that not only had Coleman not done this elementary footwork, she had made a grossly biased selection of the studies underlying the analysis (with about half of these being of her own or her group and many top-quality studies excluded), included many studies that use deficient methodology (not least those of her own), and – as if that was not enough – undertaken her meta-analysis ignoring several standard ingredients employed and agreed to by researchers world-wide in order to avoid common mistakes and biases. Based on that, I voiced concern about the integrity and quality of the BJP peer review process and editorial policy and speculated about a call for retraction of Coleman's paper (which, in the scientific world means that the content of the article is no longer considered to be valid science). The sub-standard scientific quality pointed out by the critics is reason enough, but since Coleman's conjecture (for this seems what it is) was immediately taken up by anti-abortion extremists world-wide, the editor needs to consider the obvious harm that continued support of the article can have – a harm, due to the scientific flaws of Coleman's work, that is effected for no good reason.

After that, two more critical (so-called "rapid") responses to Coleman's article have been published in BJP. One of these (by David Ferguson,  John Horwood and Joseph Boden) attempts to defend Coleman, mainly by attacking one of the critics. However, the very serious criticism voiced in the other responses is simply ignored. Moreover, it is obvious that Ferguson et.al. seem to be as oblivious to the elementary distinction between statistical correlation and causal linkage as is Coleman. They write:
....despite the claims made in previous reviews about the absence of association between abortion and mental health, when data are pooled across studies there is consistent evidence suggesting that women having abortions are at modestly increased risks of mental health problems when compared with women coming to term with unplanned/unwanted pregnancies.
Note here that the expressions are "association between abortion and mental health" and "increased risk". Does this support Coleman's conjecture about a causal link? No, it does not, as everyone who has ever taken a primer in statistical method knows. In fact, "association" and "increased risk" means the same, and this meaning is that there is a statistical correlation between having an abortion and suffering from subsequent mental health problems that is stronger than that between carrying a pregnancy to term and suffering from subsequent mental health problems. Yes, you read rightly, the same statistical correlation that is generally agreed on by everyone. Ferguson et.al. either seems to have mistaken what the issue worthy of inquiry is from the outset, or missed some crucial lessons of science class. In short, this response is a misnomer and completely irrelevant to the debate on Coleman's conjectured findings.

So, the basis for assessing Coleman's article as ripe for retraction seems to stand. Not surprisingly then that just such a call was today sent to BJP. I happened to come to know about it through one of the internet forums of my own field of research (the Bioethics International group on Facebook), asked the author of the call to see it, and received his permission to quote it verbatim. It will still take a few days for BJP to decide whether or not to publish it among the "rapid responses", but until then (or in case the editor should chose to try to avoid the embarrassment of publishing it), you can read it here in its entirety:
Coleman Article Should be Retracted, Not Debated in a Subsequent Issue of BJP

Serious flaws in the reporting and conduct of the Coleman review should have been identified in pre-publication review and not left for readers of BJP to sort through subsequently. The article should be retracted and should not given the dignity of post-publication debate in a subsequent issue of the journal.

The review lacks the fundamental transparency that is expected of systematic reviews and meta-analyses and needed to allow readers to independently evaluate its conduct and interpretation of results without having first to go back to the original studies. Search strategies are not even provided in sufficient detail for readers to ascertain the adequacy and completeness of the retrieval of relevant studies.
Results for 36 effects obtained from 22 studies that are integrated into a single effect size represent highly diverse outcomes ranging from smoking of marijuana to suicide. The overall effect size that is calculated does not generalize back to the individual outcomes in any meaningful way. This aspect of the meta-analysis recalls a photo often incorporated into workshops on meta-analysis. The photo depicts the famous road sign for New Cuyama, California in which a total of 4663 is indicated for a population of 562, an elevation of 2150 feet, and a date of establishment of 1951.  The calculation of an estimate of the heterogeneity of the effect size reported by Coleman is missing, in violation of standards for reporting a meta-analysis.

Multiple effects sizes are obtained from individual studies are integrated in a way that violates basic assumptions of independence of individual effect sizes that are required for a meaningful meta analysis. The 22 studies include 13 from Coleman's author group, and so the meta analysis violates usual expectations that a meta analysis be independent of the author group who generated the original studies. David Reardon who is a co-author of Coleman on a number of these studies has declared his strategy [1]:

"For the purpose of passing restrictive laws to protect women from unwanted and/or dangerous abortions, it does not matter if people have a pro-life view...In some cases, it is not even necessary to convince people of abortion's dangers. It is sufficient to simply raise enough doubts about abortion that they will refuse to actively oppose the proposed anti-
abortion initiative. In other words, if we can convince many of those who do not see abortion to be a 'serious moral evil' that they should support anti-abortion policies that protect women and reduce abortion rates, that is a sufficiently good end to justify NRS efforts. Converting these people to a pro-life view, where they respect life rather than simply fear abortion, is a second step. The latter is another good goal, but it is not
necessary to the accomplishment of other good goals, such as the passage of laws that protect women from dangerous abortions and thereby dramatically reduce abortion rates."

Many of the studies included in the Coleman meta-analysis, including most of the studies conducted by her group, are strongly criticized by other researchers and excluded from consideration in other systematic reviews, including a forthcoming report by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists
(RCPsych). One can only speculate on the timing of the BJP's publishing of Coleman's review relative to the impending release of the RCPsych report. Results of some of the original Coleman studies are not replicated in subsequent re-analyses of the same data sets by others. Coleman integrates results from studies without controlling for measures of mental health outcomes obtained prior to an abortion and in a number of instances, the mental health outcomes entered into her meta analysis were obtained before the abortion. In other instances, the effects reflect differences between women who obtained an abortion for an unwanted pregnancy versus women who delivered a wanted baby, a grossly
inappropriate comparison if the intention is to obtain a valid estimate of the effects of abortion on mental health.

It is a mater of  technical details, but important to evaluating Coleman's meta analysis that she used the wrong formula to calculate population-attributable risk and violated basic assumptions for such a calculation.

These serious flaws were apparent in a cursory reading of Coleman's article. I am confident that a closer read and a retrieval of the original studies and others that were ignored by Coleman would have yielded still more problems. But I think this analysis reaches the threshold for demonstrating the necessity of retracting the Coleman article and it begs an explanation for the nature of the peer review that led to the article being accepted.

The Coleman article is not a contribution to scientific literature but rather represents the revenge of Coleman and her offer group on the scientific community which has held their work to basic objective scientific standards, criticized its poor quality, and excluded from
integration into systematic reviews on the basis of objective criteria.

1. Reardon DC (2002). A defense of the neglected rhetorical strategy (NRS). Ethics Med 18 (2): 23-32.
James C. Coyne, Ph.D.
Director, Behavioral Oncology Program
Abramson Cancer Center and
Professor of Psychology
Department of Psychiatry
University of Pennsylvania School of Medicine
Careful as I am, not being an expert in this field, I still must say that the combination of the massive sound criticism against Coleman's analysis and methodology, as well as the obvious fault that I can spot myself, should have the editor make the retraction move. The obvious ideological agenda underlying the research of Coleman and her team, pointed out also in another of the rapid responses, adds to this, since it makes probable the hypothesis that the faults of Coleman are not (only) the result of incompetence, they are deliberately engineered to achieve the shallow appearance of publicisable scientific claims in order to give the political anti-abortion movement its 15 minutes fame.

Tuesday, 4 October 2011

New Book on the Ethics of Screening in Health Care and Medicine

So, once again, some self-promotion, but this time not only, since the new book I'm plugging in this way is the result of a truly collaborative enterprise with Niklas Juth, senior lecturer in medical ethics at the Karolinska Institute. Published by Springer, the title of this book is The Ethics of Screening in Health Care and Medicine: Serving Society or Serving the Patient?

 To quote the summary:

Medical or health-oriented screening programs are amongst the most debated aspects of health care and public health practices in health care and public health ethics, as well as health policy discussions. In spite of this, most treatments of screening in the research literature restrict themselves to isolated scientific aspects, sometimes complemented by economic analyses or loose speculations regarding policy aspects. At the same time, recent advances in medical genetics and technology, as well as a rapidly growing societal focus on public health concerns, inspires an increase in suggested or recently started screening programs.
This book involves an in-depth analysis of the ethical, political and philosophical issues related to health-oriented screening programs. It explores the considerations that arise when heath care interacts with other societal institutions on a large scale, as is the case with screening: What values may be promoted or compromised by screening programs? What conflicts of values do typically arise – both internally and in relation to the goals of health care, on the one hand, and the goals of public health and the general society, on the other? What aspects of screening are relevant for determining whether it should be undertaken or not and how it should be organised in order to remain defensible? What implications does the ethics of screening have for health care ethics as a whole?
These questions are addressed by applying philosophical methods of conceptual analysis, as well as models and theories from moral and political philosophy, medical ethics, and public health ethics, to a large number of ongoing and proposed screening programs which makes this book the first comprehensive work on the ethics of screening. Analyses and suggestions are made that are of potential interest to health care staff, medical researchers, policy makers and the general public.
The book is available for purchase via its homepage, linked to above, and as e-book via its Springerlink page, where there is opportunity to sample the contents, parts of chapters, bibliography and the index. More generous sampling is accessible through Google books. Note, that if you are a student, academic, health care professional or official or policy maker, it may very well be the case that you can access a free e-book copy through a library (e.g., your university library) that subscribes to Springerlink!