Take sustainability serious in healthcare to avoid harming future patients!

 

In a brand new blog post at the BMJ Journal of Medical Ethics blog, me, Davide Fumagalli and Erik Malmqvist write about a severe ethical challenge for healthcare systems that arises due to structural deficiencies in established systems for healthcare resource allocation: 

 Most countries with publicly funded healthcare systems have ethically informed priority setting schemes to decide how to allocate scarce resources. Established principles in such schemes recognise patients’ need of care, the effects of interventions, and background requirements of equal consideration and cost-effectiveness. However, the typical use of such schemes is alarmingly short-sighted, systematically allowing the future resource base of healthcare to be undermined. In short: our way of helping current patients is systematically exposing future patients to serious harm and risk.

As a remedy, we propose that a sustainability principle is added to estableshed ethical framworks that govern this central aspect of health policy. Read more about the challenge, as well as our proposal over at the JME blog!

 

Highly Problematic Stance on Fake "Antivaxx" Authorship By the Indian Journal of Medical Ethics

It is a recognised challenge of my research field, bioethics, to include and empower researchers and institutions from low- and midlle-resource settings. Since a few years, the leading journal of Bioethics, runs the side journal Developing World Bioethics to address this issue, and over the past few years a number of journals have appeared, based at institutions outside of the most affluent parts of the world with a natural focus on bioethical issue of relevance to such settings, as well as global health related issues. One of these is the Indian Journal of Medical Ethics, that has quickly been rising in the ranks and attracting respect for its consistent work.

However, very recently the IJME has been dragged into potential scandal. First, the editor, Amar Jesani, decided to publish an article by a fake author, claiming fake credentials and affiliations, of an obvious antivaxx junk article of the sort that antivaxxers – just like tobacco-industry sponsored scientists used to do regarding the dangers of smoking – are constantly trying to peddle to various journals to create an image of "scientific controversy" around the use of vaccines to fight infectious disease and build public health. The fakes were all very easy to detect, and already the fact that the "author" was not using the email-domain of, and has no profile at the webpages of, the institution (Karolinska Institutet) to which he claimed affiliation should have rung immediate alarm-bells. But then, when this is pointed out, and the journal is alerted to this research fraud, the editor Amar Jesani decides not to retract the article! Instead, the editor appears to have decided to trust the author's obviously bogus explanations for his (?) fraud, and to attempt to counter a, to my mind, quite sound statement on the matter from the Karolinska Institutet president, Ole-Petter Ottersen.

The bogus explanations and Jesani's expression of sympathy with them, and Ottersen's stringent response, is to be found here. This very surprising and ill-conceived action of Jesani is potentially extremely damaging for the IJME, and in effect risks to soil the reputation of the entire field of bioethics. The fake author's attempt at justifying the fraud is that he/she has to be anonymous to protect him-/herself from persecution for unpopular views. This, of course, is not even worth the scrap of paper it was scribbled on. The real role of the fraud is to block any investigation into conflicts of interests (the antivaxx movement is nowadays a flourishing industry of quackery), other activities of the author that would undermine confidence in the article's content, and the fact the author lied to the editor, and offered the explanation only in retrospect when the scam had been uncovered should, of course, mean that the editor should have no trust in what the author is claiming. This is a proven fraudster, and should be treated as such. Just as authors lying about ethics approval should have their papers taken out, authors who lie about other things of relevance to the evaluation and assessment of the research have their papers removed. As Ottersen says in his second blog post: an editor of an ethics journal should know this. The editorial board of the journal should immediately and strongly recommend its editor, who has obviously let his personal prestige lead him astray in this matter, to revise his position and act according to the high publication ethical standards expected of a bioethics journal that aspires to be well regarded.

Let me, lastly, comment on the possible need for author anonymity for research articles. The afterconstructed reason brough forward by the fake author and that Jesani surprisingly buys, is the idea that is often practices within news reporting. Where, eg., a newspaper may protect sources by keeping them confidential. However, that also means that whatever story is built on this, needs to present suffient additional public evidence, that is open for scrutiny, in order to compensate for the loss of control following source anonymity. This has not taken place in the case of the fraudulent article. Also, the whole spinn about author/source confidentiality is obviously a lie in the present case: Had the author had any such plan, he/she would have honestly and openly contacted the IJME editor about it, and Jesani could have pondered - bringing in the editorial board - the issue. Had they decided to approve such a request, this would have brought with it extraordinarily strong obligations to check the author credibility, CoI, etc. This is not what occurred, however. What occurred is that a con-man defrauded the journal, and the journal editor then decides, against any common sense, to trust said con-man. Unbelievable!

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Addendum Re. Using Medical Methods to Determine the Age of Unaccompanied Refugee Children

After my post on this issue a few days ago, I've debated the issue with a number of people from within medicine and also bioethics in different fora.

Due to the presence of significant uncertainties of the methods debated, my suggestion was that use of this methods should be amended by the following methodological rule (assuming 18 to be the age of adulthood, if it is different we may simply insert another variable for that):

... for any method, M, for the assessment of the age of a person, P, with a margin of error +/- X years, M is taken to indicate adulthood if, and only if, its result is 18+X years or higher, and otherwise taken to indicate childhood

Here are a few points that may be added to the complexities of this particular issue:

1. The nature of the uncertanties
Some have argued to me that the methods are not only uncertain in a way possible to describe in terms of a margin of error. One reason for this put to me is that besides the usual margin of error within the dimension of a variable, there is also the background confidence interval behind this margin, and the known effect of having this confidence deteriorate considerably when aggregated population probabilities are projected onto individual cases. I, of course, do not deny that there is also this source of uncertainty, but as far as I can see, my formula above can easily include that: X can be the aggregation of both these uncertainties (this was my original thought as well). This probably means that X becomes considerably larger than 4 (the number used in the example in the original post, based on claims by critics of the model). However, this in no way undermines my suggestion, as this will probably mean that all unaccompanied refugee children will most likely be determined to be children (and, if there are any people like that, in addition a number of refugee adults who falsely claim to be children). That is, the best interest of children, as well as the proper priority of legal provisions is upheld. Suppose, for instance, that the margin of error, accounting for all sources of uncertainty, becomes +/- 15 years. Then my rule says that P is to be considered an adult if, and only if, M finds P to be 33 years or more.

Another claim has been that some of the methods depend on the existence of relevant tables and charts or background data, and that such are missing in this case, meaning that the methods are not really uncertain, there is no method at all. The bewildering thing is that the same people are at the same time officially repeating the argument that the methods are uncertain and have unacceptably wide margins of error. These two claims are, of course, inconsistent; if it's not possible to have any result at all, there is no margin of error, and if there is a margin of error there is some results that create this margin. If it turns out that, in fact, the variable X (accounting for all kinds of sources of uncertainty), cannot be given any empirically based numerical estimate, I concede that my rule is inapplicable. However, if even an interval numerical estimate can be grounded, my rule can be used, by simply adding (supported by the same basic principles as before) that, the high extreme of this interval should be used to define X (in order to err in the right direction). Again, this may mean that the method will determine all tested as children, but, as already argued, it is difficult to see what the ethical or legal problem with that would be.

2. Professional Health Care Ethics and Ethics
Another aspect that has been raised is the fact that my suggestions means that health care professionals pragmatically accommodate to flawed public policies in the best interest of concerned parties (i.e. the children). This is wrong, some say, health care professionals should demand to regulate themselves and never do anything they themselves collegially don't find suitable to do, not even if this is harming third parties. Some have even gone so far at to claim that it is irresponsible of a health care professional to ever act the slightest in any other interest than his or her patient's.

The latter would, of course, mean that we would have to abandon all public health practices, communicable disease management, forensic medicine, large segments of insurance and sports medicine, and not least the involvement of doctors in issuing certificates underlying decisions by public authorities, such as sick leave or work-related disability benefits, and so on. Since health care professional organisations have as yet made no move whatsoever in such directions, I trust that this is not the line underlying the criticism in the present case. In other words, formalised professional health care ethics already accepts a number of cases where medical methods are used to other ends than the best interest of patients and many of these uses are being pragmatically accommodated to still make the best out of an imperfect thing. A very clear illustration is the assessment of "ability to work" nowadays made routinely by medical doctors in many countries, strategically adapted not to harm their patients while still abiding by required formalities.

It is thus unclear to what extent the principle of never doing anything to right the wrongs of public policies is a part of professional health care ethics. Even more unclear is if, had it been such a part, it would have been ethically defensible. To illustrate with the issue at hand, suppose that the health care professional community was to refuse to participate in the practice decided by the Swedish government. This may have three outcomes: (a) the government and parliament creates a legal room for some other class of officials to use the methods (not using my rule), (b) no method is used, (c) alternative suggested methods based on psychological models are used.

• If (c) is the outcome, the issue reappears, as also these methods can be expected to have margins of error, sources of uncertainty and so on. Then my rule can be used to secure that determinations err in the right direction.

• If (a) is the outcome, the results for the persons concerned, namely the children, is worse than if the profession had chosen to participate, using my rule to secure that they act solely in the best interest of the children, although also accommodating societal requests.

• If (b) is the outcome, the situation stands that unaccompanied refugee children where there is uncertainty as to whether or not they are children, will not be given their rights as children.

Now, compare this with (d): health professionals decide to pragmatically accommodate, and use the methods, amended by my rule.

• If (d) is the outcome, the concerned children's interests and Sweden's legal needs are better served than if any of (a) and (b). If these children are seen as patients, it would then be in their best interest to go for (d) rather than (a) or (b). If there is an option (c), this is even better, provided that my rule is used, but if not it may be better for the patients to go for (d).

3. The Ethics of Clean Hands, Politics of Power and Professional Integrity as Strategic Tool
Against this form of reasoning, some debaters I've talked to have claimed that the downsides for refugee children of the options (a) and (b) (as well as (c) without my rule) cannot be laid at the door of health professionals, but is the sole moral responsibility of the government. That is, they apply the standard of an "ethics of clean hands", denouncing responsibility for bad outcomes they could have avoided by acting differently just because the same is true of some other acting party (here, the government). This is like when the car driver, displeased with the rule that gives pedestrians priority at crosswalks, blames the government while electing to run people over, who cross motivated by the rule. Not very splendid ethics, I'd say.

Another version of this reasoning instead comes in the form of a political power bidding in the name of professional autonomy. It is simply the claim that health professionals should insist on the right to decide for themselves what standards they act on. While this is understandable (we all would like the privilege not to give a damn about the opinions of others, don't we?), it either comes without any underlying defense, or is compatible with sometimes choosing to compromise with other parts, interests and powers in society. As mentioned, the latter seems what in fact is happening in a number of areas, so then the question moves to what reasons pro or contra are present in the area at hand. Here, I have argued that (d) is the superior position.

The same outcome seems to ensue when analysing a final (and, to my view, better) variant of this sort of argument. Instead of an empty insistence on professional autonomy at all cost, this argument points to the political importance of professional integrity as a strategic tool in certain areas. The most obvious of these are torture, capital punishment and military interrogation. Here, the profession has adopted zero tolerance policies, which are thought to have an accumulated preventive effect, as these practices in various ways "need" the participation of doctors. However, this point does not demonstrate that age determination of unaccompanied refugee children belongs to this set of absolutely prohibited practices. As those who criticise the presently proposed methods also say that they could accept methods with a better degree of precision and exactness, it doesn't seem that they are trying to argue this in the present case. Which is understandable, as that would mean arguing against any claim to special considerations of the interests and rights of children.

In sum, therefore, unless it is demonstrated that there is no method at all that could produce any sort of empirically grounded numerical estimate (even in the form of a wide interval) in this area, my suggestion holds up to scrutiny. In fact, it is better supported by both professional health care ethics and more general ethical analysis, than alternative suggestions.

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On Using Physiological or Biomedical Methods to Determine the Age of Unaccompanied Refugee Children

  In my country, there has for some time been a lot of political debate around how to handle the rising number of refugees from, primarily, Syria/Iraq, Afghanistan and North Africa. This as the pressure on border EU member states, and the impossible situation of trying to hold back people on the run from intolerable circumstances that I blogged about not so far ago, has meant that much more people are now entering Sweden to seek asylum in a short time, as most other member states are unwilling to participate in a scheme of sharing the economic and logistical load it means to process these requests in a way required by human rights and international agreements, as well as legal security. For, while there is no such thing as a right to have asylum, to seek it is an absolute international legal right, and already this means that a receiving country has a lot of obligations. And one group of refugee people towards which such obligations are especially strict are unaccompanied children, and many of these who actually arrive to Sweden are mostly in their teens, usually lacking certifiable identity documentation.

Now, yesterday, the Swedish government, pressed by the logistic and organisational pressure, declared that the already announced difficulties had now become intolerable, and that a number of measures was to be put into place to complement the already a few weeks back instigated active border controls (which, until then, had been non-existent in accordance with the so-called Schengen accord on free internal EU mobility). The move is very controversial, and many doubt that the logistical and organisational reasons cited are the only ones behind it, if nothing else, worries about how political opinion will shift in the presence of my country's anti-immigration, semi-racist party, the Sweden Democrats (see here, here and here), are bound to have played a part, as these are presently laying mostly low to wait things out after some botched attempts to take the initiative, and being actively ignored by the other parties, as it has announced that its only idea is to close the borders entirely. One thing is entirely clear, though, the problem behind the decision is neither one of money, nor one of space, Sweden has plenty and plenty of both of those, and neith is it about "volumes", as the term goes, but mostly about flow; not how many people arrive, but how many arrive in a short time.

 One of the measures decreed by the Government concerns the unaccompanied refugee children, and it is to (re)start using certain physiological or biomedical methods to ascertain the age of these children. No one is debating the need for such ascertaining, but the debate is about this particular proposal, as many Swedish medical specialists (for two international sources, see here and here) also the medical research specialist organisation Swedish Society of Medicine, point out that the proposed methods are very uncertain and have wide margins of error, up to 4 years plus or minus. This means that the risk is imminent that a child of 14 is determined to be an adult, and that Sweden would thus knowingly risk to default on its particularly strong and demanding obligations towards children. The fact that there is also a risk that some 21-year olds come to enjoy these special protections and care is a non-issue in that light. However, the government seems insistent, so what should be done? General refusal of doctors and other medical staff to participate in what has been proved to be unprofessional practice? (as they would seem to be required to do by the Swedish health and Medical Services Act)? This is certainly a live option from a medical ethical standpoint as well, although it also means that most unaccompanied refugee children are left without proof of age.

However, there is another solution, which would satisfy both the government's decree, the worries from the point of view, the need for unaccompanied refugee children to have their age ascertained, and the overwhelming reason to have Swedish policy abide by its own legal standards. This solution is, moreover, applicable to any method for this purpose. It rests on the assumption that for Sweden to meet its own legal requirements is a primary consideration that trumps other reasons and interests in this area. This means that overestimating a refugee child's age and assess this person as adult is far worse than underestimating a refugee adult's age and assess this person as a child. Based on this premise, we may now argue that, therefore, using a method for age assessment in this area that is uncertain, we should use it in a way that makes us err in the right direction. That is, to the extent that we draw faulty conclusions, these should rather be the wrongful classification of adults as children than the wrongful classification of children as adults. this rules gives us access to a simple mathematical solution to the conundrum: we simply adjust the conclusions drawn with the help of the method in light of its uncertainties, so that we are certain to err in the right direction. Thus, for any method, M, for the assessment of the age of a person, P, with a margin of error +/- X years, M is taken to indicate adulthood if, and only if, its result is 18+X years or higher, and otherwise taken to indicate childhood. Regarding the methods cited earlier, this would mean that a person who is apparently an unaccompanied refugee child (who lacks reliable documents), is concluded to be a child, as long as these methods do not declare the age to be 22 years or higher.

As said, this solution makes it possible to abide by the governmental decision, while acting inside medical professional and ethical boundaries, and while both securing the need of refugee children to have their age determined to claim their rights, and the paramount need for the state of Sweden to honour its own legal and international obligations.

Due to debates related to this post in other fora, here's an addendum I made a few days later.

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Guest Editorial on the Ethics of How to Balance Risks and Chances of Benefits in Neurosurgery with High Stakes

When you're a medical ethics or bioethics researcher, it is always an important proof of the value of what you do when policy makers and professionals in the fields you relate to find your ideas relevant to consider in their decision-making. Therefore, I'm pretty happy and proud about this recent publication:  On kind invitation by the editor in chief, I have written a guest editorial for the European neurosurgery journal, Acta Neurochirurgica, and yesterday it went online. The title is 'The ethics of “primo non nocere”, professional responsibility and shared decision making in high-stakes neurosurgery', and so far the journal management has chosen to make it freely accessible for download:

 Should that generosity ever go away, I have uploaded my own submitted version (not including corrections made in copy-editing and proofreading) here.

In the article, I analyse a debate between to neurosurgical teams (of Jannick Brennum and Hugues Duffau, respectively) on whether or not it would be  ethically acceptable to offer an option to people with fatal brain disease (e.g., cancer), to offer an option of going for more radical surgery to boost the chance of longer survival, which at the same time brings increased risks of major functional disability (such as loss of eyesight or ability to walk). I show that this seemingly straightforward issue actualises a cluster of rather different ethical questions, and that both sides of the debate may have been lured astray or getting lost in this situation. I end by suggesting a "diagnosis" of what the question is at heart about, and offer a thought experiment to hopefully help the medical professionals to further their debate on this particular issue. I don't have any pretension of solving the issue, but as my thought experiment suggests, I do harbour suspicions that some of the reasoning going on this far among the discussants may have been influenced by an irrational temporal bias.

UK Medical Records Sellout Delayed: NHS Realises It Needs to Inform People of their Rights

So, some of you may recall my rather negative comments on a UK national plan to make NHS medical records which are not even fully anonymised available to not only research universities, but also – totally unnecessary from a medical research standpoint – private industry in the pharma and insurance fields. This in spite of the fact that it takes just a few snippets of information combined with a medical sample to correctly trace the individual from whom the sample has been taken these days. Former posts are here, here and here. A very recent report in the Guardian is here.

Yesterday, the BBC reported that the plan – which unnecessarily jeopardizes the interests, integrity and liberty of masses of people, besides putting them at risk of being discriminated against for health reasons – has been delayed, since the NHS "has accepted the communications campaign, which gives people the chance to opt out, needs to be improved". That is, the "campaign" consisting of no information at all whatsoever, and which was made public only thanks to some vigilant bloggers – especially MedConfidential. The "campaign" consisting of the NHS apparently deliberately making its very best to hide from the public that they have the unconditional right to opt out of the whole scheme and how they may go about claiming that right. No wonder that the lead-heavy players in the field such as "The Royal College of GPs, the British Medical Association and patient watchdog Healthwatch England have all voiced concerns".

The plan is to devise an information campaign, which – lets hope – actually informs people about their right and gives them as easy access to the form to fill out to opt out as they facilitate the sellout of patient medical details and records. By August it will all be ready to roll-out the system, the responsible ones promise. I believe it when I see it.

Just in case they don't: here's once again the link to all you need to opt out. If I lived in the UK, I certainly would fill out and hand it in immediately! The inconsiderate hurry, carelessness and obvious money-hunger of the forces having pushed this setup into place inspire everything but confidence and trust. I'm sure there will be more to come eventually.

What's This Thing Called Online Automated Bibliometrics and Citation, Anyway? - Scam, Fraud or just Plain Hustling?

It's been a while since the last substantial post, blaming deadlines, deadlines, deadlines for that. Having submitted a major delivery this Friday, here's a sort of inhale before I jump right into the next leg of the fall semester triathlon – a major research bid that I'll be heading.

So, this week, the distinguished science journal Nature's online news section published an entertaining piece on what the outcome may be when all researchers, regardless of field, are ranked according to citation – how much their work is referred to by other researchers – using open online automated resources, such as Google Scholar, or its special citation section. Using a service called Scholarometer, Nature had this guy, slightly surprisingly to many, coming out on top (wonder who he is? - click the pic!):

Strange, isn't it? Not when considering that they have been using the so-called h-index, a mathematical construct devised to reflect the citation weight (rather than rate) of a scholar (that is, this is h-index as used in Google Scholar, in the more professionally advanced and commercial Web of Knowldge, it is something else, but the purpose is the same), thereby reflecting the value of having more articles with more citations rather than just many concentrated to one publication. They then perform what is referred to as normalisation for different scholars in relation to the size of their respective fields. So, what makes Marx come out on top is that he is a more well-cited historian than what, e.g., Albert Einstein is a well-cited physicist, considering that physics is a very much larger discipline than history is. Now, of course, none of this says anything about quality or influence on the progress of research (no more than what the Billboard chart says regarding music) – it merely measures popularity as an object of citation among fellow scholars. In fact, the notion that citation proves anything over and above that others have taken some sort of interest in one's work is highly contestable – said without denying the no doubt important use that citation and citation tracking has in science and research.

But here's the funny thing. Having been pointed to the Scholarometer toy, I of course couldn't resist checking out my own pet fields! So here's what came out when looking at the h-index ranking in bioethics – the field where much of my most weighty specialisation is located (click the image to view a scaled up version):

I could recognize some names, such as Simo Vehmas who happens to be a good friend, but several others were completely unfamiliar to me.  Now, bioethics broadly conceived is a large field so it need not be surprising that one doesn't know the name of completely decent fellows within it, but the fact that I could not place any of the top four names made me wonder. But then it struck me: wait a second, I do know one of those names, the top one at that, but certainly not in the role of a bioethicist, but as a world-renowned researcher in reproductive genetic medicine and leader of the team that performed the first successful preimplantation genetic diagnosis in the early 1990's. I happened to know this, since I published a book on the ethics in the aftermath of this technological advance in 1999 (available for online reading and download through that link). So Alan H Handyside is a prime medical researcher, which of course is what ups his h-index to such heights, as may be confirmed by inspecting a Google Scholar search on his name - what makes him top name in bioethics is, seeemingly, merely that someone tagged his name with that disciplinary affiliation. So what about A Pandiella? Same story it appears, this is a cell-biologist with a no doubt impressive citation count and, I'm certain, many important results up the sleeve. Moving on to R Frydman it's almost the same story, as the bulk of the publications are here in reproductive biomedicine, but it's more complicated as it appears that there is also another R Frydman, who is publishing in the field of health policy/economics, but these persons are treated as one! Next one, J Kimmelman is likely to be a similar story, since there is one with a good number of publications clearly in bioethics [retrospective note added after publication of this post: this person, Jonathan Kimmelman has added a comment below and clarified his affiliation, which is indeed in bioethics] and another publishing in very specialised biomedical science that has attracted vast numbers of citations (I checked some of the respective author affiliations in this case and they don't seem to match either). Last, before we get to my friend Simo, we have F Olivennes, who again seems to be a purely biomedical researcher in the field of reproductive medicine and embryology, who for some reason has been tagged as belonging to bioethics.

These, then are the top researchers of my field according to Scholarometer - no wonder I never heard of them in that role. And, in fact, it seems that the problem appears already at the Google Scholar source, for checking the top name of the straight citation ranking for bioethics, we meet this guy – yup, yet another biomedical researcher classified as a bioethicist. Number two is this guy, whoever he is, same story all over again, and then come some names I'm familiar with and respect in the way one would expect of people ranked to be at the top of one's field. Just to twist the knife some extra turns, I also did a quick check for medical ethics; same story, this is the top guy, apparently, and this is no. three I hear (number two in this ranking actually is a well-known bioethicist who happens to also be a medical researcher, so that kind of animal does exist).

So, what we may conclude is that for these fields, attempts at measuring citation has been severely corrupted by failures of disciplinary/field classification that swamp rankings with citation counts of no relevance for the field at all. I haven't looked through the entire publication lists of the people mentioned, but many of them appear to have basically no output belonging to ethics of any sort. They might, of course, have tagged along on a few ethics papers led by others as clinical/scientific experts (which is fine), but this does not make them highly cited bioethicists, it makes them medical researchers whose medical citation counts look impressive in the context of a field-normalisation to bioethics rather than medicine. In addition, we have seen an obvious identity problem, where the automated online citation counters are unable to distinguish people with similar surname plus initial – makes for quite a lot of error, I would say.

But what is the root of the classification errors with regard to field-normalised/specific citation measures? There are several (possibly overlapping) possibilities. One is, of course, that authors misclassify themselves, as may happen in Google Scholar Citation, where you as author decide what fields to belong to. For example, I could myself have made a strategic choice to pass myself off as belonging to the philosophy of medicine field, which would not exactly be lie albeit bending it a bit, and with my current total citation of 408 ended up in a handsome 6th place, rather than the less impressive placings I enjoy as bio- or medical ethicist or just ethicist. But not all authors are in this system, as you have to actively join it and manage it a bit for it to work (thus your responsibility for how you classify yourself), so the problem might also come from the classification done by the Google Scholar staff; I wouldn't be surprised if several of the strange things described earlier are due to Google's experts confusing "bioethics" with "biometrics" or "biotechnical", for example. The qualification of this staff for doing what they are doing is completely blacked out to me, as I suspect it is to most other scholars, and still many us – like the team behind Scholarometer – take it rather serious. Now, with regard to Scholarometer, there may certainly be error sources located there as well, since one may require of an academically construed automation tool that it is checked for serious error of the sort I have been displaying – which has apparently not occurred to or engaged the team at Indiana University Bloomington responsible for the product.

But wait a second! Wouldn't that mean to, sort of, making the automated citation counter, sort of, not automated? Yes indeed, that is what it means! And hence the title of this little peak into the fascinating games sometimes played in the world of academia to no apparent use for anyone. Alas, though, through the way in which governments and other funders of research are increasingly using bibliometrics and citation as quality indicators to determine the allocation of funds, preferably in an as automated way as possible (partly because of the hype represented by Scholarometer and the article in Nature), thus falling prey to the sort of weirdness here described, this sad example of pretending to have a technology that works when one hasn't, is actually putting fellow scholars and researchers at risk of losing funds and other resources, miss jobs and promotions, et cetera, for no good reason at all.

My plea to Nature and other journals, Scholarometer and Google Scholar is simply this: stop pretending that there's something there that is actually not in evidence. Those who provide these services: make them work as they should or shut them down. Scholarly media: ignore them until they have something to show for real and not merely for fancy.

See you soon!
 

Update: The University of Minnesota Psychiatry Research Ethics Scandal

This is to update a little bit on the situation with regard to the disgraceful twists and ugly and very possible bona fide cover-up activities and general lack of transparency of the University of Minnesota management to avoid a real investigation of the tragic, Astra Zeneca sponsored psychiatry drug trials that caused several suicides and that raise a number of serious queries about irregularities and abuse, such as possibly falsified consent forms. I have reported about this increasingly shameful affair here, here and here.

A petition to the governor of Minnesota to launch an independent investigation of the University of Minnesota psychiatry department has assembled almost 3 000 names – many of which are prominent medical researchers or practitioners and bioethicists from all over the world, who are baffled by the University's attitude and actions – and on Facebook, a Community Alliance for Ethics in Minnesota Psychiatry page has been launched.

Today, Carl Elliott, medical ethicist at the very same university who relentlessly has been pressing for release of vital documents and investigations, summarises where the whole thing currently stands in this blog post at Huffington Post. Carl's final judgement of his own university is not uplifting, and you can read or follow links to descriptions of the latest disgraceful dance-steps of the management to avoid exposure of what for every such move just keeps looking dirtier and dirtier:

In the 23 years I have been teaching and writing about the ethics of medical research, I have never come across a case of abuse this outrageous. Nor have I ever encountered university officials so aggressive in stonewalling legitimate investigation and intimidating critics.

I will, of course, continue to report on the future developments with regard to this business. In the meantime, if you haven't already done so, you may inspect and consider signing the petition to the Minnesota governor for an independent investigation of University of Minnesota Psychiatry.

Senate Probe into Pharma Sponsoring of US Bioethics Center

The last few days, a buzz in the world of bioethics has been about the inclusion into a US Senate probe into the ties between the pain-killer pharma industry and various "medical" and patient interest groups, of the Center for Practical Bioethics, to quote their webpage, "a nonprofit, free-standing and independent organization". The CPB is particularly known in the US for its direct outreach and activism visavis politicians, health care institutions and the medical establishment - not least in the area of end of life and palliative care.

The probe specifically targets the possible ways in which painkiller producing pharma companies, among which are giant Johnson & Johnson, via financial donations and in other ways, have had the mentioned groups - among them CPB - inspire and/or promote "misleading information about narcotic pain-killers". In short: the suspicion is that the companies have paid the organisations money to play up the reasons for using opiate based painkillers (e.g., morphine) or palliative meds that function like opiates, while playing down the salient negative side-effects and risks of such drugs. The background of the probe is said to be "an epidemic of accidental deaths and addiction resulting from the increased sale and use of powerful narcotic painkillers.".

The tie to CPB is thereby established by its well-known and long-term advocacy of effective palliative care and pain-relief. The center's founder Myra Christopher holds the Kathleen M. Foley Chair in Pain and Palliative Care at CPB, sponsored by the company Purdue Pharma, manufacturer of OxyContin and other palliative drugs. According to the Kansas City Star, CPB is well known for its ties to Purdue Pharma as well as several other pharma companies:

...as recently as last month, Purdue was a leading sponsor of the center’s annual dinner and symposium, contributing $25,000 of the $280,000 that the event raised

Myra Christopher is one of the experts mentioned by name in the letter announcing the Senate probe.

Also The Washington Post has reported about the probe, and a longer version of that article can be read here. A particularly fishy part of the story expanded on there is that, as the probe was announced, The American Pain Foundation, self-described as "the nation’s largest organization for pain patients", and one of the organisations targeted by the probe, announced its own shut-down due to "irreparable economic circumstances". From the bioethics and CPB angle, this becomes extra uncomfortable, since Myra Christopher has held honorary positions in APF.

Further details about some publications/reports of Christopher that have had a role in advocating expanded use of strong painkillers, or to play down the ethical importance of, e.g. addiction risks or calling into question routines for monitoring patients who are on painkillers for such risks, can be found in the second half of the Kansas City Star article, which also contains comment by bioethics researchers Carl Elliott and Summer Johnson McGee.

Both of these hold out that the notion of pain and suffering as a health problem in its own right is fully defensible one. In consequence, pain can motivate medication that brings various health risks – just as risk of dysfunction or death can. However, the Senate probe does not seem to question this general point. Both Johnson McGee and Elliott also point to the practical problems created by  a supposed academic and independent institution advocating policies of great financial benefit to certain parties while, at the same time, being funded by these very parties. My own take is that, even if the money does not lead to outright and calculated intellectual dishonesty or fraudulent behaviour, human psychology has to be taken into account. The money arrives because the funding party likes what one is saying and as one becomes increasingly dependent on the financial support, one will (like it or not, conscious or not) become less and less likely to say something else.

Christopher is reported as insisting that the money from Purdue Pharma always has arrived with "no strings attached". It remains to be seen if the Senate probe will unveil information consistent with that claim or not. But even if it did, that does not take away the problem described above, and to me, the problem with CPB financial dependence on the pharma industry grows as the quote hints that Christopher does not realise this elementary point.

Read more here: http://www.kansascity.com/2012/05/11/3607147/senate-panel-studies-bioethics.html#storylink=cpy

Further Deterioration in Bioethics: The Journal of Clinical Research and Bioethics

Some of you might remember a piece that discussed some disturbing general tendencies with regard to quality-deterioration and misconduct in my own field of choice, bioethics. There, I focused quite a bit on the regrettable and rather obvious negative side-effect of the easiness of  setting up online open access academic publishing operations, that it opens the field for unserious players, sub-standard publications and outright fronts for earning money on internet-traffic and hideous "open access fees". These operations are in turn used by self-professed bioethics specialists who are unable to peddle their amateurish rubbish to established journals, where peer-review is usually very demanding and difficult to pass, thereby creating a glossy surface of credibility and status on their CVs. In that post, I used as an illustrating example a recent scandal in the online open access journal BMC Medical Ethics, where two such types, Mohamed Y Rady and Joseph L Verheijde had an article retracted for blatant plagiarism, which they dishonorably tried to brush under the carpet by claiming it to be "unintentional" (see my former post).


Among the things I learned while doing the research for that post, but didn't write about at the time, was that Mohamed Rady is actually listed as being on the editorial board of an even fishier online open access setup, The Journal of Clinical Research and Bioethics. Now, if BMC Medical Ethics is seen as the somewhat shabby underbrush (to their credit, they have actually modified the "unofficial impact factor" badge into a "tracked for impact factor" one!), the JCRB is definitely residing at a level closer to the ground. This much I had picked up via the persistent emails requesting manuscripts (and "open access fees") that I and many colleagues are constantly spammed with. However, not until today was I made aware of just how much of an actual cat hole the JCRB operation is.


My Finnish colleague, Pekka Louhiala supplies the following story, quoted verbatim with his permission from the closed Facebook-group Bioethics International (if you're interested in joining, contact Steve Miles on Facebook), except for the title of the manuscript and the dates, which I have edited in order to shield the authors of the concerned paper – as Pekka told me, they not be burdened by the rather severe misconduct of JCRB. The dates are given so that A in times precedes B, and B precedes C.

I'd like to report a case which, if not unique, tells about questionable
practices in the Journal of Clinical Research & Bioethics

On [Date C], I agreed to review a manuscript titled "XXX" [editing by CM]  for the journal. I read the paper carefully and wrote my review, suggesting rejection because the paper had major shortcomings, for example no own analysis on the ethical issues. The second reviewer agreed that it should be rejected.

To my surprise I found the paper publishes in the journal in exactly the
form I had seen! According to the table of contents it had been "Received
[Date A]; Accepted [Date B]; Published [Date C]".

What had happened? According to member of the editorial board there had been some delay because of his sick leave. However, the contact person in the journal knew about it. Obviously the staff in the journal had asked for another review
without informing the member of the editorial board.

According to this new reviewer, "The manuscript brings a very informative
and critical review on the ethical aspects of [topic of the paper, edited out by CM]. The text is well written, with no spelling or grammar errors, what makes it easy to follow by the readers.". This review has been written by a person who, according to ResearchGate, does not have a single publication on the topic.

In addition, I noticed the following:

1) The website of the journal does not mention an editor-in-chief, obviously there is no academic EoC.
2) The emails to the member of the editorial board are signed only by a first name
with no other information. 

My conclusion

It seems to me the the primary interest of the journal is to collect the fees from the authors and not to keep a high academic standard.

It may appear harsh to jump directly to the conclusion that Pekka does here, but when one inspects the details about the "open access fee" one is required to pay to be published in this fine forum (click pic to enlarge), the hypothesis gains in credibility:

Add Pekka's story above (date of publication preceding the date of the first round of reviews had been delivered, just to mention the most blatant thing), plus the fact that JCRB is keeping Mohamed Rady on its editorial board as a guarantee for academic integrity and quality and I don't think that anyone needs much more evidence. I actually feel sorry for some of the people listed as members of the editorial board, several of whom I suspect are unaware of the true nature of the JCRB operation. Well, they need not be anymore. If they have any sense of integrity they will hand in their resignations immediately.

Just to clarify: I have nothing against open access or online solutions to academic publishing – on the contrary, I love both as long as they uphold academic standards of quality and integrity. However, as mentioned and once again evidenced, the simplicity of setting up something that looks like an academic journal just to make cash that this creates unfortunately attracts some scum and scam. Now, if not before, we know that the Journal of Clinical Research and Bioethics belongs in this latter category.

Rapid Response to Coleman's Article in BJP Forthcoming

"

So, following my former posts on this subject (here, here and here), I decided to enter the discussion following Priscilla Coleman's article on abortion and mental health in the British Journal of Psychiatry. My response, entitled "The Correct Use of Ethics and Precaution with Regard to Abortion and Mental Health" concerns not the scientific quality of Coleman's work or the plausibility of her conclusion, but rather the practical implications of this field of research. This is a topic cautiously touched on by Coleman herself and, much less cautiously, addressed by several commentators in the ensuing debate. I basically argue that all of the claims made to this effect are unwarranted and based on faulty reasoning. Since the letter is in submission I will not expose it here until it is either published or rejected.

Interested readers may in the meantime find great pleasure in reading the most recent rapid response from Ben Goldacre and William Lee.

Stay tuned!

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.

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!