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Roger Ebert had it Right

5 April, 2013 1 comment

“‘Kindness’ covers all of my political beliefs,” he wrote, at the end of his memoirs. “No need to spell them out. I believe that if, at the end, according to our abilities, we have done something to make others a little happier, and something to make ourselves a little happier, that is about the best we can do. To make others less happy is a crime. To make ourselves unhappy is where all crime starts. We must try to contribute joy to the world. That is true no matter what our problems, our health, our circumstances. We must try. I didn’t always know this and am happy I lived long enough to find it out.”

- Roger Ebert. Now, sadly, the late Roger Ebert.

The Problems With Obligatory Dangerousness

6 January, 2013 Reply

Happy New Year, first of all.

The other day I happened upon a 2008 paper by Large, Nielssen, Ryan, and Hayes, entitled “The danger of dangerousness: why we must remove the dangerousness criterion from our mental health acts.” (J Med Ethics 2008;34:877-881). I won’t link to it, as it’s not freely available. However, I will summarise the main arguments as best I can, and then discuss both my agreement and concerns.

The authors’ point is that dangerousness is not a logical, useful, or ethically-sound, criterion on which to base involuntary psychiatric treatment. They then suggest a person’s capacity to consent as a better replacement.

They start with some historical background on the Obligatory Dangerousness Criterion (i.e. not simply that dangerousness can justify involuntary detention and treatment, but that only dangerousness (to self or others, generally) can do so). They then present arguments against the validity and value of an ODC: that the reasoning behind it is flawed, and its effects unhelpful and possibly even harmful.

First they argue that an ODC is unnecessary as a justification for overriding a mentally ill person’s autonomy, because their illness has already robbed them of their autonomy. This is the point at which I began annotating my PDF… it seems to me to be a rather sweeping generalisation to write, as they do:

“In most cases mentally ill people who refuse treatment do so because their mental illness has robbed them of their capacity to consent to that treatment.”

O rly? “most cases”? That’s definitely a statement I would have liked to have seen backed up by a slew of references – especially as it forms the basis of their later suggestion.

Anyway…

They go on to make I think more cogent arguments against an ODC. First they draw a comparison with non-psychiatric situations where a person might be unable to consent to treatment, and make the point that dangerousness is not a part of the decision-making about their treatment.

Second (and deserving its own paragraph), they discuss our inability to be clear about dangerousness in any really reliable way. Even using the best available actuarial tools, in controlled research settings, you see unsupportably-large amounts of misclassification of risk (they cite particularly the MacArthur Study of Mental Disorder and Violence, in which – despite a higher baseline prevalence of risk than one would usually be dealing with, which increases one’s positive predictive value – 29% of the study subjects were misclassified).

And that’s the best case scenario. By a long way. Most studies agree that a psychiatrist has no better ability to predict who will or won’t kill themselves or someone else, than flipping a coin.

So, I agree with these authors: that seriously undermines the justification for an ODC.

Next they take on the utility of an ODC. One might argue on utilitarian grounds that if an ODC is useful, then let’s go with it even if it’s not logically or clinically justified. I wouldn’t, but one might…. However, they discuss some evidence showing that the Duration of Untreated Psychosis is longer (by 5 months) in countries with an ODC compared to countries without – and they say that was not able to be explained by clinical characteristics of the patients, or by the funding or delivery of psychiatric services. The longer the DUP, essentially the worse the clinical outcome for the ill person. They then cite studies showing a statistical correlation between longer DUP and greater risk of violence, suggesting (in an indirect manner, it should be said) that the adverse effects of an ODC (assuming that is in fact what is causing the problems) are not just limited to the person themselves, but also may involve harm to others.

So, an ODC doesn’t make sense, and isn’t useful. But no-one wants to return to just locking up psychiatrically ill people because they’re psychiatrically ill, so what do we use instead? These authors suggest an assessment of capacity:

“Mental health acts should be redrafted so that treatment without consent can be provided to a mentally ill person if and only if:
1. It can be reasonably held by an independent authority that the mentally ill person lacks the capacity to consent to the proposed treatment.
2. It can be reasonably held by an independent authority that the mentally ill person will gain substantial benefit from the proposed treatment, or alternatively, if a proxy decision maker believes that the mentally ill person would have consented to the treatment had he or she the calacrity to do so.
3. The treatment is provided in the least restrictive environment practicable.”

They go on to say that such a change in criteria:

“…would return the fulcrum for compulsion to its proper place. That is, that the mentally ill person has, usually by virtue of their illness, lost the capacity to see themselves as ill, and as in need of treatment.”

And that, I have a problem with. While I agree with the argument against an ODC, I have serious reservations about the use of capacity as a replacement. In practice I think it would mean people would be detained simply for refusing treatment – with their lack of capacity to consent to treatment being assumed, tautologically, by virtue of their refusal of treatment.

Taking a step back from the practical reality, this also requires a substantial value judgement about both mental illness and the available treatments, and an assumption that the ill person must necessarily share our adjudged values – or that if they don’t, it must be a reflection of their illness, and warrant involuntary treatment.

I accept that there are established methods for the assessment of capacity, and their (mandatory) use might address my first reservation; however, I’m left with the second, and I’m not sure how to surmount it.

In addition, if we were to allow involuntary treatment of someone who lacks the capacity to consent, then why only in psychiatric illness? Why even specifically in psychiatric illness? Shouldn’t this argument then just represent a call for a “Health Act” allowing involuntary treatment of anyone who lacks capacity to consent to treatment of whatever ailment they have?

Cat … pigeons….

And are we talking passive assent or real informed consent? – And how would we monitor the consent processes in relation to such a “Health Act”?

Sadly, I don’t have any answers. I do think the ODC should go. It’s senseless, and probably either useless or actually harmful. However, I’m unconvinced that capacity to consent is a reasonable replacement, and I can’t think offhand of anything else.

Not an easy thing, figuring out what might constitute a reasonable justification for removing a person’s basic human rights …

For Goodness’ Sake?

19 December, 2013 Reply

Merry Christmas (almost). Time for carols, perhaps…
 
He watches when you’re sleeping
He knows when you’re awake
He knows if you’ve been bad or good
So be good for goodness’ sake
 
STOP!!
 
In what universe can that be seen as being good “for goodness’ sake”? The song celebrates being good expressly for the sake of material reward, based on the judgements of some external omnipotent other…
 
Hmmmm… ;)
 
And I’m not sure (based on an n=2 study of my own children) that model of behavioural control is even useful in small children. :P

 

Purpose, Created?

22 November, 2013 Reply

Here’s an odd thing: a guest blog on Scientific American, calling on us to consider the possibility of a Creator of our universe.

Mmmmmmkay….

First of all, Stephanie Zvan, likewise writing a guest blog on Scientific American, has neatly deconstructed the failure that is Naff’s rather, well, naff, post. Go read that. I’ll wait ….

Back? Cool. Because that’s not the point I wished to take on. I would take the same position as Zvan (including taking issue with Naff’s characterisation of some very reasoned statements by Dawkins as “infuriated”), but the issue I want to address is the one, stated explicitly in the second paragraph, and permeating the whole blog, that existence lacks meaning and purpose unless it be vouchsafed us by a Creator:

“The other is the shiny new set of atheists who claim that science demonstrates beyond reasonable doubt that our existence is accidental, purposeless, and doomed.”

I’ve blithered on about this a number of times before, but I don’t get tired of saying it: we create our own meaning; we find and define our own purpose. That is the meaning of life, in my view.

Just as no godling could remove my responsibility for my deeds, no external being or force – or god – can bestow upon me purpose or meaning. They dwell within. For most of us they probably do involve things external to ourselves – but they were not created by those external things; we invest those things/people/causes with meaning for ourselves.

And yet Naff perpetuates the tired old trope that without god (or ancient aliens from another universe) to create us, our life is void of meaning. What a sad existence he must have, if he honestly cannot define himself other than by what might be granted him by some other.

And if that’s not the case, then I really don’t understand why he feels he must make the (extremely weak) point that he does.

Halal (Dhabihah) Slaughter: Fundamentally Wrong

16 June, 2013 5 comments

The news recently has been fired up by footage of appalling brutality in a slaughterhouse in Indonesia. As a result the Australian government has suspended live export to those abattoirs. What doesn’t appear to have been said anywhere near as prominently or loudly is that Halal slaughter is fundamentally sick and messed up.

First let me make it clear that what is shown in the video footage from Indonesia is very definitely not Halal. Halal (or rather Dhabihah) slaughter actually proscribes pretty much everything occurring therein – so the meat coming from those abattoirs is in fact Haram (forbidden). The animal should be treated gently until the moment of slaughter; they should not se other animals killed… It’s as though they read the requirements of Halal and decided to mostly do the opposite.

20110616-102507.jpg

Mostly.

While I am not therefore equating Dhabihah slaughter – and the resulting halal meat – with that brutality, I do think it is completely wrong: quite sick, in fact. Why do I even see it as relevant, seeing as the practices in those abattoirs are not Dhabihah? Because they’ve started a part of a conversation about live export for slaughter. Because that is only happening in the name of religious observance and a desire for halal meat.

And simply because I truly think it needs to stop.

First, have a look here, at the prescribed method of slaughter.

“According to Islamic tradition, the animal is brought to the place of slaughter and laid down gently so as to not injure it. The blade must be kept hidden until the very last moment while the jugular of the animal is felt. The conventional method used to slaughter the animal involves cutting the large arteries in the neck along with the esophagus and vertebrate trachea with one swipe of an non-serrated blade. Care must be taken that the nervous system is not damaged, as this may cause the animal to die before exsanguination has taken place. While blood is draining, the animal is not handled until it has died. If any other method is used its meat will not be halal.”

Spot the sick part? It’s right there in the middle:

“Care must be taken that the nervous system is not damaged, as this may cause the animal to die before exsanguination has taken place.”

Srsly.

The animal has to remain alive while it bleeds to death.

Oh. Yay.

According to Wiki, the Dhabihah method of slaughter described above is performed in order to comply with this from the Qu’ran:

“Forbidden for you are carrion, and blood, and flesh of swine, and that which has been slaughtered while proclaiming the name of any other than God, and one killed by strangling, and one killed with blunt weapons, and one which died by falling, and that which was gored by the horns of some animal, and one eaten by a wild beast, except those whom you slaughter; and that which is slaughtered at the altar and that which is distributed by the throwing of arrows [for an omen]; this is an act of sin.”
—– Al-Maa’idah 5:3

Now a prohibition against carrion makes sense. Don’t eat rotten meat; you could get sick and die. Sure. I’ll go with that. Pity it got religiously codified and therefore seen as mandatory and unalterable despite being quite bloody barmy…. But we’re not talking carrion.

Let’s be clear: there is no nice way to kill another living being. It’s something we do – and I think we should be acutely aware of it – but it’s not really very nice. There are however, more and less humane ways to go about it. Cutting an animal’s throat in such a way that it remains alive and aware while bleeding to death is fundamentally sick and messed-up. And there is no sense to it. No utility. No gain. It doesn’t make the meat more healthy. It doesn’t even make it taste better (if that could even be a justification for such cruelty).

Seriously, if someone can give me a rational justification for the requirement that an animal be kept alive to bleed to death, tell me; I’m waiting….

And to be clear: “because a bloody old book said so” is most assuredly not a rational justification.

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