Journal of Bioethical Inquiry, Volume 8, Number 1 (March 2011)
Guest Editor: Michael Robertson

Editorials

Editorial

Kate Cregan

Issues and Challenges in Research on the Ethics of Medical Tourism: Reflections From a Conference

Jeremy Snyder, Valorie Crooks, and Leigh Turner
The authors co-organized (Snyder and Crooks) and gave a keynote presentation at (Turner) a conference on ethical issues in medical tourism. Medical tourism involves travel across international borders with the intention of receiving medical care. This care is typically paid for out-of-pocket and is motivated by an interest in cost savings and/or avoiding wait times for care in the patient’s home country. This practice raises numerous ethical concerns, including potentially exacerbating health inequities in destination and source countries and disrupting continuity of care for patients. In this report, we synthesize conference presentations and present three lessons from the conference: 1) Medical tourism research has the potential for cross- or inter-disciplinarity but must bridge the gap between researchers trained in ethical theory and scholars unfamiliar with normative frameworks; 2) Medical tourism research must engage with empirical research from a variety of disciplines; and 3) Ethical analyses of medical tourism must incorporate both individual and population-level perspectives. While these lessons are presented in the context of research on medical tourism, we argue that they are applicable in other areas of research where global practices, such as human subject research and health worker migration, are occurring in the face of limited regulatory oversight.

Recent Developments

Recent Developments in Law

Cameron Stewart, Bill Madden, Tina Cockburn, and John Coggon

Symposium

Neuroethics and Mental Health—Old Wine in New Bottles or a Legitimate New Field of Bioethical Inquiry

Michael Robertson
Neuroethics is a relatively novel field of investigation. Applied to mental health practice and research, neuroethics would seem to enlighten many traditional ethical connundra. This editorial introduces this symposium on neuroethics in the Journal of Bioethical Inquiry.

“This Is Why You’ve Been Suffering”: Reflections of Providers on Neuroimaging in Mental Health Care and Erratum

Emily Borgelt, Daniel Z. Buchman, and Judy Illes
Mental health care providers increasingly confront challenges posed by the introduction of new neurotechnology into the clinic, but little is known about the impact of such capabilities on practice patterns and relationships with patients. To address this important gap, we sought providers’ perspectives on the potential clinical translation of functional neuroimaging for prediction and diagnosis of mental illness. We conducted 32 semi-structured telephone interviews with mental health care providers representing psychiatry, psychology, family medicine, and allied mental health. Our results suggest that mental health providers have begun to re-conceptualize mental illness with a neuroscience gaze. They report an epistemic commitment to the value of a brain scan to provide a meaningful explanation of mental illness for their clients. If functional neuroimaging continues along its projected trajectory to translation, providers will ultimately have to negotiate its role in mental health. Their perspectives, therefore, enrich bioethical discourse surrounding neurotechnology and inform the translational pathway.

Psychiatric Molecular Genetics and the Ethics of Social Promises

John Z. Sadler
A recent literature review of commentaries and “state of the art” articles from researchers in psychiatric genetics (PMG) offers a consensus about progress in the science of genetics, disappointments in the discovery of new and effective treatments, and a general optimism about the future of the field. I argue that optimism for the field of psychiatric molecular genetics (PMG) is overwrought, and consider progress in the field in reference to a sample estimate of US National Institute of Mental Health funding for this paradigm for the years 2008 and 2009. I conclude that the amounts of financial investment in PMG is questionable from an ethical perspective, given other research and clinical needs in the USA.

The Gold-Plated Leucotomy Standard and Deep Brain Stimulation

Grant Gillett
Walter Freeman, the self styled neurosurgeon, became famous (or infamous) for psychosurgery. The operation of frontal leucotomy swept through the world (with Freeman himself performing something like 18,000 cases) but it has tainted the whole idea of psychosurgery down to the present era. Modes of psychosurgery such as Deep Brain Stimulation and other highly selective neurosurgical procedures for neurological and psychiatric conditions are in ever-increasing use in current practice. The new, more exciting techniques are based in a widely held philosophical position on the relationship between the mind, brain and soul, which is the key to ethical debates in this area. Psychosurgery has always posed questions of responsibility, personality, character, identity, spirit, relationship, integrity, and human flourishing and they do not go away when we enter the brave new world of neuroethics and Deep Brain Stimulation.

Criminal Law as It Pertains to Patients Suffering From Psychiatric Diseases

Maxwell R. Bennett and Peter M. S. Hacker
The McNaughton rules for determining whether a person can be successfully defended on the grounds of mental incompetence were determined by a committee of the House of Lords in 1843. They arose as a consequence of the trial of Daniel McNaughton for the killing of Prime Minister Sir Robert Peel’s secretary. In retrospect it is clear that McNaughton suffered from schizophrenia. The successful defence of McNaughton on the grounds of mental incompetence by his advocate Sir Alexander Cockburn involved a profound shift in the criteria for such a defence, and was largely based on the then recently published “scientific” thesis of the great US psychiatrist Isaac Ray, entitled A Treatise on the Medical Jurisprudence of Insanity. Subsequent discussion of this defence in the House of Lords led to the McNaughton rules, still the basis of the defence of mental incompetence in the courts of much of the English-speaking world. This essay considers one of these rules in the light of the discoveries of cognitive neuroscience made during the 160 years since Ray’s treatise. A major consideration is the relationship between “the power of self-control” and “irresistible impulse” as conceived by Cockburn on the one hand, and by cognitive neuroscience on the other. The essay concludes with an analysis of the notion of “free will” and of the extent to which a subject can exert restraint in the absence of particular synaptic connections in the brain.

A New Challenge for Research Ethics: Incidental Findings in Neuroimaging

Bert Heinrichs
It has become evident that neuroimaging raises new normative questions that cannot be addressed adequately within the (in this regard unspecific) frameworks of existing research ethics. Questions that are especially troubling are, among others, provoked by incidental findings. Two questions are particularly intricate in view of incidental findings: (1) How can the research subject’s right not to know be guaranteed? And (2) should a diagnostic check of scans by a neuroradiologist become an obligatory part of neuroscientific research protocols? The present paper examines these question against the background of two recent recommendations. The differentiation between “difference position” and “similarity position” serves as an analytic tool to further investigate the issue and to develop a distinct proposal for answering the questions.

Original Research

What Constitutes Adequate Public Consultation? Xenotransplantation Proceeds in Australia

Peta S. Cook
The Australian moratorium on human clinical trials of xenotransplantation was lifted in December 2009. This decision follows public consultations on whether xenotransplantation should or should not proceed in Australia, which occurred in 2002 and 2004. However, the public consultation, in its design and process, did not facilitate meaningful public engagement and involvement, thus marginalising the public and devaluing their social experiences and diverse knowledges. This brief article questions what constitutes adequate public consultation, and suggests that consensus conferences or citizen juries should be explored as a mechanism for meaningful public engagement for future public consultation exercises in Australia.

Art and Bioethics: Shifts in Understanding Across Genres

Paul Ulhas Macneill and Bronaċ Ferran
This paper describes and discusses overlapping interests and concerns of art and bioethics and suggests that bioethics would benefit from opening to contributions from the arts. There is a description of recent events in bioethics that have included art, and trends in art that relate to bioethics. The paper outlines art exhibits and performances within two major international bioethics congress programs alongside a discussion of the work of leading hybrid and bio artists who experiment with material (including their own bodies) at the ambiguous intersections between art, bio art and bioethics. Their work seeks to engage audiences in challenging ethical precepts and assumptions about life and existence. We consider the response of art and social theorists and compare these with the responses of bioethicists to comparable cases in bioethics. We note divergent views within the arts and within bioethics in relation to some pivotal questions including questions about what limits, if any, can apply in particular cases and on what basis. This approach allows for a transfer of information and perspectives, challenges assumptions in both art and bioethics and opens up a space for future exchange and dialogue along the shifting borders between these genres.

One Flu Over the Cuckoo’s Nest: Comparing Legislated Coercive Treatment for Mental Illness With That for Other Illness

Christopher James Ryan
Many of the world’s mental health acts, including all Australian legislation, allow for the coercive detention and treatment of people with mental illnesses if they are deemed likely to harm themselves or others. Numerous authors have argued that legislated powers to impose coercive treatment in psychiatric illness should pivot on the presence or absence of capacity not likely harm, but no Australian act uses this criterion. In this paper, I add a novel element to these arguments by comparing the use of the harm to others justification for coercive treatment in mental illness with its use in illness due to infectious disease, and suggest a double standard applies. People with mental illness are subjected to coercive treatments at levels of risk to others far, far lower than would precipitate coercive treatment in people with influenza. In effect, this element of mental health legislation represents an example of sanism—state-sanctioned discrimination against people with mental illnesses.

Reviews

When Experiments Travel: Clinical Trials and the Global Search for Human Subjects

Kevin A. Schulman

Case Studies

Republication: Limits to Responsibility and Care?

Malcolm Parker

Response

Robert King

Response

Tony Wild

Response

Christopher James Ryan

In That Case: Taking the Hard Road

Bill Lukin