IME Grant Application

These are the two short essays I wrote for my grant application from the Institute of Medical Ethics. The first is a proposal for a topic of interest and the latter a personal statement covering my reasons for choosing Medical Ethics. I have held these essays back for quite some time, partly not to tempt fate and partly because doing so seemed (dare I say it) MORE self-indulgent than my normal posts.

Nonetheless I am more than curious for feedback and have made a promise to myself to post as much of what I write as is humanly possible.

Does Fairness mean Equality?

By striving for fairness are we undermining the very purpose of fairness?

The principle of equality has deep historical and cultural roots. The idea that “every man is born equal” is both attractive and iconic. There is however a fallacy here, which is that no man is born equal. There are inherent characteristics imbued at birth (and subsequently during development) that make this idea incoherent.

Equality is defined in the Oxford English Dictionary as “The condition of being equal in quantity, amount, value, intensity, etc.” The suggestion here is that equality means uniformity. This is not only undesirable, but impossible. No two organisms can have the same makeup and occupy the same place in space and time. There are always advantages conferred by these differences that make complete equality unworkable. Human society consists of even greater differences: those of genetics, gender, ethnicity, class, social background and countless others. These differences cannot be ignored for they can determine the course of one’s life dramatically, and - depending on one’s views of free will – they can be outside an individual’s control.

This complex philosophical question is difficult to answer, and beyond the scope of this essay. However, studying empirical evidence, it is clear that there is a strong correlation (of varying degrees) between many of these factors and many health and social problems.

This is mostly acknowledged in healthcare, and common sense has dismissed dogmatic ideas of uniformity and universality. It would be ridiculous for instance to provide cervical screening to male patients. However there is the potential to widen this principle beyond the simple remit of obvious differences.

There have been attempts to provide fairness through inequality on a socio-political level through policies of Affirmative Action. There is debate over the ethical implications of these policies, both from a practical and moral perspective. The moral argument can be reduced to ideas of reverse discrimination. On the practical side, it is argued that these policies change public perceptions so fundamentally that they undermine the very objectives attempted to be reached.

In contrast, there is also the potential that actions like this could help redistribute resources to where they are most needed. When visiting a General Practitioner in Lewisham I was told that screening attendance was far lower there than in other, more affluent, areas of the country. The interventions for those conditions were therefore less successful as diagnosis was delayed. It might be fairer to invest more in encouraging individuals from these areas to attend screenings. However, it was the GP’s opinion that it was the responsibility of those who did not attend and further investment from an already overstretched service is not justified.

The ability for society to accept these ideas is heavily influenced by resource availability. In the current climate there is increased strain on resources in healthcare and the country as a whole. Deciding how these resources should be distributed will be increasingly more important in healthcare in the near future.

There are clearly differing views within society of what real justice is. Ideas vary between individuals and parties. It is possible that by doing away with certain ideas of equity, society can actually become fairer by appreciating differences and aiming to counteract their negative effects.

Whilst this may sound rather attractive on paper, there are clear issues in translating ethical principles into ethical practice. As with any principle it will not be interpreted nor applied identically by every individual. There will always be those who, willingly or unwillingly, misuse the idea to justify actions that undermine its very purpose.

Equality is a core belief within our society, regardless of its flaws. It is deeply ingrained into almost every citizen’s understanding of social justice. Policies that suggest favouritism of certain groups over others could easily challenge this understanding to such a degree that the principle is invalidated. It might be better to accept the devil you know than the devil you don’t.

It is possible to be so consumed by making an idea work in theory that it loses its practical use. Amartya Sen famously criticised Rawls (and others) in The Idea of Justice for ascribing to what he named “transcendental institutionalism” – the search for a perfect notion of justice. Justice is a complex, imperfect entity and establishing a real connection between theory and practice is of key importance.

Reasons for choosing Medical Ethics

Medical ethics is an essential part of clinical practice. It is within this specialty that we are most able to address the dilemmas that arise in the healthcare profession and question what ought to be done.

The deeper I have explored, the more I have learnt that the practice of medicine is far more muddled than is often acknowledged, particularly in discussions at student level. The reality involves constant debate over practice and conflicts arise between many parties: between patients and doctors; between doctors and their peers; and between doctors and the government. Each group has a different set of priorities and there is rarely complete agreement over any major healthcare policy decision.

This is exacerbated by the fact that some doctors do not perform their role as well as they could. My experience in the clinical setting as both a patient and a student has been varied in this regard. Many (if not most) doctors performed their roles admirably and undoubtedly supported their patients to the best of their abilities. However, this is not universal and some doctors clearly performed better than others. I have encountered more than one doctor who appeared self-interested and dismissive of their patients’ feelings and concerns. I have even heard stories from my peers of doctors performing actions that are clearly negligent and unprofessional.

These are not isolated events; in fact Medicine is no stranger to scandal. Throughout history there are cases of questionable ethical decision-making by those at even the highest levels of authority. Most notorious of course are the Nazi experiments during the Second World War and the consequent Doctors’ Trials in Nuremberg. There are however more recent examples: those of Baby P and the Staffordshire Hospital Crisis have demonstrated the potential for repeated failure on multiple levels of the healthcare service.

With such potential, I feel a keen sense of duty as a future medical practitioner to learn the skills necessary for good clinical judgement – not only for my patients’ sakes, but to feel comfortable with the decisions I make.

This is my long term goal, but there is an immediate sense of gratification that can be felt by pursuing this study. I take great interest in ethical issues and relish attempting to understand complex problems and find practical solutions to ethical dilemmas. Decisions are made in a constantly changing socio-political landscape. There are many variables that can alter how decisions are made: There can be changes in resources themselves (such as changes to NHS funding); changes of social values (such as those of assisted suicide and mental health); and also due to advances in technology (bioethical issues). I already take an individual interest in all of these matters and being able to integrate them into my thought process is something I enjoy.

In my spare time I love to write and maintain a blog (www.sharkattack-i.blogspot.com) in which I try to explore many of the issues that I find myself musing over. I try to cover a broad range of topics, but most of my writings focus on key interests of ethics, politics and film.

I am also a member of the KCL Film Society and Debating Society; both of which provide the opportunity to express my opinion, as well as listen to opinions completely different to my own. Debating also offers the unique opportunity to argue opinions from a viewpoint that one doesn’t hold - something which helps foster a deeper understanding of other views, as well as improving one’s reasoning and oratorical skills.

I hope that when I complete the course I will have gained skills to make effective decisions in clinical practice, as well as having broadened my mind by sharing my views with other interested students. I have no doubt that this will be the case.

Views on Pornography

I was recently directed to a BBC News article covering a survey on the consumption of pornography in adults aged 18-24. The study showed an overwhelming prevalence in the use of internet pornography - something hardly surprising in the digital age.

The issue of pornography is a difficult one to discuss as it involves many different levels. A line can be drawn between two categories of arguments: problems in the production of pornography (i.e. the subjects of pornographic material) and the viewing of pornography (i.e. the viewer). I personally have no problem with people having sex on film, but the production and distribution should be (and are) controlled - at very least to some degree.

Pornography and erotica have existed (as far as I know) for hundreds of years. Japanese Shunga, the Kama Sutra and early erotic fiction have all been used to evoke erotic feelings in their viewers/readers. They have also been considered - at one point or another - graphic, lewd and improper; ultimately resulting in censorship. Modern attempts at censorship in the UK have been mostly unsuccessful. The Earl of Longford's famous campaign of the 1970s subjected him to much ridicule.

The dawning of the digital age has vastly increased the access to pornographic material - particularly free material. As covered in the aforementioned article, this has lead to a surge in viewership by young adults, both male and female. The survey suggested an association between high consumption of pornography and 'worry'. The link seems sound - at least in the sample group - but determining a causal relationship is challenging. It is equally reasonable, based on this evidence, to suggest that worrying about relationships causes people to use more pornography.

Nonetheless it is unlikely that any such study is able to determine causality of psychological harm as this is notoriously difficult to do. I would hypothesise that both have some impact in different individuals. It is also worth noting that any medium that can so strongly influence a critical component of human interaction (i.e. sex) comes with some danger. Accurately assessing this risk is near impossible and so raw opinion drives much of the debate over pornography.

My view is that creative sexual expression is an essential part of modern society. I believe the definition of pornography often includes the caveat of "no literary or artistic value", but I don't know if I can so clearly draw the line between art and non-art. As I discuss here I am not entirely sure most modern art has much 'artistic value'.

Nonetheless, normal sexual development should involve some form of exploration. Pornography and erotica provide a convenient medium for this, without carrying the risks (emotional or medical) of normal sexual interaction. However, much like any fantasy, the problem lies in adequately distinguishing between this fantasy and reality. The (often deliberate) misrepresentation of reality is a endemic problem in our society: unhealthy body shapes are flaunted on catwalks, violence is glorified in cinema and junk food is [was] advertised to children. Frankly, the list is endless. We are all bombarded with images and representations of lives and lifestyles that have the potential to cause us harm.

Understanding (and controlling) these elements is an overwhelming challenge and one subject to constant iteration through social change. With regards to pornography there seems a worrying trend in its use by younger audiences [1][2]. Children are naturally more susceptible to the detrimental effects of such material and yet internet pornography has no real way of determining how old its viewer is. With such overwhelming access, regulation becomes more important and yet more difficult.

This is particularly worrying as more extreme pornography is increasingly available. The representations/connotations of violence, submission and imbalance are of particular concern. This also creates an added risk for the performers in the industry - an issue covered less than I would like. Pornography carries many risks and, whilst far less than sex workers, it carries dangers of infection, financial insecurity, coercion, manipulation and even emotional/sexual abuse.

These issues are all important, but I would like to end with a call for better perspective as is often lost with such heavily-debated issues. It seems that pornography has become a lightning rod for discussions over free speech and sexual conformity. There are many areas in which various media have the potential to cause substantial sociological and psychological damage. It is my belief that harmony is best maintained by ensuring moderation in the consumption and the regulation of this material - perhaps an obvious but nonetheless important point.

Discussing Justice

It seems justice has been on my mind. This has been somewhat exacerbated by the presence of Malcolm Sandel's series [simply entitled 'Justice'] on iPlayer. This series of lectures has highlighted to me several flaws within our way of thinking about Justice. It possible that my views on this point are deeply and unfairly critical but (in the spirit of these posts) I shall pursue regardless.

I suppose the first key flaw I noticed was the fragmented nature of our discussions about morality and legality. These two concepts, whilst overlapping have very different ramifications. It's perhaps best to start by defining these two concepts as I see them: morality as the subjective belief of what is right/wrong; legality as an attempt to translate subjective moral beliefs into 'objective' rules for practical application.

I doubt many would disagree with my definition of morality, but I suspect some might disagree with the ideas defining legality. If only because it does not state whose moral beliefs and what the application actually is. I leave these aspects unclear because currently I don't think we have adequate answers for them.

I mentioned in a previous post that I question the purpose of our legal system. In part because there seems an incomplete connection between this idea of legality and the resultant consequences. I have had many conversations regarding the legalities of an act, but rarely do these conversations cross over into the realm of sentencing or imprisonment.

This strikes me as irrational. Personally I see these final steps as more important than prosecution. I will (as ever) demonstrate my point using hyperbolic analogies. Let's take two acts that are equally illegal: theft and murder. If the murderer were given community service and the thief given life imprisonment, it's unlikely that many would see justice as being served. In this example, the important aspect is not the legality of the act, but what is done with the criminal as a result of that illegality. Murder is worse than theft and therefore the murderer deserves a hasher sentence.

To apply this principle to more contested scenarios, I will mention one that has been previously presented to me: A young woman is terminally ill and begs her mother to end her suffering. The mother searches for an alternate way to assist her daughter without having to end her life and after months of seeing her daughter in agony, she finally gives in to her request and helps her end her life.

My understanding is that under English law assisted suicide is still murder. Regardless of legality, I cannot see what the purpose is of jailing someone for such a crime. The mother does not seem to pose any risk to society, she has not taken any life unwillingly nor against the wishes of any other members of her family. Calling her crime murder means she is judged alongside other murderers, whose crimes I consider far worse and far more dangerous.

The defendant is described as a "devoted mother" acting out of love, rather than malice or disrespect for the lives of others. The key issues for me are: what bad would become of letting her walk free and what could be gained by prosecution, other than the dogmatic implementation of the law?

I suppose now is the time to return to the question of why the law exists. There are of course many ways of implementing the law: fines, prisons, community service, etc. What principles do we believe these fulfil? Do we aim to punish criminals, to prevent crime or to protect citizens becoming the subjects of crime?

Answering these questions seems critical in assessing the validity of our justice system. I personally see little value in punishment, but place great value in prevention and protection. I have previously expressed these views in my post about the prison system.

Using legality as the centre of any argument about a legal case seems unfitting. Really we should talk about what we think should happen as a result.

Prisons

I am no fan of the prison system. I believe its primary aims are to punish criminals and segregate them from mainstream society in order to protect the majority. The effect of this is to create social environments formed entirely of those who are also criminals. This effect is hardening and only makes it more difficult to integrate with society upon release.

Often this social alienation can be one of the precipitating factors in crime to begin with, so acts that blatantly exacerbate this seem very short-sighted. Re-offending rates are high with a tendency for crimes to increase in severity. The effect also spreads - children with family members who've been in prison are multiple times more likely to commit crimes themselves.

I am much more in favour of programmes that target those at risk of committing crime and preventing them ever entering the prison system. The earlier the better. That essentially means tackling poverty, improving welfare and revolutionising the education system. These are expensive measures - ones which few are truly willing to pay for.

The sad truth is that most can escape crime more easily by economic means and thus are presented with a far cheaper option than paying ludicrous amounts of tax - they can simply move to a safer area.

Those who suffer as a result are those already being failed by the state. Poverty is the source for both the criminals and the greatest victims of crime.

There are possible alternatives to prisons in the form of restorative justice, however the argument is hardly won in the political arena. Many doubt the efficacy of such schemes. Whilst the jury may be still be out (no pun intended) I reserve my right to hate prisons regardless.

Art

For some reason in a discussion I noticed in myself a frustration when hearing mention of Art (in this sense I'm purely talking about art displayed in galleries). Whilst I've certainly never found myself enamored with the medium I didn't notice such strong, stark, negative feelings in me before.

I suppose this post will most likely constitute a bit of a rant, but there are certain elements of my vastly unfair and irrational criticism that might have some legitimacy. Let me be clear, my problems with the medium lie less in its value as creative expression, but rather with the 'art world'.

It's perhaps best to start with the oddity that put me down this road of thought in the first place. In art I feel there is a great need (seemingly greater than any other medium) for uniqueness. Galleries pay millions to hang paintings, to show sculptures and to display installations created by the original artist. Whilst it may be worth paying for a first edition or original manuscript of a famous book, the intention is certainly that these works were meant to be distributed - the wider the better. Copying a novel, poem or film doesn't depreciate the value of the art itself, only the physical vehicle by which it is delivered.

Somehow this principle is reversed in the art world. The physical 'vehicle' is seemingly more important than any other identical copy. Even an indistinguishably similar forgery is worth infinitely less than the original, regardless of the emotion it evokes in the onlooker.

Conversely an undetected forgery is somehow worth exactly the same as the original. Only when its authenticity is assessed - using increasingly complicated techniques - does the value ever come into question.

There seems to be a necessary amount of self-denial required to make this system work - a false importance needed to be injected by the viewer, rather than a universal importance.

This question of the importance of authenticity and historicity is addressed - and in my opinion, adequately answered - in the Philip K Dick novel, The Man in the High Castle. The creation of art has greater value than the objects which physically embody this value and the connection we place in the object is subjective: seeing Lincoln's top hat might be significant because Lincoln wore it, but the hat itself has no value - after all, it is just a hat. It did not free the slaves nor perform the Gettysberg address nor die in a theatre. However, it does serve the purpose of an emotional conduit, through which we can feel a connection to its famous owner. We search, perhaps naively, for a connection to the long-gone subject through the object.

For all my ranting, I don't have any problem with this. Ultimately the connection we feel is genuine and important. For instance, I would never take away the mementos of a long dead friend for the purile reason of it not being 'real'.

However, what I do take issue with is the monetary valuing of this commodity; this emotional connection. A process that ultimately strikes me as incredibly undemocratic.

To make a(~nother) preposterous analogy, if Bill Gates, or any other infinitely rich person, were to buy the only copy of a literary work to form part of their private collection, there would be uproar. Ok, maybe not if it were Russell Brands Bookey Wook, but for virtually any text with remote artistic value, this would be shocking.

It is my belief that techonolgy will provide the ultimate liberation of Art from the shackles of oligarchical economic control. After all, it is the invention of the printing press that allow William Tyndale to take advantage and disseminate great works to the public. This act was of course illegal and Tyndale's punishment was infamously dire. We owe much as a society to the sacrifice he and others made.

I also read (rather fondly) that it was acts of literary piracy that allowed the spread of the works of Robert Louis Stevenson abroad to Australian and American readers, where he received his greatest fame and praise.

I am also at this point inclined to once again mention The Man in the High Castle, in which the fictional novel, The Grasshopper Lies Heavy is spread both illegally and widely.

To draw more modern parallels, it is the internet that has allowed widespread distribution of digital media. So perhaps, one day, we will wonder around virtual art galleries, where every man woman and child can hold a great work of art in their hands; barriers of distance or cost long dissolved. Perhaps we will wonder what it must've been like to live in a world so restricted.

Rant OVER and out.

Money and Justice

I feel very uneasy with the regularity with which we use the idea of money as a proxy for all reward and punishment. I much rather systems that provide more tangible, direct consequences. Ultimately money has no intrinsic value - it is purely a means to an end (i.e. to buy something else you need). Taking money out of the equation means that the gains are far more straight-forward.

However, I am certainly not against money per se. It is an incredibly useful system that in fact forms one of the major foundations upon which civilisation has been built. Without money and the universal value of goods and services, long-distance trade is near impossible. As a society and civilisation we owe a lot to money.

Nevertheless, I do believe there is a case to be made in highlighting an over-reliance on money, to the point where real value is lost.

As you may have guessed from the title, this thought process led me to thinking about the fundamentals of our justice system (good segue!). It's no real shock to highlight the illogical connection between money and justice.

Our legal system is supposedly based on ideals of fairness. Yet, there are of course many other factors in determining the success in any case - many of which can be greatly improved by having a baJILLion dollars! Rich people can afford better lawyers, they can pay higher fines and (with enough money) they can even bribe the judge...These may not all be strictly legal, but they are certainly possible.

I don't see it as my place to comment on the more criminal solutions to legal problems as I'm sure condemnation is unnecessary, but I do wonder about the other two - particularly the idea of fines and legal payments in general.

My first thought was to question what the purpose of fines actually is. There are three major reasons I can see for fines being useful. On the more pragmatic side the money can be used to repair any damage caused by the original offence and cover any legal fees. There's also the fact that fines can be a significant deterrent to those who wish to commit crimes and finally, the fine can serve as punishment to those who commit the crime.

It's in these last two that I see a real problem. Assuming the fine for a crime is flat, surely someone with more money is simply less affected than others with less. I can't imagine a £50 fine being anything less than a slap on the wrists for someone with enough money to pay. Upping the fine only exaggerates the effects. For say a £50,000 fine it might mean bankruptcy to some and pocket change to others.

It is perhaps inappropriate to apply the principles used in one's personal life to such a large scale problem, but on the rare occasion when I have to lay the smackdown, I would almost always tailor the punishment to both fit the 'crime' and the individual. A mismatch between the two can often lead to suboptimal smackdownage and increased reoffending rates.

Forgive me for taking the analogy so far, but I do feel unconvinced that the principles driving the use of fines are best fulfilled by flat rates. The punishment for the same crime can be arbitrary and miniscule for some and life-changing for others.

The idea that subsequently popped into my head was 'means-tested fines'. Ok, so I'm not totally serious about this idea, but it does strike me as interesting. Even more so because I've heard no mention of anything similar. If fines were 'means-tested' they would be adjusted to be more in-line with a proportion of income/assets rather than fixed values. The punishment would be in line with the amount of difficulty it causes for the perpetrator.

I see several problems with this idea. It relies on accurately calculating the income of the defendant in any civil/criminal case. This would most likely be costly, lengthy and widely open to loophole abuse. The very people the change is meant to target would also be best equipped to evade excess payment.

Nevertheless, on a more theoretical level, it seems to make a lot more sense. It would certainly feel more 'fair' to pay proportional to your income.


ADDENDUM:

Just to illustrate what kind of poorly researched toss I write, here are two articles illustrating the existence of the principle in Finland and also previous proposals to have it introduced here. I'm not sure whether it ever was implemented, but the Telegraph complained about it (no surprises there).