Saturday, July 18, 2015

Conservative government tries to con Canadians on Assisted Dying

Canada's Supreme Court found unanimously that the criminalisation of assisted dying violates our Charter rights. Mr Harper's government was hell-bent on persuading the Court that assisted dying would pose a serious threat to vulnerable people, and whatnot else. The Crown's expert witnesses were sufficiently weak in the evidence that they presented that not a single judge on the Supreme Court (the majority of whom were appointed by Mr Harper) sided with the government.

Mr Harper, ever so keen on pleasing his party's religious fundamentalist voter base, has now appointed a panel of three to manage a consultative process with Canadians and to recommend to the federal government how it should regulate assisted dying. Mr Harper's government has a long-standing tradition of ignoring Supreme Court judgments or of trying to subvert them. I'm afraid, the same will happen with the Court's assisted dying ruling. Mr Harper will fail on this occasion, too.

Two of the three folks on the panel are anti-euthanasia activists. They duly told us that their personal views would not affect their recommendations. That is pretty funny.

For at least one of them, the panel's current Chair, Dr Harvey Chochinov, we know that this reassurance is worth little. I have written about his activities in the past.

Dr Chochinov was (as his fellow panelist and fellow anti-choice activist Catherine Frazee) an expert witness the Crown attorneys wheeled in to bolster their anti-choice case in the Supreme Court. His analysis and expertise sank pretty much without a trace. To give you an indication to what extent Dr Chochinov's personal views on the subject influence even his expert opinion in a Canadian court, consider the following:

A little-known Canadian on-line journal called Current Oncology published – curiously timed for the BC Supreme Court proceedings - a piece by Jose Pereira an Ottawa based anti-euthanasia campaigner. The on-line journal ran the article at the time as a regular article, implying that it underwent anonymous peer review. It eventually relegated it to an opinion piece status after it became clear how error-ridden it actually was.  Jocelyn Downie and colleagues undertook a line-by-line analysis of said article, since also published in said on-line outfit. It turned out to be the case that many of Pereira’s claims were not only not backed by the references he chose to insert, but that literature he cited actually reached conclusions different to those he reported. Dr Chochinov, chair of Mr Harper's anti-choice panel, didn’t hesitate to call the discredited piece by Pereira an ‘excellent article’ in his expert report. (Carter v. Canada (Attorney General), 2012 BCSC 886 (Expert Report, Dr. Harvey Chochinov at pp 16-17).

You tell me, is that an indication of a professional capable of rising above the fray and not letting his personal views influence his professional work? I think not. 

So, when his fellow anti-euthanasia activist, Dr Frazee assures a skeptical public that she and her fellow panelists would not let their personal views on assisted dying interfere with the panel's work, pardon me for not believing a word of what she is saying. Her panel chairman has gone so far as to praise in Court, as an expert witness for the Crown, a piece of research that served his ideological convictions, even though it was patently obvious that said piece of research was nothing much other than an agitprop exercise by a fellow anti-choice activist.

The good news for us Canadians is that it won't matter what this panel reports. By the time it reports, the government that appointed it won't be anymore. Even if, courtesy of NDP/Lib vote splitting, it sneaks back in, the Supreme Court will eventually ensure that our constitutional rights are protected, no matter what Dr Chochinov and colleagues report back to government.

It is troublesome that Dr Chochinov and his fellow-panelists saw it fit to accept Mr Harper's invitation, given the obvious election campaign related nature of their appointment. But then, Dr Chochinov has a less than stellar record when it comes to ethical judgment. So, perhaps he is the right man for Mr Harper's job after all...

Friday, June 19, 2015

2014 JCR Impact Factor for Bioethics and Medical Ethics Journals

Caution: this list does not reflect 'quality', or 'best' unless you assume that a lot of people citing and criticising obviously flawed content published in a journal would demonstrate that that journal is a high quality outlet. All it does is indicate how frequently articles in that journal were cited over a predetermined period of time. It doesn't tell us anything about the reasons for the citations. I included journals I found in JCR's medical ethics as well as its ethics list. - Not that it should matter, but for the sake of it, I co-edit 2 and 6 on this list.

Abbreviated Journal Title {2014}            Total Cites                 Impact Factor
AM J BIOETHICS 1363 5.288
DEV WORLD BIOETH 238 2.054
HASTINGS CENT REP 988 1.684
J MED ETHICS 2845 1.511
BMC MED ETHICS 404 1.495
BIOETHICS 982 1.483
NEUROETHICS-NETH 205 1.311
J EMPIR RES HUM RES 365 1.25
PUBLIC HEALTH ETH-UK 190 1.182
J LAW MED ETHICS 1189 1.097
HEALTH CARE ANAL 357 0.958
KENNEDY INST ETHIC J 285 0.867
J MED PHILOS 675 0.851
ACCOUNT RES 173 0.826
J BIOETHIC INQ 165 0.747
NANOETHICS 146 0.703
MED HEALTH CARE PHIL 448 0.7
CAMB Q HEALTHC ETHIC 344 0.682
MED LAW REV 153 0.65
THEOR MED BIOETH 325 0.537
INT J FEM APPROACHES 48 0.486
REV ROM BIOET 112 0.462
ETHIK MED 56 0.326
ACTA BIOETH 45 0.074

Friday, June 05, 2015

The dangers of assisted suicide – making a mountain out of a mole hill


I recently came across this piece by an Australian psychiatrist, John Buchanan, published in Australia's only quality broadsheets, Melbourne's The Age and Sydney's Sydney Morning Herald. Much as I am flattered by being described in Australia as an influential bioethicist, he got it badly wrong in his commentary. Here's a reply to Buchanan's analysis (I did, of course, send it to the paper's OpEd editor but didn't receive so much as an acknowledgment that they received it, much less do they apparently want to publish this response - so far for the influential bioethicist thing :-).
John Buchanan argued in this paper (May 27) that Victoria’s Parliament should reject a motion by the Greens to review the state’s assisted dying prohibitions. His main concern is that assisted dying legislation could not protect against abuse. Buchanan is primarily worried about assisted dying legislation’s impact on disabled patients, the mentally ill, and other vulnerable people.  
As an Australian making a living as an academic in Canada I have been privileged to chair on behalf of the Royal Society of Canada an international expert panel drafting a report on end-of-life decision-making. Among our recommendations was that Canada ought to decriminalise assisted dying. In a unanimous decision the country’s Supreme Court came recently to the same conclusion. On the face of it, it is quite unlikely that the expert panel that I chaired as well as the honourable Supreme Court justices would have missed existing evidence of the abuse of vulnerable people in jurisdictions that have decriminalised.

This perhaps is a good indication as any, that doomsday sayers such as Buchanan have got it wrong on this issue. His arguments are all too familiar to those of us who have been involved in these debates. Let me address some of them.
Among his evidence is a reference to a Dutch ‘medical ethicist’ who changed his mind on euthanasia. Said ethicist’s views are presented as a quote from a notorious British newspaper not known to feature quality content. It turns out, this ‘medical ethicist’ is Theo Boer, a Christian theologian employed at a Dutch Protestant university. Boer cuts a pretty lonely figure on this issue in the Netherlands. The existing assisted dying regime is overwhelmingly supported both by Dutch clinicians as well as the Dutch people. Clutching at straws is a familiar theme when it comes to anti-choice activism.

Buchanan serves another staple of anti-choice campaigners, personal anecdotes. He mentions hospital administrators getting all fired up about assisted dying so that they can empty hospital beds. There’s naturally also a fair bunch of greedy relatives and whatnot else. It is odd indeed that we must take his word for it. In a case currently windings its way thru the courts in New Zealand, similar anecdotes have been presented by the handful of clinicians travelling the globe to prevent legal assisted dying from coming about. Unsurprisingly, actual peer reviewed scientific literature does not support these claims. Perhaps anti-choice campaigners are drawn in strange ways to abusive hospital administrators and greedy relatives. A recent survey of permissive jurisdictions concluded that the average patient requesting assistance in dying is a late-stage middle-class male cancer patient. At no time has it been demonstrably shown that in permissive jurisdictions vulnerable disabled or mentally ill patients have been disproportionately affected by assisted dying. If anything, the existing evidence could be interpreted as showing that they have trouble accessing assisted dying.
There is something deeply troubling about the trope of alleged abuse meted out against disabled people, beyond the mere absence of credible evidence to support it. Disabled people have often been at the forefront of attempts to decriminalised assisted dying, because they often are least able to end their lives on their own accord, precisely due to their disability. A case in point is Canadian Steven Fletcher, a quadriplegic Conservative Member of Parliament. Paralysed from his neck down, a result of a car accident involving a moose in 1996, it was Fletcher who introduced assisted dying legislation in the Canadian House of Commons. 

Buchanan also claims darkly that Belgium and the Netherlands have widened access criteria. For that to be of concern we would already need to have concluded that there is something wrong about assisted dying. That, however, is what is in dispute. If I lived in a jurisdiction that had decriminalised assisted dying, I would want my government to monitor carefully how the existing regime works out and to adjust it in response to societal need. That might well entail changes to access criteria. Any such change as such is not evidence of something gone awry. 
Buchanan further makes the suggestion that we should improve the quality and availability of palliative care. He is right, we suggested that much in our Canadian report. He is wrong to assume that this is an either-or type situation. We know that even with the best palliative care there will be a fair number of patients who want an assisted death regardless. Study after study produced by palliative care specialists opposed to assisted dying comes to this very same conclusion. Palliative care will never be a panacea to resolve everyone’s suffering to their satisfaction.

Buchanan ends with the conclusion that ‘the risks of assisted suicide legislation are too great.’ His whole piece provides no evidence to support that conclusion. The problem for Buchanan and others like him is that we do not live in the 1970s any longer. We actually know what happened over many years in jurisdictions that have introduced assisted dying. Precisely the lack of evidence of abuse is the reason for why an increasing number of jurisdictions are decriminalising assisted dying. It is time for Australia to follow suit. Leaving things as they are condemns many of us to a death that is disrespectful of our final considered choices.

Monday, May 18, 2015

Desperate patients campaigning publicly for living donor organs

Interesting debate in Canada this week. The short version is this: reportedly wealthy, well-liked owner of Ottawa Senators needs urgently a liver transplant. He (well, his friends, but that's beside the point) uses his means (access to mass media) to campaign publicly for a living donor organ donation. Within a few days there's hundreds potential donors, reportedly money isn't changing hands, but who knows. The hospital where he is being prepared for surgery says that he's likely to receive his - hopefully - life preserving transplant some time this week. The transplant success rate is anywhere between 85%-90%.

Naturally the media and the usual-suspect ethicists got all fired up about rich folks 'jumping the queue' of people waiting for transplant organs, and the ethics of it all.

I thought it might be good to sort thru some of the issues here.

The Canadian Liver Foundation published an instructive background report in 2013 that I do recommend to your attention. Reportedly, in Canada, about 5,000 patients die annually while waiting for liver transplants, tendency: numbers rising. About 400 patients receive successful transplants, roughly every third patient waiting for a liver transplant dies because there are insufficient numbers of donors. Importantly, living donor donations (relatives, friends, otherwise altruistic others) don't actually affect people on the mentioned waiting lists directly, because these waiting lists are for people waiting for donations from deceased donors (ie folks who signed up to be organ donors in case of their demise) . If you manage to coax your workmate or a suitable relative into donating bits and pieces of their liver you will likely be able to live, unlike many of those who fail to do so and who keep on languishing on our waiting lists. Living donors regenerate their livers within a few months, the surgery is reportedly a relatively unproblematic, it's a low-risk procedure requiring of you to take a few weeks off work. So, it is a sacrifice, but not a major sacrifice, considering that human lives are at stake.

When you look at the Ottawa club owner's situation, it's not clear that he is guilty of any objectionable behaviour. Those folks who responded to his plea would not have donated to random others, they wanted to help him. Reportedly he is 'well liked'. Nobody stuck on a waiting list was any worse off as a result of his high-profile attempt at getting his hands on a living donor liver.

What is problematic isn't so much this individual's response, what is objectionable is a system that gives rise to such responses. While clinical need is a reasonable prioritisation and triage criterion, 'whoever shouts loudest' or is 'most likeable' are not ethically defensible selection criteria. And yet, if 'whoever shouts loudest' does not affect the existing waiting list negatively, it seems to me that there is no good reason for people not to try to 'shout loudest' given that their survival depends on it.

What ought to be criticised is the lack of available transplant organs that gives rise to such activities. Here much could be done to improve our current status quo, an immediately available strategy could be to switch our donation systems to an opt-out or presumed consent system. This is known to increase available transplant organs significantly. We should investigate the possibility of incentivising potential organ donors financially. There are various questions that need to be answered prior to implementing payments for organs, among them concerns about the exploitation of vulnerable, impoverished people as well as what the actual impact of such incentives would be on the availability of transplant organs.

Tuesday, May 05, 2015

Australian Academics' Confused Responses to Sacking of Medical Journal of Australia Editor

The Board of the Australian Medical Association (AMA) fired yet another Editor in Chief of its flagship publication, the Medical Journal of Australia.  Australian public health icon Stephen Leeder is the latest victim of the AMA's shenanigans. The MJA, like the Canadian Medical Association Journal, is by and large an also-run kind of academic publication. Doctors in those countries get a free copy by virtue of their membership in the association, it's doubtful that they do much more than check job ads and perhaps read the odd editorial during a break. Nobody would seriously expect cutting edge medical research findings of international significance published in these sorts of publication. However, they do serve an important role as regional medical publications.

Often these journals are run in manners that can best be described as unprofessional, by the associations that own them. There are plenty of examples of interference with the editorial independence of editors by these associations, the half-life of editors appointed by them is typically low, too.

For some reason good people continue to apply for these positions, only to be shafted at the next unexpected opportunity. What happened this time around? Apparently the AMA, behind Leeder's back, decided to outsource the production of the journal to international publishing behemoth Elsevier. Elsevier is publisher of illustrious publications among medical journals that you will have actually heard of before, such as for instance The Lancet. Like most international publishing houses Elsevier has a dreadful reputation among academics, mostly for its price gauging (ask your librarian in case you have doubts about this claim), but also for a range of deeply unethical activities such as creating fake medical journals to promote particular drugs for pharmaceutical companies.

It is not at all unreasonable for Leeder to not want to be involved with Elsevier and leave (or get fired by the AMA if he refuses to leave). The same is true for the members of the journal's Editorial Advisory Committee who also resigned bar one (someone looking for an Editor-in-Chief job by any chance?). And yes, Leeder had good reason to question  the decision and should have resigned in a huff over the shenanigans that happened mostly behind his back. Folks are also correct to be upset about the AMA's decision to go to bed with Elsevier, of all commercial publishers that would have been willing to take over the production of the journal. Fair enough criticism.

For some reason in Down Under this is also debated as a threat to editorial independence. Reports the Sydney Morning Herald, 'one of the signatories, Professor Gary Wittert, the head of medicine at Adelaide University, said AMPCo's track record in sacking editors, including Dr Annette Katelaris in 2012, and its commercial arrangements with Elsevier "does not inspire confidence in editorial independence".' This charge clearly doesn't stick. As of today there is no evidence that Elsevier interferes with the editorial independence (ie the published content) of its editors. It is as simple as that.

A bunch of Australian academics that wrote to the AMA Board to criticise the decision also lamented that The Lancet has published a controversial piece about goings-on in Gaza as well as a controversial paper on vaccines and autism that it failed to retract for about a decade. That is about as bizarre a complaint as it gets. Here the publisher is in effect held accountable for non-interference with its journal editor's editorial independence, and that is also held against it by these academics. Medical journal editors in days gone by were crusaders for particular causes (in the current Lancet editor's case it's global health), and they were expected to write and publish sharply worded editorials with a view to changing the world of health. In this instance Australian academics think that's another reason why the AMA called it wrongly, they don't want to see their journal being produced by a publisher that respects its editors doing precisely that. In any case, it is worth repeating that Elsevier wouldn't even have that sort of oversight in the case of the MJA, because it's not that the journal is being sold to the company, only its production is outsourced to it.

The owners of journals are well within their rights to change the production modi of their journals. They can even outsource the production to international publishing houses (eg in bioethics the Hastings Center's Hastings Center Report is these days produced to some extent by Wiley, with zero impact on the publication's editorial independence). Editors are well within their rights to protest such decisions and to resign (or face the chop) if they ultimately do not wish to go along with such commercial decisions. A threat to editorial independence such decisions are not.

One would expect senior academics to appreciate these differences.

Sunday, May 03, 2015

Treatment resistant depression and access to assisted dying

I have long been in favour of offering access to assisted dying to competent people suffering from treatment resistant major depressive disorder. Other than the occasional newspaper column or blog entry I didn't have time to actually write a proper peer reviewed paper on the issue. Well, that's finally rectified. It came out yesterday. I jointly authored it with Suzanne van de Vathorst of Amsterdam University's Medical Centre. Here's the abstract:

Competent patients suffering from treatment-resistant depressive disorder should be treated no different in the context of assisted dying to other patients suffering from chronic conditions that render their lives permanently not worth living to them. Jurisdictions that are considering, or that have, decriminalised assisted dying are discriminating unfairly against patients suffering from treatment-resistant depression if they exclude such patients from the class of citizens entitled to receive assistance in dying.

Sam Harris vs Noam Chomsky - atheist writer in search of a cause?

It was one of those Facebook moments, I saw a link to Sam Harris' website promising an exchange between him and Noam Chomsky. I thought that that would likely be an odd conversation to have. Here's a neuroscientist who essentially wrote one short - but bestselling - atheist polemic that I enjoyed reading a great deal. Then came a dreadful book on how science can determine human values and I didn't bother reading whatever he produced since then. Well, then there's Noam Chomsky. You will know (of) Noam Chomsky. He doesn't need an introduction. Love him or loathe him, unlike Harris he is one of America's foremost intellectuals.

I have come to know Chomsky as an invariably courteous correspondent who takes the time to reply to emails even while being overwhelmed with many other competing demands on his time. I couldn't believe - and I encourage you to read the beginning of Harris' exchange with Chomsky - Harris approach to this exchange. You would have thought that there would have been a mutual interest on both sides to have a public debate with a view to publishing the content of that debate.

Nothing could be further from the truth. Harris tells Chomsky that there are purported millions of followers both have that would just appreciate this debate. Chomsky doesn't clearly care one way or another. I must say, I have never heard such nonsense before. I can't wait for Harris to write to the Pope with a similar declaration, insisting that the Pope just must reply to him, because both men have millions of followers that can't wait to read said exchange.

Anyhow, I wasn't surprised to see Chomsky being too polite to tell Harris to go away and leave him alone (he tried initially, but being the guy he is, he eventually relents and engages Harris). Harris, ever keen on publicity, writes early on that he wants Chomsky to reply in such a way that the exchange can be published. Chomsky says 'no', it's one thing to agree to an informal email forth-n-back with someone harassing you for replies, it's quite another to see that published. Well, to cut a long (email conversation) short, Harris eventually coaxes Chomsky into agreeing to let him publish the exchange on his website.  You can tell, Chomsky mostly wants to end the conversation, so he succumbs to Harris bugging him, in order to move on with his actual work, rather than indulge Harris any longer.

I can't help but wonder what Harris' next publicity stunt will look like. My bet, Harris emails Pope. Dreadul, just dreadful. I finally got the meaning of 'people full of themselves'. It tells you all that you need to know about Harris that he chose to actually publish this exchange.

Tuesday, April 14, 2015

The trouble with international ethics guidelines


In nearly regular intervals arguments flare up among bioethicists as well as political activists about the substantive guidance proffered in international ethics guidance documents such as the World Medical Association’s (WMA’s) Declaration of Helsinki or the Council for International Organisation of Medical Sciences’ (CIOMS’) research ethics guidance documents. Who doesn’t recall the arguments about standards of care in clinical trials undertaken in developing countries, or the post-trial benefits debate?[1] Monographs, anthologies, as well as an endless stream of graduate student theses focused on particular aspects of these debates. There is nothing wrong with these efforts. As someone who spends significant amounts of time vetting other people’s content, as a journal editor, academic supervisor and external examiner of graduate students’ theses I have read a lot of content dedicated to these debates over the years.

What has always struck me as strange is that virtually nobody seems to question the relevance of these documents. They are usually taken as authoritative statements, not dissimilar to consensus statements clinicians might publish in medical journals. And yet, it is far from clear that anyone should accept these declarations and guidelines as relevant documents of that kind.[2] Take the WMA’s Declaration of Helsinki as a case in point: it is interesting in so far as it has been one of the most bitterly fought over international research ethics guidance documents just a few years ago. It is still being revised in fairly frequent intervals, alas the old battle axes in this dispute have by and large moved on to other issues. There is little professional interest in substantive changes to what once were highly sensitive provisions in the Declaration.

At least the WMA has some claim to represent the world’s doctors. Still, the Declaration offers no justifications for its guidance, so it is unclear why anyone who undertakes biomedical research and isn’t a medical doctor should bother about it. It is also doubtful that the national medical associations debated in any meaningful way proposed revisions to the Declaration and instructed their delegates to the WMA’s General Assembly to vote in particular ways that actually represent the views of the members of these national associations. You might also wonder why a local GP’s views and vote ought to matter a great deal in matters research ethics in the first place. CIOMS remains a fairly smallish operator with even less of a claim to represent meaningfully people involved in biomedical research.[3] Its initial claim to fame was that it put itself forward to interpret the WMA Declaration of Helsinki. Once that – kind of - established its legitimacy this interpretation morphed into its own guidance document. At least CIOMS has a habit of trying to justify its guidance, as opposed to engaging merely in ex cathedra declarations like the WMA is wont to do.

The situation doesn’t get any better when one looks at international institutions such as the World Health Organisation (WHO). While undoubtedly United Nations insiders are clued in with regard to the status of myriad WHO documents, the wider public, and indeed policy makers outside the corridors of WHO offices, almost certainly do not. A case in point: After spectacularly failing in its response to the Ebola outbreaks WHO engaged in what can best be described as wild activism to show that it is doing something. It issued eventually an ethical guidance document that declared that it is OK to use unregistered experimental interventions on Ebola virus disease patients.[4] The authors of this document, celebrated as they were as experts on the subject matter, had mostly never published a word on either Ebola virus disease or, indeed, on the difficult subject of emergency access to experimental drugs in case of patients with catastrophic illnesses. The latter topic has been a matter of intense debate over the last few decades in bioethics. I should know, I have been involved in these debates. The WHO’s experts may have been nice people interested in this topic, who were known somehow to WHO people in charge of inviting someone ‘expert’, alas very few of their experts had any demonstrable expertise when they willingly pontificated publicly on WHO letterhead on this subject matter. Much like CIOMS, the authors of this guidance document ought to be commended for having made the effort to provide justifications for their recommendations.

The results of the WHO meeting were eventually reported the world all over as the WHO ‘approving’ the use of experimental drugs in patients with Ebola virus disease.[5] It turns out that the WHO has no jurisdiction to approve anything of that sort, and, equally as importantly, WHO never actually did approve what it was reported to have approved. The WHO documents produced by the people it invited to pontificate on this subject, state actually in small print that they merely reflect the views of the people who wrote them down, and that they are not the official view of WHO. Their views, in other words, ought to carry no more weight than the views of any other groups of academics who hang out together at conferences and draft papers in their spare time. This hasn’t stopped academics writing about this subject to mention the WHO documents as if they carried any meaningful regulatory or other weight.[6]

WHO is at the time of writing in the process of developing procedures for the selection and use of such experimental agents in Ebola virus disease patients.[7]  I suspect the status of these documents won’t be of more significant regulatory weight than that of any of its other Ebola crisis triggered documents. That is not to say that they will be bad documents. It appears to be the case that these documents will be an amalgam of best practice guidelines from nations that have many decades of regulatory experience with emergency access to investigational agents in patients with catastrophic illnesses. However, if, for instance, Liberia and the USA decided to establish an emergency access program for a particular therapeutic experimental agent, and they chose to ignore WHO (who is apparently keen to inject itself into these bilateral processes) what exactly would WHO be able to do about that? Nothing that I can think of.

What is the value of these sorts of guidance documents then? I think they are valuable as documents that drive debate among interested parties about the substantive controversial issues that they address. They might also be of value to organisations such as the International Committee of the Red Cross, Doctors without Borders, and others, who want guidelines for their own emergency access plans without spending too much time thinking about ethically defensible operational frameworks themselves. Last but not least, they might be useful to developing nations without the capacity to develop their own regulatory frameworks and who decide to resort to WHO guidance documents and protocols.

However, given these questions about the status and the legitimacy of these documents, if the old adage caveat emptor ever applied anywhere, it should apply to these guidelines, declarations and policies. Anyone choosing to adopt them ought to adopt them because they consider them ethically defensible, and not because they happen to come from WMA, CIOMS or indeed the WHO.




[1] Schuklenk, U. 1998. Unethical Perinatal HIV Transmission Trials Establish Bad Precedent. Bioethics 12: 311-318.
 
[2] Schuklenk U. 2004. The Standard of Care Debate: Against the Myth of an ‘International Consensus Opinion’. Journal of Medical Ethics 30: 194-197.
[3] Schuklenk U. 2004. Ibid.
[4] WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva, August 12, 2014. http://www.who.int/mediacentre/news/statements/2014/ebola-ethical-review-summary/en/ [Accessed March 16, 2015.] See also WHO. 2014. Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD) Geneva: Report of an advisory panel to WHO. Geneva, n.d. http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf [Accessed March 17, 2015.]
[5] Eg Anonymous. 2015. WHO approves experimental treatment for Ebola. AlJazeera August 12, 2014. http://www.aljazeera.com/news/africa/2014/08/who-approves-experimental-treatment-ebola-2014812122023925143.html, McKay B, Loftus, P. 2014. Ebola Virus: Experimental Drugs Approved for Use in Fighting Outbreak in West Africa. Wall Street Journal August 13, 2014.   http://www.wsj.com/articles/experimental-drugs-are-approved-for-use-in-fighting-ebola-in-west-africa-1407884538 [Accessed March 17, 2015]
 
[6] Hayden EC, Reardon S. 2014. Should experimental drugs be used in the Ebola outbreak? Nature August 12 doi:10.1038/nature.2014.15698.
[7] WHO. 2015. Public consultation on emergency use assessment and listings procedures for medical products during public health emergencies. http://www.who.int/medicines/news/public_consult_med_prods/en/ [Accessed March 18, 2015.]