Monday, November 29, 2010

Why is suicide a crime?

Which leads us to the question of why suicide is a crime. Not being anywhere close to being the smartest person in the world, I can only reproduce an excerpt from Cecil Adam's "The Straight Dope".

"Views on suicide have varied widely, both historically and culturally. Certain Asian societies not only haven't condemned suicide but have sometimes expected or even rewarded it--Japan is the obvious example, with its tradition of hara-kiri, but by no means the only one. Consider the Indian practice of suttee--before the British outlawed it in 1829, an average of 500 widows immolated themselves in their husbands' funeral pyres each year, and were often regarded as nearly divine for doing so.

The ancient Greeks and Romans tended to take a practical view of suicide. Most philosophers accepted that there were circumstances in which it was honorable--for example, to save the lives of others, or as a protest against tyranny. Judaism traditionally forbids self-destruction, but nonetheless many Jews continue to mythologize the mass suicide at Masada, where 960 are believed to have killed themselves rather than surrender to the Romans. Early Christians were even more ambivalent about suicide, as you might expect from followers of a religion founded on martyrdom. Virgins who preferred suicide to dishonor were also celebrated, and at least one, Saint Pelagia, was canonized. Islam alone among these three faiths has a clear scriptural ban on suicide, but as recent events have made plain, that hasn't prevented certain zealots from arriving at permissive interpretations thereof.

The Christian opposition to suicide hardened starting with fifth-century theologian Augustine of Hippo, who argued that offing yourself is never justifiable because it violates God's injunction "thou shalt not kill." Suicides were deemed to have committed a mortal sin and denied Christian burial. Church law influenced civil law, and by the tenth century suicide in England was considered not just a crime but a felony. English common law distinguished a suicide, who was by definition of unsound mind, from a felo-de-se or "evildoer against himself," who had coolly decided to end it all and thereby perpetrated an infamous crime. Such a person forfeited his entire estate to the crown. Furthermore his corpse was subjected to public indignities, such as being dragged through the streets and hung from the gallows, and was finally consigned to "ignominious burial," as the legal scholars put it--the favored method was beneath a crossroads with a stake driven through the body. Other European states established similar laws, apparently hoping they would serve as deterrents. As time went on the punishments lessened. By the 17th century an English suicide forfeited only personal property; his heirs could still get his real estate. But the basic notion of suicide as a crime wasn't swept away in France till the revolution, and in England it took even longer: ignominious burial wasn't abolished until 1823 nor property forfeiture till 1870, and the deed itself remained a crime (albeit only a misdemeanor, and a rarely prosecuted one at that) until 1961. In many jurisdictions you can still be prosecuted for helping someone kill himself, and assisted suicide remains a hotly debated topic not just in the UK but in much of the world.

In the U.S. suicide has never been treated as a crime nor punished by property forfeiture or ignominious burial. (Some states listed it on the books as a felony but imposed no penalty.) Curiously, as of 1963, six states still considered attempted suicide a crime--North and South Dakota, Washington, New Jersey, Nevada, and Oklahoma. Of course they didn't take matters as seriously as the Roman emperor Hadrian, who in 117 AD declared attempted suicide by soldiers a form of desertion and made it--no joke this time--a capital offense.

— Cecil Adams

Singapore obesity and the BMI

The recently completed National Health Survey showed a jump in the prevalence of obesity from 6.9% in 2004, to 10.8% in 2010. Strangely I can't find the report of the important survey online. Since it is unclear what the definitions of obesity here are, I must assume the survey used the WHO internationally accepted definitions of a BMI cut-off of 30 kg/m2. Between 25-30 kg/m2, you would just be overweight.

(You can check your BMI here.)

The problem with this definition is that Asians and women have greater percentage of body fat for any given BMI. What this means is that we are more 'obese' than we think by applying international (mostly Caucasian) definitions.

Regular exercises reduces primarily body fat and reduces( improves) the BMI. However, weight exercises which bulk up muscle tissue may artifactually increase the BMI.

Bisphenol-A - time for AVA to review?

Bisphenol-A has now been banned from all baby bottles in Europe. This stems from the increasing concern about the safety of the chemical that is found in hard plastic bottles.

There have been bans in Canada and Australia, and a few US states. The US National Toxicology Program (NTP) had issued a report in 2008 expressing 'some concern' about "effects on development of the prostate gland and brain and for behavioral effects in fetuses, infants and children". earlier this year, the FDA came round to the position that there was also "some concern" on their part.

Meanwhile our AVA has been silent about this problem.

IVF errors, or negligence?

So it has now been revealed that not only the Thomson Medical Centre was sloppy, but the Gleneagles IVF and the O&G Partners Fertility also did not follow procedures. They did not comply with procedures, and did not provide for a second operator to counter-check.

I don't know..... to my simple mole-mind, this doesn't really qualify for a procedural lapse, or human error. Smacks of negligence to me.

Seems to me that we haven't taken such clinic audits and licensing seriously enough.

Tuesday, November 23, 2010

IVF "lapses"

I must say I was disappointed that the MOH could not bring itself to go beyond just identifying "lapses" as being the causes of the error. Though it's kinda expected. It doesn;t say very much. We all know that accidents are due to lapses.

What we want really to find out is why those lapses occured. Was there a systemic problem that increased likelihood of lapses. Were the quality assurance procedures adequate? Were there previous audit findings that were not remedied? Were weaknesses in the system identified before but left unattended to for too long?

Human error can often be the consequence of systemic failures.

Wednesday, November 17, 2010

Patient Assisted Suicide

Last month, the SMA News carried an article by Drs Jacqueline Chin and Jacinta Tan about an ongoing research project in the NUS Centre for Biomedical Ethics to study attitudes on "end of life decisions". Such research is critical, as are healthy open debates on these issues. Hopefully, these will pave the way to sound decision making about euthanasia and the related practice of patient assisted suicide.

Personally though I am not hopeful. Attitudes here are relatively conservative and too 'kiasu' about the sliding down the slippery slope. Public opinions are constrained too much by sensitiveness towards perceived religious values. This is not wrong. But it does limit our options to be "progressive".

Let's see what happens.

For those who are interested, you can contact Drs Chin and Tan at: Dr Jacqueline Chin or Dr Jacinta Tan at

Tuesday, November 16, 2010

I was horrified this morning to pick up the Straits Times and read those incredibly racist remarks about racial profiling by Dr Lee Wei Ling.

Really unexpected. And surprised that the newspaper allowed that through.

I wonder how she would feel to be on the receiving end of some really negative "racial profiling". And how she would go about "racial profiling" our ethnic groups here in Singapore.

C'mon Wei Ling, you're way wrong about this.

'Nuff said.

Sunday, November 14, 2010

Euthanasia #9 - quo vadis?

Watching a loved one die an agonizingly slow death from terminal ovarian cancer is not the best way to pass a Sunday afternoon. She has said her goodbyes and now waits patiently for the end. Everyday her body wastes away.... literally rotting away before our eyes. Her body autocannibalizes itself...and the bugs begin to have a go at the rest. Yet she still breathes, blinks....and gasps meaninglessly.

We had some debates about euthanasia 2 years ago after Minister of Health floated one of his balloons on the subject. Since then there has been no progress on the idea. The idea seems to have died a natural death. Almost as soon as the idea was floated, it seems.

What gives.

Friday, November 12, 2010

Investigating aviation errors and IVF mistakes - a fair comparison?

Minister of Health Khaw Boon Wan made an interesting reference to the investigation of aviation errors while commenting or the recent IVF mistake which occurred at the Thomson Medical Centre.

He said: "Like the health sector, the aviation sector used to approach safety and errors through a largely fault-finding approach. When a plane crashed or hit a problem, the first question was to nail down the culprit: who was responsible, was the pilot at fault, was the engineer negligent etc? This used to be their approach a decade or two ago.

But they have since moved away from that approach. Instead, they took a system approach. Each time an adverse event occurs, they will conduct an objective and thorough investigation, not to witch hunt, but to identify the causes, especially if there are systemic flaws. Because they moved away from fault-finding, everyone was open in their comments, resulting in a speedy and accurate assessment of the true situation. Under the previous approach, the tendency was to protect one’s interest, resulting sometimes in cover-ups and the truth became elusive.

It's a very enlightened approach, and one to be applauded, although at some point in time there needs to be some accountability and someone has to take responsibility for not putting in place adequate measures to prevent errors. The MOM comes in hard for employers who put their workers in jeopardy by being negligent in not ensuring adequate workplace safety. In our research laboratories, the principle investigator faces a possible jailable outcome should lab safety measures be violated, or he has been negligent. Should not we expect the same rigour when medical professionals are negligent in situations such as this?

But I digress. The real purpose of this post is to explore the appropriateness or lack of, in the comparison with the investigation of aviation errors.

Avoidance of fault finding and cover-ups are two faces of the same coin. Often breakdowns in the integrity of a system/process extends beyond the party holding the smoking gun. If an error occurs in the regulatory functions, this would be less likely to be flagged out if the investigating team comes from the regulators themselves. In the investigation of aviation errors, to avoid this conflict of interests, an independent body forms the investigating team. Only thus, can the true extent of errors be discovered. If the investigating team is formed by the regulator, it is more than likely that a "fault" will be found only in the party in possession of the smoking gun.

In this instance of the IVF error, the investigating team is the Ministry of Health team. Yet it is the Ministry of Health which audits and regulates this industry. How can the Ministry then identify weaknesses in its own audit/regulatory systems covering the IVF facilities which allowed high likelihood of errors such as this to be committed? This is uncertain.
Should we not require some sort of pre-implantation diagnosis of paternity to be documented as validation of the integrity of the process before the embryo is implanted? Doing so will at least ensure that at the very least, there are no costly mistakes beyond the irreversible step of implantation.

Perhaps the Ministry of Health could consider releasing the last audit findings of Thomson Medical Centre so that the public can gauge if the audit was done with the stringency we expect, and/or the facility failed to act of recommendations.

As the Minister pointed out, this should not be to find fault but to enable everyone to correct all the deficiencies of the system. Following which, we can move on.

Thursday, November 4, 2010

Organ trade tenesmus in Malaysia

Malaysia is for living unrelated donors....., or not?

First it was reported that Minister of Health for Malaysia Datuk Seri Liow Tiong Lai said his Ministry was looking at improving the National Transplantation Act which was being drafted to serve as a guideline on unrelated live organ donations.

He said the new law would enable the authorities to monitor live organ donors which at present were encouraged for only family members and relatives of patients.

"We have to be careful because commercialisation of organs is a big problem. The selling and buying of organs is against human principles and not ethical," he said, adding that if non-relatives want to make live organ donations, it should be out of sincerity and not for monetary gains.

Sure sounded very much like Singapore's position a year or two ago.

Then almost in response, the Health Director General Tan Sri Dr Ismail Merican in the 4th November New Straits Times, was reported as saying, "Malaysia is against living unrelated donors donating organs because of the risk of organ trading and trafficking...... If living donation is to be carried out, it should come from genetically, legally or emotionally related donors."

Hmmmm..... a bit of tenesmus there.

Singapore, by the way passed a law allowing compensation of organ donors, effectively allowing living unrelated donors to receive compensation for donating their organs. Not sure if it is just engaging in semantics to suggest that this is essentially organ trading.

What is needed now after more than 18 months of this law, is for MOH to update us with respect to how many such unrelated living donations have been effected, and the details of such donations. One of the major concerns had been the exploitation of poor donors from neighbouring countries, and servicing of wealthy recipients who are no citizens. It would be really nice and reassuring if the MOH to tell us what the numbers are, and how we are actually monitoring/regulating the situation.

Thomson Medical Centre - suspension of assisted reproduction activities

Well done, MOH!! The Thomson Medical Centre has been whacked with a suspension following the IVF mix-up. Iwould have prefered that the suspension had been immediate upon news of the mistake, but better late than never.

What is further required is a full and proper audit of all IVF facilities to ensure that procedures are not only in place, but that centres are in full compliance of procedures. In addition, regular annual audits should be implemented, perhaps with a way to monitor outcomes... for example routine genetic screening of babies to ensure babies are who the centres say they are.

Wednesday, November 3, 2010

Singapore's "first" IVF mix-up?

In the process of being taken over by billionaire Peter Lim, the Thomson Medical Centre gets this unexpected bombshell - a dreaded mix-up in the IVF procesure where the mother's egg had been apparently fertilized by the wrong sperms!

Previous posts had highlighted this error and asked for clarity on this issue with respect to the local situation. Now this dreaded error has been reported in Singapore. It is no comfort to say that the risk is very low. A single accident is one too many already. Patients deserve better.

There needs to be more public assurances about the practices procedures and processes in place that will prevent accidents of this sort.

I think a public 'fessing up of what actually went wrong is needed. Dr Cheng LC of Thomson Medical Centre was quoted to have said: ... the centre's operating procedures "meet all regulatory requirements, and are of the highest international standards".

All very vague. Just what are these regulatory requirements? And are they adequate?

The Ministry of Health should tell us how the various IVF units fare in terms of the procedures and procedural compliance. Or are they never ever audited?

Monday, November 1, 2010

The NTU-Imperial College Medical School

So it's out in the open now, as NTU and Imperial College London signed an agreement to form Singapore's 3rd Medical School. Target is 150 students, which is quite substantial compared to the current 250-300 at the NUS Medical School.

Prof Stephen Smith is the Founding Dean designate for the new school. A gynaecologist, Prof Smith was the Principal of the ICL in 2004, and subsequently also became the Chief Executive of the Imperial College Healthcare NHS Trust.

The formation of the 3rd Medical School is being watched with considerable interests from those who have been involved with medical education in Singapore. How will it differ from the approach NUS had taken? So far the leadership have been saying all the right things. Exploiting existing strengths in engineering and business, the new Imperial College London-Nanyang Technological University Medical School (ICNMS), will focus on training good doctors "equipped for tomorrow's challenges".

All nice words.

Many are hoping it will not fall into the same trap that the other medical school did by over-investing in the clinician-scientist mission. No doubt we need clinician-scientists to fuel the biomedical industry, but this should not be the main mission of a medical school. Singapore needs good caring doctors who can look after patients - not doctors whose primary mission is to serve the biomedical industry. Many have felt that the NUS Medical School had so over-reached itself to pursue the research agenda that the medical mission had been severely compromised.

If the new ICNMS remain true to the educational mission, the worrying outcome may be that many committed medical educators may decide to jump ship for a school environment that is much more aligned to medical education and the training of good doctors.

Death blow to the idea of gene patents


In a landmark ruling, the US government has finally come out to declare that patent genes are not legal. This is the tail-end of a struggle which began earlier this year with Myriad Genetics claims to the breast cancer genes BRCA1 and BRCA2. No doubt Myriad will appeal the ruling. And they have a lot of muscle on their side, given that another 2000 or so genes are also under patent cover elsewhere, with an industry worth billions of dollars at stake. Also covered under the ruling are diagnostic tests based on gene sequences.

This blogger cannot be more pleased with the ruling.

Hopefully it may also recalibrate the research funding towards more understanding rather than just chasing after patents and the fast buck.