Sunday, 29 November 2015

Addendum Re. Using Medical Methods to Determine the Age of Unaccompanied Refugee Children

After my post on this issue a few days ago, I've debated the issue with a number of people from within medicine and also bioethics in different fora.

Due to the presence of significant uncertainties of the methods debated, my suggestion was that use of this methods should be amended by the following methodological rule (assuming 18 to be the age of adulthood, if it is different we may simply insert another variable for that):

... for any method, M, for the assessment of the age of a person, P, with a margin of error +/- X years, M is taken to indicate adulthood if, and only if, its result is 18+X years or higher, and otherwise taken to indicate childhood

Here are a few points that may be added to the complexities of this particular issue:

1. The nature of the uncertanties
Some have argued to me that the methods are not only uncertain in a way possible to describe in terms of a margin of error. One reason for this put to me is that besides the usual margin of error within the dimension of a variable, there is also the background confidence interval behind this margin, and the known effect of having this confidence deteriorate considerably when aggregated population probabilities are projected onto individual cases. I, of course, do not deny that there is also this source of uncertainty, but as far as I can see, my formula above can easily include that: X can be the aggregation of both these uncertainties (this was my original thought as well). This probably means that X becomes considerably larger than 4 (the number used in the example in the original post, based on claims by critics of the model). However, this in no way undermines my suggestion, as this will probably mean that all unaccompanied refugee children will most likely be determined to be children (and, if there are any people like that, in addition a number of refugee adults who falsely claim to be children). That is, the best interest of children, as well as the proper priority of legal provisions is upheld. Suppose, for instance, that the margin of error, accounting for all sources of uncertainty, becomes +/- 15 years. Then my rule says that P is to be considered an adult if, and only if, M finds P to be 33 years or more.

Another claim has been that some of the methods depend on the existence of relevant tables and charts or background data, and that such are missing in this case, meaning that the methods are not really uncertain, there is no method at all. The bewildering thing is that the same people are at the same time officially repeating the argument that the methods are uncertain and have unacceptably wide margins of error. These two claims are, of course, inconsistent; if it's not possible to have any result at all, there is no margin of error, and if there is a margin of error there is some results that create this margin. If it turns out that, in fact, the variable X (accounting for all kinds of sources of uncertainty), cannot be given any empirically based numerical estimate, I concede that my rule is inapplicable. However, if even an interval numerical estimate can be grounded, my rule can be used, by simply adding (supported by the same basic principles as before) that, the high extreme of this interval should be used to define X (in order to err in the right direction). Again, this may mean that the method will determine all tested as children, but, as already argued, it is difficult to see what the ethical or legal problem with that would be.

2. Professional Health Care Ethics and Ethics
Another aspect that has been raised is the fact that my suggestions means that health care professionals pragmatically accommodate to flawed public policies in the best interest of concerned parties (i.e. the children). This is wrong, some say, health care professionals should demand to regulate themselves and never do anything they themselves collegially don't find suitable to do, not even if this is harming third parties. Some have even gone so far at to claim that it is irresponsible of a health care professional to ever act the slightest in any other interest than his or her patient's.

The latter would, of course, mean that we would have to abandon all public health practices, communicable disease management, forensic medicine, large segments of insurance and sports medicine, and not least the involvement of doctors in issuing certificates underlying decisions by public authorities, such as sick leave or work-related disability benefits, and so on. Since health care professional organisations have as yet made no move whatsoever in such directions, I trust that this is not the line underlying the criticism in the present case. In other words, formalised professional health care ethics already accepts a number of cases where medical methods are used to other ends than the best interest of patients and many of these uses are being pragmatically accommodated to still make the best out of an imperfect thing. A very clear illustration is the assessment of "ability to work" nowadays made routinely by medical doctors in many countries, strategically adapted not to harm their patients while still abiding by required formalities.

It is thus unclear to what extent the principle of never doing anything to right the wrongs of public policies is a part of professional health care ethics. Even more unclear is if, had it been such a part, it would have been ethically defensible. To illustrate with the issue at hand, suppose that the health care professional community was to refuse to participate in the practice decided by the Swedish government. This may have three outcomes: (a) the government and parliament creates a legal room for some other class of officials to use the methods (not using my rule), (b) no method is used, (c) alternative suggested methods based on psychological models are used.

  • If (c) is the outcome, the issue reappears, as also these methods can be expected to have margins of error, sources of uncertainty and so on. Then my rule can be used to secure that determinations err in the right direction.
  • If (a) is the outcome, the results for the persons concerned, namely the children, is worse than if the profession had chosen to participate, using my rule to secure that they act solely in the best interest of the children, although also accommodating societal requests.
  • If (b) is the outcome, the situation stands that unaccompanied refugee children where there is uncertainty as to whether or not they are children, will not be given their rights as children.

Now, compare this with (d): health professionals decide to pragmatically accommodate, and use the methods, amended by my rule.
  • If (d) is the outcome, the concerned children's interests and Sweden's legal needs are better served than if any of (a) and (b). If these children are seen as patients, it would then be in their best interest to go for (d) rather than (a) or (b). If there is an option (c), this is even better, provided that my rule is used, but if not it may be better for the patients to go for (d).

3. The Ethics of Clean Hands, Politics of Power and Professional Integrity as Strategic Tool
Against this form of reasoning, some debaters I've talked to have claimed that the downsides for refugee children of the options (a) and (b) (as well as (c) without my rule) cannot be laid at the door of health professionals, but is the sole moral responsibility of the government. That is, they apply the standard of an "ethics of clean hands", denouncing responsibility for bad outcomes they could have avoided by acting differently just because the same is true of some other acting party (here, the government). This is like when the car driver, displeased with the rule that gives pedestrians priority at crosswalks, blames the government while electing to run people over, who cross motivated by the rule. Not very splendid ethics, I'd say.

Another version of this reasoning instead comes in the form of a political power bidding in the name of professional autonomy. It is simply the claim that health professionals should insist on the right to decide for themselves what standards they act on. While this is understandable (we all would like the privilege not to give a damn about the opinions of others, don't we?), it either comes without any underlying defense, or is compatible with sometimes choosing to compromise with other parts, interests and powers in society. As mentioned, the latter seems what in fact is happening in a number of areas, so then the question moves to what reasons pro or contra are present in the area at hand. Here, I have argued that (d) is the superior position.

The same outcome seems to ensue when analysing a final (and, to my view, better) variant of this sort of argument. Instead of an empty insistence on professional autonomy at all cost, this argument points to the political importance of professional integrity as a strategic tool in certain areas. The most obvious of these are torture, capital punishment and military interrogation. Here, the profession has adopted zero tolerance policies, which are thought to have an accumulated preventive effect, as these practices in various ways "need" the participation of doctors. However, this point does not demonstrate that age determination of unaccompanied refugee children belongs to this set of absolutely prohibited practices. As those who criticise the presently proposed methods also say that they could accept methods with a better degree of precision and exactness, it doesn't seem that they are trying to argue this in the present case. Which is understandable, as that would mean arguing against any claim to special considerations of the interests and rights of children.

In sum, therefore, unless it is demonstrated that there is no method at all that could produce any sort of empirically grounded numerical estimate (even in the form of a wide interval) in this area, my suggestion holds up to scrutiny. In fact, it is better supported by both professional health care ethics and more general ethical analysis, than alternative suggestions.


Wednesday, 25 November 2015

On Using Physiological or Biomedical Methods to Determine the Age of Unaccompanied Refugee Children

  In my country, there has for some time been a lot of political debate around how to handle the rising number of refugees from, primarily, Syria/Iraq, Afghanistan and North Africa. This as the pressure on border EU member states, and the impossible situation of trying to hold back people on the run from intolerable circumstances that I blogged about not so far ago, has meant that much more people are now entering Sweden to seek asylum in a short time, as most other member states are unwilling to participate in a scheme of sharing the economic and logistical load it means to process these requests in a way required by human rights and international agreements, as well as legal security. For, while there is no such thing as a right to have asylum, to seek it is an absolute international legal right, and already this means that a receiving country has a lot of obligations. And one group of refugee people towards which such obligations are especially strict are unaccompanied children, and many of these who actually arrive to Sweden are mostly in their teens, usually lacking certifiable identity documentation.

Now, yesterday, the Swedish government, pressed by the logistic and organisational pressure, declared that the already announced difficulties had now become intolerable, and that a number of measures was to be put into place to complement the already a few weeks back instigated active border controls (which, until then, had been non-existent in accordance with the so-called Schengen accord on free internal EU mobility). The move is very controversial, and many doubt that the logistical and organisational reasons cited are the only ones behind it, if nothing else, worries about how political opinion will shift in the presence of my country's anti-immigration, semi-racist party, the Sweden Democrats (see here, here and here), are bound to have played a part, as these are presently laying mostly low to wait things out after some botched attempts to take the initiative, and being actively ignored by the other parties, as it has announced that its only idea is to close the borders entirely. One thing is entirely clear, though, the problem behind the decision is neither one of money, nor one of space, Sweden has plenty and plenty of both of those, and neith is it about "volumes", as the term goes, but mostly about flow; not how many people arrive, but how many arrive in a short time.

 One of the measures decreed by the Government concerns the unaccompanied refugee children, and it is to (re)start using certain physiological or biomedical methods to ascertain the age of these children. No one is debating the need for such ascertaining, but the debate is about this particular proposal, as many Swedish medical specialists (for two international sources, see here and here) also the medical research specialist organisation Swedish Society of Medicine, point out that the proposed methods are very uncertain and have wide margins of error, up to 4 years plus or minus. This means that the risk is imminent that a child of 14 is determined to be an adult, and that Sweden would thus knowingly risk to default on its particularly strong and demanding obligations towards children. The fact that there is also a risk that some 21-year olds come to enjoy these special protections and care is a non-issue in that light. However, the government seems insistent, so what should be done? General refusal of doctors and other medical staff to participate in what has been proved to be unprofessional practice? (as they would seem to be required to do by the Swedish health and Medical Services Act)? This is certainly a live option from a medical ethical standpoint as well, although it also means that most unaccompanied refugee children are left without proof of age.

However, there is another solution, which would satisfy both the government's decree, the worries from the point of view, the need for unaccompanied refugee children to have their age ascertained, and the overwhelming reason to have Swedish policy abide by its own legal standards. This solution is, moreover, applicable to any method for this purpose. It rests on the assumption that for Sweden to meet its own legal requirements is a primary consideration that trumps other reasons and interests in this area. This means that overestimating a refugee child's age and assess this person as adult is far worse than underestimating a refugee adult's age and assess this person as a child. Based on this premise, we may now argue that, therefore, using a method for age assessment in this area that is uncertain, we should use it in a way that makes us err in the right direction. That is, to the extent that we draw faulty conclusions, these should rather be the wrongful classification of adults as children than the wrongful classification of children as adults. this rules gives us access to a simple mathematical solution to the conundrum: we simply adjust the conclusions drawn with the help of the method in light of its uncertainties, so that we are certain to err in the right direction. Thus, for any method, M, for the assessment of the age of a person, P, with a margin of error +/- X years, M is taken to indicate adulthood if, and only if, its result is 18+X years or higher, and otherwise taken to indicate childhood. Regarding the methods cited earlier, this would mean that a person who is apparently an unaccompanied refugee child (who lacks reliable documents), is concluded to be a child, as long as these methods do not declare the age to be 22 years or higher.

As said, this solution makes it possible to abide by the governmental decision, while acting inside medical professional and ethical boundaries, and while both securing the need of refugee children to have their age determined to claim their rights, and the paramount need for the state of Sweden to honour its own legal and international obligations.

Due to debates related to this post in other fora, here's an addendum I made a few days later.


Tuesday, 24 November 2015

New Cross-disciplinary Antiobiotic Resistance Research Centre at my University

Yesterday, I received the delightful news that a big bid, in which I am one of several co-applicants, to establish a centre for research, education, innovation and change in the area of antibiotic resistance research, CARe at my university has been awarded a more than €5 million base funding for the coming 6-7 years in an internal university competition called the UGot Challenges, that's been going on for about 2 years.

The lead applicants of CARe are Joakim Larsson, professor of environmental biomedicine, and Fredrik Carlsson, professor of environmental and behavioural economics, and the co-applicants involve many senior researchers from the medical field, industry and societal collaborators, and several social scientists and humanities scholars, in the latter case, also my departmental colleagues philosophy professor Bengt Brülde and theory of science senior professor Margareta Hallberg. The aim of the centre is thus outspokenly and strongly cross-disciplinary, involving 6 faculties, acknowledging the challenge of antibiotic resistance, like many other broad challenges such as climate change, to involve many crucial aspects beyond those covered by natural and medical science and technology development. The primary scientific and technological target of CARe will moreover be what is presently considered as the last straw and stage of antibiotics to fight multi-resistant bacteria, so-called carbapenems, the development and use of which, of course, imply a large number of complex ethical issues, e.g. with regard to the need for highly restricted prescription in order not to boost further the current destructive trend in resistance development among bacteria, or exceptional need for haste in introducing new substances in spite of knowledge gaps or uncertainties.

Here is the official announcement from the university:

UGOT Challenges information (English)

Stage 2 decision
The university Vice-Chancellor has made the decision on the outcome of UGOT Challenges Stage 21 based on external evaluation. All 12 groups that were invited to stage 2 submitted a proposal before the deadline. 6 of the proposals have been approved.

Approved proposals
Centre for Antibiotic Resistance Research at University of Gothenburg. Joakim Larsson and Fredrik Carlsson
Centre for Collective Action Research. Sverker C Jagers and Sam Dupont
The Swedish Mariculture Research Center at University of Gothenburg. Kristina Sundell
Centre for Ageing and Health – studies on capability in ageing – from genes to society. Ingmar Skoog
Center for Critical Heritage Studies. Kristian Kristiansen and Ola Wetterberg
Centre for Future Chemical Risk Assessment and Management Strategies at the University of Gothenburg. Thomas Backhaus and Jessica Coria

Documents supporting the decision are available at
The host departments have been assigned to submit a formal application to establish the centres in early 2016. When funding has been granted for an existing centre the operational plan should be updated.

About UGOT Challenges
University of Gothenburg will invest 300 million SEK in research under the theme "global societal challenges" over the next years. The aim is that a number of new centres will be started from 2016.