There are many in Africa who believe that sexual orientation is a matter of choice and view the act as unnatural. Religious groups in particular oppose male homosexuality due to sodomy being viewed a sin [1] . If a certain act is viewed as a sin, and it is optional, then it is only logical that this activity should be prohibited under law. In a sense, it is moral to have laws restricting homosexuality in place via this logic. [2] The U.S. and other Western states should not condemn African states and reduce aid for legislating in a way they consider moral.  [1] Islam and Africa ‘Islam and Homosexuality’  [2] Should donors rethink aid to states that persecute gay people? Ware,G. 25/01/12


Western Money, Western Discretion  When Western States threaten to cut aid, they are referring to their own money. This money should therefore be spent at the discretion of the donating country. In 2012, the USA’s and UK’s budgets for aid were £12.2 billion [1] and £9 billion respectively. The UK’s spending is set to increase to about £11.3 billion by 2014 [2] . This is money which could be spent to ease economic hardships at home, as many newspapers have pointed out [3] , however it is given to other countries to aid them instead. Donating states also spend a great deal of time attempting to convince their citizens that giving aid is a good use of their money. Should they oppose a policy which they see as discriminatory then it is understandable that they should use their discretion when donating aid.  [1] Britain second in world for aid spending Dixon, H. 04/04/12  [2] Aid: how much does the UK spend, why it’s so important and how it works. Provost,C. & Tran,M. 20/03/13  [3] Britain leads the way in foreign aid-unfortunately Clark,R. 19/06/13


Cultural Imperialism has major advantages to it as well. Culture and identity has been used throughout history as a tool for fuelling the flames of conflict, leading to the mass genocides such as that of Rwanda [1] . This aspect of culture incites hatred against those who might otherwise not be targeted, such as homosexuals. [2] The desire to stamp out such attitudes does not represent a diminishment of African culture simply a change. Similar attitudes were held in the west until recently. African culture has similarly changed in the past; the comparatively recent introduction of Christianity to much of the continent (the exception being Ethiopia) was such a change.  [1] RothKopf, D ‘In Praise of Cultural Imperialism’ in Foreign Policy, no. 107 (1997) pp.38-53  [2] Ibid


While there are those who oppose gay rights in the West, there are many which support them and government policy does not have to run along the lines of consensus constantly. 2013 saw victories for gay marriage in the UK with the royal assent of the Marriage (same sex couples) Act [1] and in the USA with the removal of key elements of DOMA by the Supreme Court [2] . Those who still oppose homosexual rights are becoming the political periphery in these Western states. The current legislative success demonstrates that unity on same-sex rights is growing, and that it is not hypocritical to export this to the international stage.  [1] Marriage (Same Sex Couples) Act 2013’ Parliament of the United Kingdom 17/07/13  [2] US Supreme Court in historic rulings on gay marriage BBC 27/06/13


The reduction of aid will cause innocent people to suffer  A reduction of aid to Africa will likely affect the most vulnerable in society rather than the politicians who can adjust the law. The African continent shows signs of growth, but 40% of sub-Saharans live below the poverty line [1] . Cutting aid to states that criminalise homosexuality will increase poverty among individuals who have no influence over their government’s policy. This is an issue which both African states and African LGBT (Lesbian, Gay, Bisexuals, Transgender) groups agree upon [2] . Ahmed Lawan, a senator from Nigeria, argued that there needs to be more dialogue and diplomacy if the West is to convince them [3] . Should aggressive policies be used to leverage policy change, such as reducing aid, then African nations will be deterred from making pro-western changes to legislation. LGBT groups want donor countries to ensure that aid is distributed more evenly, and guarantee that aid directed towards human rights reaches homosexuals rather than cutting aid all together [4] . If aid is cut, it will serve to weaken ties between Africa and their donor countries, as well as worsen Human Development Indicators.  [1] Our Africa, ‘Poverty’  [2] Should donors rethink aid to states that persecute gay people? Ware,G. 25/01/12  [3] Ibid  [4] Should donors rethink aid to states that persecute gay people? Ware,G. 25/01/12


Cultural Imperialism  Cultural Imperialism is the ‘the practice of promoting a more powerful culture over a least known or desirable culture’ [1] . Culture provides an identity which is naturally coveted. Attempting to impose mainly Western, liberal values on Africa equates to a dilution of African culture. Globalisation has spread US culture throughout the world [2] . This has led many to lament the weakening of unique cultures, claiming that the USA is drowning out all cultures that do not agree morally with themselves [3] . The United Nations Educational, Scientific and Cultural Organisation (UNESCO) stated ‘that respect for the diversity of cultures, tolerance, dialogue and cooperation, in a climate of mutual trust and understanding are among the best guarantees of international peace and security’ [4] . Attempting to change Africa’s attitude towards homosexuality is an attempt to increase the influence of Western culture on the continent. These cultural ties to attitudes on homosexuality are so powerful that even strict Muslims and Christians are brought together on this issue [5] . To deprive Africans of their cultures and their morals is at odds with the UNESCO’s idea of maintaining cultural diversity throughout the world.  [1] Princeton ‘Cultural Imperialism’  [2] Ezema,I.J. ‘Globalisation, information revolution and cultural imperialism in Africa: Implications for Nigerian library and information professionals.’ University of Nigeria, Nsukka  [3] Cultural Imperialism Ekeocha, O. 08/09/13  [4] UNESCO ‘Universal Declaration on Cultural Diversity’ 02/11/01  [5] Islam and Africa ‘Islam and Homosexuality’


There is not universal endorsement of full homosexual rights in the West  The adoption of gay rights is by no means universal in the West, so why should Africa have to change their policies? US Christian evangelical groups have opposed the Obama administration’s policy towards homosexual rights in Africa. The Justice for Gay Africans campaign group claim that these groups have worsened hostility on the continent through action that they have taken in Africa [1] . Domestically there is opposition to gay rights as well. The Defence of Marriage Act (DOMA), which was signed into law by a Democrat President and a Republican congress, enabled states to refuse to recognise same sex marriages [2] and demonstrates the opposition to gay rights in donor countries. One in six homosexuals and bisexuals have been the victims of hate crime in the UK, with only one in ten cases resulting in a conviction demonstrating homophobic attitudes in the UK [3] . The lack of consensus in the West therefore makes it hard to morally justify the imposition of homosexual rights abroad.  [1] Gay Rights: Africa, the new frontier Chothia,F. 07/12/11  [2] Defence of Marriage Act  [3] Ellison,G., Gammon,A. & Guasp,A. ‘The Gay British Crime Survey 2013’ Stonewall


Reducing funds is an unfortunate, although necessary, mechanism for pressurising the political elite to legalise homosexuality. Africa’s democracies, such as Nigeria, have to be sensitive to the needs of their citizens. Even dictatorships have to maintain a grasp on the people’s will. Once the African population starts to feel the impact of reduced aid, the only viable way to remedy the situation will be to re-legislate on the same-sex issue.  Foreign aid struggles to reach those who need it the most anyway, with corruption in the Ugandan government (and the disappearance of £1.3 million) causing the UK to cut aid to Uganda in 2012 [1] . The funding itself is then redirected away from African governments, but will reach those who need it the most through non-governmental organisations which will negate the suffering predicted by critics [2] .  [1] BBC ‘UK cuts aid to Ugandan government’ 16/11/2012  [2] Gray,S. ‘Minister confirms UK will redirect aid, not cut it, for human rights violations’ Pink News 22/11/2011


A ban on trans fats will cause specific harms which cannot be fixed by switching to other fats or food preparation methods. Particularly hard hit would be small businesses, who would struggle to make the transition because they no not have the budgets to research alternative ways to make their products taste the same and so are likely to end up at a disadvantage compared to their bigger rivals. Moreover all businesses would suffer from reduced shelf life for their products.(7)  Such a ban does not make economic sense, and despite propositions claims trans fats cannot always be easily replaced. We use trans fats because they work well. For example they are needed in hydrogenation in order to convert liquid vegetable oils in to being solid, needed for example to make margarine, the amount of trans fats used for this can be reduced but not eliminated. Moreover, Michael Mason of The New York Times argues: "for preparing certain kinds of foods, there are few alternatives besides the saturated fats that have long been high on the list of artery-clogging foods.”(18)


Healthier equivalents of trans fats exist  It is easy and inexpensive to replace trans fats with other, less harmful products without significantly altering the taste of the food. Kraft eliminated trans fats from its Oreo cookies, with little public perception of any change in taste.(1) Similarly, the Wendy's restaurant chain tested a new frying oil in 370 franchises, with customers not noticing a difference in taste. Denmark imposed a national ban on trans fats with which even McDonald's has complied.(1) Replacements for trans fats will get cheaper and cheaper with time, as they are used more frequently and as the companies that produce and distribute them increase their sales volumes and are able to sell them for lower prices.  Since trans fats are not irreplaceable, objections for the sake of consumer freedom are also unconvincing. As with lead added to paint, trans fats are unnecessary additions to products that can cause significant harm. Most people remain ignorant of the presence of trans-fats in their food, and of their effects. In this area the ban on trans fats differs from restrictions placed on the sale of alcohol and tobacco and so the two kinds of bans are not comparable. Not only are trans fats easy to substitute in foodstuffs, without impairing quality or taste, the presence of trans-fats is hard to detect. It is all-but impossible for informed and conscientious consumers to avoid buying and eating trans-fats.  While banning cigarettes and alcohol mean banning an entire product category, banning the ingredient of trans fats means no such thing. Rather, it simply means that readily available replacement ingredients must be used in the preparation of the same foods. And, since these fatty replacements are widespread and cheaply available, food makers and consumers should have little difficulty making the adjustment to making and consuming the same, albeit slightly modified, foods.


The American FDA considers the use of trans fats to be 'generally safe'.(1) The British Food Standards Agency says the UK's low average consumption of trans fats makes a complete ban unnecessary.(6) These organisations are already supposed to regulate foodstuffs and monitor trans fats, if they agreed that they needed to act surely they would.  For individuals considered especially vulnerable to the effects of trans-fat consumption, such as the old or the poor, the government should consider education, not a ban. Moreover, the real issue here isn't about health, but about the right of a citizen of a free country to choose to eat whatever foods he wishes. The role of government is not to restrict the freedoms of its citizens but to protect individuals and to defend their right to act freely. Informed, adult individuals have every right to eat whatever fattening, caloric or artery-clogging meals they please. Government health boards have no right to restrict the foods law-abiding citizens choose to put into their own bodies.(10)


Trans fats are uniquely unhealthy  One of the purposes of government is identify possible threats to health and protect the people from these threats. The fact that some government regulations seem 'silly' or misplaced, or cannot easily be understood by lay-people is not a compelling argument for having no regulations at all, or for not having regulations in the case of trans fat. The commentators who denounce the 'nanny state' do not indicate what, if any, regulations or styles of regulation they approve of. Do they think there should be no inspections of restaurants by health inspectors? No regulation at all of food or drug safety by the Food and Drug Administration? Some commentators think that people should be encouraged to study the dangers of trans fats and make their own judgements about what to eat. But people have limited time to do research on such matters. It makes sense to delegate the research to a central authority, so that instead of 300 million people trying to learn about trans fats and every other lurking menace, a handful of experts can make recommendations based on the likely responses and desires of the average, informed citizen.  Non-specialists’ capacity to absorb information on complex chemical and biological subjects is quite limited. The majority of us are reliant on the research of others for most of what we know.(5) The opinion of the experts on the dangers of trans fats is conclusive: trans fats are unsafe.  The American Food and Drug Administration (FDA) considers all uses of trans fats to be 'generally regarded as safe.' This allows the use of trans fats in whatever way food producers desire. ’Safe’ for the FDA means 'a reasonable certainty in the minds of competent scientists that the substance is not harmful under its intended conditions of use', which no longer applies to trans fats. This 'generally regarded as safe' status should be revoked which in turn would greatly restrict its use in food.  The other option would be to allow local jurisdictions to regulate trans fats, but this would be more costly and lead to a patchwork of regulations.(1) The most effective method of controlling the use of trans-fats is through centralised, nationally applicable policy making. The poor and young are particularly vulnerable to the negative health effects of trans fats; at the very least, the threat posed to these groups justifies the use of informed regulation. Professor Alan Maryon-Davis, president of the UK Faculty of Public Health said in 2010: "There are great differences in the amount of trans-fats consumed by different people and we are particularly concerned about young people and those with little disposable income who eat a lot of this type of food. This is a major health inequalities issue.”(6)  The government has a legitimate interest in protecting its citizens from harms that they are not best placed to understand or avoid themselves, and so a ban on trans fats would not only save lives but would also be legitimate under the government's role to protect when citizens cannot reasonably protect themselves.


The state should ban trans fats to protect the public  One of the purposes of government is identify possible threats to health and protect the people from these threats. The fact that some government regulations seem 'silly' or misplaced, or cannot easily be understood by lay-people is not a compelling argument for having no regulations at all, or for not having regulations in the case of trans fat. The commentators who denounce the 'nanny state' do not indicate what, if any, regulations or styles of regulation they approve of. Do they think there should be no inspections of restaurants by health inspectors? No regulation at all of food or drug safety by the Food and Drug Administration? Some commentators think that people should be encouraged to study the dangers of trans fats and make their own judgements about what to eat. But people have limited time to do research on such matters. It makes sense to delegate the research to a central authority, so that instead of 300 million people trying to learn about trans fats and every other lurking menace, a handful of experts can make recommendations based on the likely responses and desires of the average, informed citizen.  Non-specialists’ capacity to absorb information on complex chemical and biological subjects is quite limited. The majority of us are reliant on the research of others for most of what we know.(5) The opinion of the experts on the dangers of trans fats is conclusive: trans fats are unsafe.  The American Food and Drug Administration (FDA) considers all uses of trans fats to be 'generally regarded as safe.' This allows the use of trans fats in whatever way food producers desire. ’Safe’ for the FDA means 'a reasonable certainty in the minds of competent scientists that the substance is not harmful under its intended conditions of use', which no longer applies to trans fats. This 'generally regarded as safe' status should be revoked which in turn would greatly restrict its use in food.  The other option would be to allow local jurisdictions to regulate trans fats, but this would be more costly and lead to a patchwork of regulations.(1) The most effective method of controlling the use of trans-fats is through centralised, nationally applicable policy making. The poor and young are particularly vulnerable to the negative health effects of trans fats; at the very least, the threat posed to these groups justifies the use of informed regulation. Professor Alan Maryon-Davis, president of the UK Faculty of Public Health said in 2010: "There are great differences in the amount of trans-fats consumed by different people and we are particularly concerned about young people and those with little disposable income who eat a lot of this type of food. This is a major health inequalities issue.”(6)  The government has a legitimate interest in protecting its citizens from harms that they are not best placed to understand or avoid themselves, and so a ban on trans fats would not only save lives but would also be legitimate under the government's role to protect when citizens cannot reasonably protect themselves.


Many large and small chains have already made the transition to alternatives to trans-fat, so it is entirely possible. These alternatives will get cheaper with time as they are used more frequently and as the companies that produce and distribute them increase their sales volumes and are able to sell them for lower prices, meaning that small and individual restaurants will indeed be able to afford them and survive. Moreover, the health concerns in this debate override purely economic concerns or the closure of small businesses, as lives are involved.


Health experts agree that banning trans fats would save thousands of lives specifically because the substance is dangerous even when consumed in very low quantities. They are simply a dangerous additive, which adds no extra value to food. 'Taste' considerations are simply a red herring, as switching to other fats would produce no meaningful change in taste, as has been demonstrated by several large food corporations who have made the shift without disappointing their customer base. The fact that other foodstuffs may be dangerous is an argument for better education or regulation regarding them, or -if merited -their own bans, but is not a case against banning trans fats. Trans-fats are significantly different to all the other unhealthy foods listed by side opposition, as trans fats are easily replaceable by less unhealthy substitutes, which things like sugar are not.


The government should provide information to consumers, not restrict choice  Milton Friedman argued in the 1980s: "If we continue on this path, there is no doubt where it will end. If the government has the responsibility of protecting us from dangerous substances, the logic surely calls for prohibiting alcohol and tobacco. . . . Insofar as the government has information not generally available about the merits or demerits of the items we ingest or the activities we engage in, let it give us the information. But let it leave us free to choose what chances we want to take with our own lives."(11)  George Mason University economist Don Boudreaux asks what a trans-fat ban is a model for: "Petty tyranny? Or perhaps for similarly inspired bans on other voluntary activities with health risks? Clerking in convenience stores? Walking in the rain?"(12) Morally the government should be consistent when it bans things, the sale of an undeniably deadly products such as tobacco is sometimes allowed so far less dangerous substances should be allowed.(13)  Education should be considered an alternative to banning trans fats or other unhealthy food. There should be aggressive education campaigns to educate consumers as has been done with tobacco.. At the moment consumers are ignorant, they need to know what they are, the dangers and the consequences. Information on trans fats should also be part of a wider program of nutrition awareness which will put it in context. . Many people have rejected tobacco as a result of raised awareness; the same will occur with trans fats. The food industry would respond to consumer demand and reduce the use of trans fats and other ingredients considered ‘bad’.(13) Information on trans-fats is not hard to come by: the Centre for Science in the Public Interest (CSPI), for example, is happy to inform about the dangers of dietary trans-fat, and has no trouble getting its declarations of doom on television and into newspapers.(11) This consumer pressure is already occurring. In the United States, for example, many fast-food chains and food manufacturers have already eliminated trans fats from their products or have pledged to phase them out. To pick one case, Wal-Mart is going to reduce its sugar, sodium content and remove all trans fats from its food.(14)  Left to its own devices, the market will solve this 'problem' in all areas which consumers consider it to be a problem, all without needing an unwieldy government ban. Therefore the government should educate its citizens regarding the health concerns surrounding trans fats, but leave it up to the citizens to choose what they eat.


Banning trans fats in uneconomical  A trans-fat ban would hurt small restaurants the most. Carlie Irwin argues: “Since most of the big chains have already started the process of eliminating trans-fat from their food, the ban would be no big deal to them. But small, independent restaurants are another story. The potential ban has small restaurant owners sweating and nervously eyeing their deep fryers. As the St. Louis Business Journal points out, many small restaurant owners don’t have the ability to effectively and efficiently reformulate their menu items. So banning trans fat could mean that your favorite independently-owned fried chicken joint down the street will be shuttering its doors.”(17)  Consequently, a trans-fat ban would breed legal exceptions and inconsistencies. For example, in Illinois bakeries were exempted from their ban because lawmakers knew that it would drive up their costs and hurt the bakeries specialty items. Many other small businesses would be similarly affected Restaurants and other specialty vendors who use trans-fat products on site would also be affected. Lawmakers then have a choice of either reducing the effect of the ban and including lots of bureaucratic exemptions or punishing these businesses.(9) Tina Pantazis, the manager of Dino's Burgers, which operates two hamburger outlets in California, argues: "The only effect [a ban on trans fat] is going to have on the consumer is that we are going to have to raise our prices."(19)


Trans fats are not uniquely unhealthy  The issue with trans-fat is that there is no better substitute. The fact is that the substitutes are also as bad, if not worse, than trans-fat itself. By banning trans-fat, restaurants will have to adopt these substitute substances, thus undermining the work of the government. This process is a waste of our resources as the government will have to spend huge amount of money to bring about a ban on trans-fat without getting any positive outcome.  The trans-fat ban would only have clear benefits if it were to cause a general reduction in the overconsumption of high-fat foods, but a restaurant ban on one ingredient will not achieve this. This will mean that money will be wasted as increased costs will be passed on to the consumer while there is no benefit.(8) Trans fats are not uniquely and excessively unhealthy. Sugar is unhealthy. Salt is unhealthy. Runny eggs, rare meat, processed flour, nearly anything consumed too frequently or excessively is potentially dangerous. We would not ban these foods because they are unhealthy so the same should apply to trans fats.  The current obesity crisis within the US is not the result of regulatory failure and will not be solved by a ban on trans fats. Better choices, better parenting, exercise and personal restraint are the keys. None of these behavioural traits can be mandated by government.(9) Even if trans fats were eliminated from food products, overall a ban would do nothing to help individuals develop healthy lifestyles. While the ban would curtail consumption of onion rings (if they were cooked in trans fats), for example, it would remain perfectly legal to gorge oneself on Häagen-Dazs or chocolate, both unhealthy foods that contain no trans-fat.(10)  The main alternatives to trans-fat is not even that much healthier. In most cases, food makers will move to saturated fat, which carries all of the same health risks, for example it has been linked to diabetes and cancer.(9) The ban is therefore unlikely to have a perceptible effect on public health.  Trans-fats actually serve two useful purposes. Firstly, trans fats serve an important function of extending the shelf life of products.(1) This is necessary for both producers and consumers as it makes producing these foods cheaper and reduces waste. It also means that consumers are less likely to consume spoiled food and become sick as a result. Secondly, trans fats are tasty and offer enjoyment to consumers. Trans fats keep foods from turning rancid on store shelves; give croissants their flakiness, keep muffins moist and satisfy the sweet tooth. The enjoyment of such tasty foods has a qualitative value to one's emotions and happiness.(3) Therefore trans fats are not uniquely unhealthy and a ban would not improve general public health -it would simply remove a useful and tasty substance from the market. Thus a ban is unjustified.


Calling for an "education campaign" to inform consumers of what they are eating may sound sufficient, but this is very often just not enough. No matter what the government does, people will simply miss the "instructional" information provided by the government and will continue to consume trans fats without full information regarding its negative effects. In such circumstances, it is the government's job to step in a take action through a ban or other measures.  Moreover, when a harmful trend such as the use of trans-fats becomes endemic and entrenched, it becomes increasingly difficult for citizens to always be aware of the fact that a food has trans fats in them and make the "choice" to eat or not to eat them.(15)  Producers include trans fats into foods without adjusting labelling, further affecting consumers’ ability to purchase foods that do not include trans-fats. The trans fats hidden in many processed foods are worse for a person's health than saturated fats. In 2005, CHOICE, an Australian watchdog tested more than 50 processed foods and found many contained trans fats at unacceptably high levels. After re-tests it was still clear that, while the fast-food chains had reduced their levels of trans fats, and some of the foods tested previously had eliminated trans fats altogether, others now contained even more than before. Foods such as pies, cakes and doughnuts may contain trans fats without the consumer even knowing about it.(16)


It is not cruel if it can be shown that this restriction is in the patient’s own interest. The status quo prevents patients from living out their last days on a stream of experimental drugs. We prevent drug companies from using them as risk-free testing (under your policy drug companies would presumably be able to shrug off any responsibility for adverse consequences by saying that it was the patient’s choice to try an experimental drug), and allow them instead to receive the appropriate support for someone at the end of their life, and come to terms with that.  Further, it is important to remember that drugs at this stage are not necessarily miracle cures! If someone is refused access to a trial this is normally to reduce the risk of adverse consequences: it is wrong to give someone an experimental drug that could negatively impact the quality of their final days.


It is cruel to deny people the last hope  At a point when all ordinary medical avenues have been expended, and the outcome appears bleak, new treatments still undergoing trials can be seen as the last hope.  People are often aware of the existence of currently experimental drugs, they are likely to research into possible cures, and indeed there may have been attempts by their doctor to get the patient onto the trial.  However, not everyone who could benefit from treatment is accepted onto a clinical trial: some trials, at some stages, restrict their recruitment to, for example, patients with no complicating factors or other illnesses.  It is unethical and cruel to make people live out their last days knowing that there was something that could have helped, but to which access was restricted through no fault of their own: thus, you should allow anyone with a terminal illness access to such treatments.


First, note that the reason for the existence of the placebo arm is to determine if the drug is more effective than placebo, so in some cases the drug will not be, and nothing will have been lost!  Second, for this point to stand, it has to be shown why the present generation should be prioritised above all future ones: the consequences of giving the present patients a slightly increased chance of survival is to negatively impact patients in the future in a myriad ways (see opposition arguments).  Third, there are a number of reasons to doubt that this is, in fact in the present patient’s best interest: it is not the case that terminally ill people have ‘nothing to lose’ and can therefore be used as human guinea pigs (providing there is an, as yet unspecified, probability of survival). The large-scale provision of un-trialled drugs may well result in side-effects denigrating the quality of the patient’s remaining years.  Finally, the practical consequence considered can be sidestepped through a) better supervision of trials and b) improved doctor-patient relationships (a particular problem during the AIDS crisis). Further, note that the case of AIDS is something of an anomalous one: AIDS patients were more numerous and politicised than any other group before or since, thus enabling this sort of trial-breaking behaviour.


Freedom of Choice  We live in a free society, and accept that people have the right to do as they please; including exposing themselves to risk, as long as in so doing they do not harm others (Mill’s harm principle).1  To deny people the right to choose to take drugs that are still undergoing testing that, whilst they are risky, may save their lives, is a violation of this principle: in choosing to expose themselves to that risk, no-one else is harmed and indeed in the long run others may be saved as a result of the tests. Further, with the assistance of medical professionals and other support, the decision to take this risk can easily be well-informed and consensual.  1 Wilson, Fred, "John Stuart Mill", in Edward N. Zalta (ed.), The Stanford Encyclopedia of Philosophy (Spring 2012 Edition),


It is not the case that this is a policy with no harms other than to the person with a terminal illness (see opposition arguments).  Second, it seems unreasonable to suggest people are making a free and informed choice in this instance: no-one has sufficient information for taking the drug to represent anything but a gamble; this is why there is a need for tests.


It is unethical to force a ‘volunteer’ to take the chance of being randomised onto the placebo arm of a trial  Under the status quo, someone with a terminal illness is offered two choices: death, or to join a trial (where such trials exist). However, when they join a trial they face the possibility that they will be given a placebo, not the drug.  Whilst this is probably in the best interest of future patients (a good clinical trial will determine the efficacy of the new treatment), it rides roughshod over the rights of the current patients (not to be sacrificed for future generations) and the duty of physicians to act in the best interests of their present patients.  There are two consequences here: the first is that it is morally dubious to use the present patients as mere means to an end, rather than acting in their own best interests, especially where, if randomized to the placebo arm the outcome of death is a certainty.  The second consequence is a practical one: compliance with the trial is lessened at the point at which patients can take alternative measures to increase their chance of survival. This was best documented during the early stages of the AIDS crisis in the 1980s, where there was evidence of ‘cheating’ during the trials1. People lied or bribed their way into clinical studies; and shared drugs to dilute the ‘risk’ of being on placebo.  This has the obvious impact of casting doubt on the scientific results of the trials: you can no longer be sure who has taken what, and what other conditions they may have.  1 Schüklenk, Udo, and Lowry, Christopher, ‘Terminal illness and access to Phase 1 experimental agents, surgeries and devices: reviewing the ethical arguments’, British Medical Bulletin, Vol.89, 2009, pp.7-22,


There is no reason why, under this model, you could not retain suitable precautions to ensure that this doesn’t happen.  For example, you could continue the obligation for companies to sell the drug at cost (they would, naturally, continue to be incentivised by the huge profits they expect to make when the drug is licensed). Further, you could impose financial sanctions on companies that refused to take appropriate action towards completing testing.


First, this may well be overridden by the individual rights of present patients (see proposition arguments).  Second, the greater time taken to recruit is one that may be offset by greater numbers: whilst the trial will be of a lower quality (no control group, etc.) there will nevertheless be a greater number of people willing to take the drug (people who wouldn’t have wanted to be part of a trial, but are willing to try the new treatment). Consequently, it may well be possible to compensate for the other problems with the trial. Further, alternative trialling models can be employed, for example using patients who choose not to take the drug as the control group. Whilst you lose the benefit here of having a double-blind trial (as under the status quo), you gain in terms of the benefits to current patients.


This gives people false hope  If these drugs are made available, you risk giving many people false hope in the last days of their lives. People, particularly when in desperate situations, tend to overestimate a treatment’s efficacy.  Given that these treatments are still undergoing the trial process, it is possible that they are ineffective, or have side-effects that outweigh any benefits.  Thus, to allow such drugs and treatments to be handed out during the testing process, there is a great risk of giving people false hope. This is especially the case given the compromised role of the physician in this scenario: ordinarily, if a patient wants an experimental drug, they can have a discussion with their physician that stresses the ‘in trial’ nature of the drug, and thus the uncertainty of it working. Subsequent experiences (the inconveniences of trials; filling in forms and receiving expenses) reinforce the idea that these drugs were experimental, and that the bulk of the benefit from the trial accrues for future patients.  Consequently, in that scenario it is easier for the physician to help the patient to come to terms with the end of life; to deal with this and to realise that any trial drugs give only a slim chance of improvement. In the scenario envisaged by this proposition, experimental drugs can be acquired as easily as licensed ones, and therefore there is no longer that clear distinction for the patient between ‘doing all you can’ in the ordinary sense, (trying every treatment that is known to be effective) and trying ‘one more (experimental) drug’.  Therefore, the patient is less likely to be able to come to terms with their own condition, and therefore less likely to be able to deal with the emotional trauma inflicted not only upon them, but on close family and loved ones.


This policy enhances the role of drug reps and advertising, at the cost of evidence-based medicine  By allowing anyone who is critically ill to use experimental drugs you enhance the already dubious role of drug company reps: especially in the USA, (where doctors do not operate under the NHS guidance found in the UK), there is already a problem of patterns of prescription being altered by the techniques of drug reps, rather than by evidence1. Where drugs are for sale before they have completed testing, there is even less evidence available, and therefore less ability for physicians to contest the claims of either reps or their own patients (who may have heard of the drug during their own research). Hence you magnify the problem of potentially ineffective of even harmful prescription.  1 Harris, Gwyn, ‘Pharmaceutical representatives do influence physician behaviour’, Family Practice, Vol.26 2009, pp.169-70,


This reduces the incentive for pharmaceutical companies to complete the testing process  Testing new drugs is a very expensive process, in 2000 the average cost was estimated at around 86 million for the large scale phase III tests1 however this is contested and it could be much higher it represents 40% of pharmaceutical companies R&D expenditures, which since a recent estimated the development cost of a drug can be up to $5.8billion (due to including failures) the cost of trials would in some cases then be $2billion,2 which is currently funded by pharmaceutical companies. They fund these tests because it is either impossible, very difficult or very risky to access large markets before testing has been completed (e.g. in the USA companies are only allowed to sell new drugs “off-study”, i.e. during trials, at cost3)  If you allow all terminally ill patients access to experimental drugs, you reduce the incentive for companies to continue testing their products: they will have access to a large market prior to the completion of testing, and will therefore have no incentive to complete trials, which are expensive and risk finding the product ineffective.  1 DiMasi, Joseph A. et al., ‘The price of innovation: new estimates of drug development costs’, Journal of Health Economics, Vol.22, 2003, pp.151-185, p.162   2 Roy, Avik S. A., ‘Stifling New Cures: The True Cost of Lengthy Clinical Drug Trials’, Project FDA Report, No. 5, April 2012,   3 Schüklenk, Udo, and Lowry, Christopher, ‘Terminal illness and access to Phase 1 experimental agents, surgeries and devices: reviewing the ethical arguments’, British Medical Bulletin, Vol.89, 2009, pp.7-22,


Disastrous impact on medical trials  We need medical trials. It is important to have large groups of recruits, which can often be very difficult: a problem with the speed at which new treatments for rare diseases is the rate of recruitment (and therefore the length of time taken to complete the trial)1.  If you pass this motion, trials will face large problems with recruitment, an area where there are already sometimes shortages2: if people can get access to the drug without a) the possibility of being placed in the placebo arm or b) inconveniences of being part of a trial, there is a reduced chance of them choosing to enter the trial.  Consequently, the sample size in trials will be decreased. This will have a couple of outcomes:  First trials will take a longer time to be completed as a result of fewer volunteers and this is bad for patients currently taking the new drug as well as for future patients. This is because it will take longer to determine the safety of the drug meaning if it is dangerous those taking the drug will be taking it for longer before the danger is fully appreciated and if safe then the drug will have taken longer to get to the market than it could have. The longer the trials take to complete, the more people are forced to decide whether to take the drug in the absence of reliable information. This means that, at such a stressful time, people are effectively forced to gamble the quality of their remaining years with the hope of gaining a few more (new drugs are unlikely to be ‘miracle cures’. Rather, they are likely to extend life by driving the disease into remission).  It is important to remember that, at this stage, it has yet to be determined whether new drugs are more effective than old ones, and second, that the sorts of drugs used to treat terminal illnesses tend to come with substantial side effects. As a consequence, if many people are using a new treatment before trialling has been completed, they may be using something that is not effective and has side-effects that significantly impact the quality of the last years of their life.  Finally, the longer trials are delayed, the greater the chance that future trials will be biased by media hype ad speculation. It is both easy and profitable for media outlets to exaggerate early successes of a drug with claims and headlines such as “wonder drug”.  This is problematic because of the tendency towards confirmation bias on the part of researchers: the greater their expectation of a positive result, the more likely they are to alter data to receive that result. Note that this is not as a result of deliberate fraud or deception, but rather, the result of any number of small decisions that, cumulatively, create a large result.  1 Jenkins, John, ‘Considerations for Clinical Trial Designs’, U.S. Food and Drug Administration,   2 ‘Volunteer for research at UNClinicalStudies.org’, University of Michigan Comprehensive Cancer Center,


Drugs that are still undergoing clinical trials do not have a complete void of information about them. Presumably this policy covers drugs that have completed at least some testing in humans (say, phase one of the trials), and therefore at least some information would be available on which doctors and patients could base their decisions.  Further, it is implausible to suggest that doctors are entirely under the sway of advertisers: whilst drug reps under the status quo have some influence in getting a doctor to use one drug rather than another, this is in instances where there is little to choose between those products, and (importantly!) both are licensed, safe and effective. They would clearly not be so reckless as to blindly follow a drugs rep and prescribe an untested product to their patient.


Doctors are trained in the presentation of news to their patients. This includes the delivery of bad news, and the dispelling of media-myths. Patients with terminal illnesses are often well-informed about their disease, and (in particular those with chronic conditions) often gain a good understanding of the possibilities of future treatments.  The risk that they may all get carried away on a wave of false hope is, consequently, minimal. Patients in this circumstance are more than capable of reaching, in conjunction with their physician, an informed decision regarding experimental drugs, and make a choice accordingly. The moderate risk of someone making an error in no way outweighs the chance of giving someone some more time with their family.  Countries that already allow access to treatments that have not completed trials do not just allow the doctor to simply proscribe the drug as with any other. Rather the doctor will need to apply for access to the drug.1 In addition the drugs company will also have to give its approval.2 As a result it is unlikely that the patient will consider this the same way as they do normal drugs.  1 ‘Special Access Programme – Drugs’, Health Canada, 15 August 2005,   2 ‘Compassionate Use of Unapproved Investigational Product’, Pfizer,


Although the use of virtual networks and doctors may provide solutions to share knowledge it creates other difficulties. The use of VDP as an educational tool clearly has downsides. First it is not designed for training; if it were why not use a tool specifically for training? As the VDP is not any educational benefits have to be considered secondary. Unlike with a specifically educational tool there is no way for the experts to test that the knowledge they are passing on is being learnt or that their advice is being followed.  Additionally, if the use of virtual doctors is educating medical officers on the ground does it ensure the newly trained professional will stay in Zambia? The bigger picture of what the officers do, and whether the government implement competitive labour policies, requires consideration.


The network approach: promoting learning  The use of ICT and creating a network of professional experts enables learning and knowledge transfer between health workers and academics. In addition to the brain-drain, whereby skilled health professionals continue to emigrate from Zambia, Zambia also shows a slow rate of training of new health workers. Therefore the VDP provides a vital learning tool. VDP provides practical skills by healthcare workers to learn from first-hand experience while having access to a field of experts, or advisers, able to answer any questions. The quality of healthcare will be improved as workers in remote locations are given access to information and correct answers for diagnosis. A global pool of skills can be drawn upon, and utilised, when required.


Mobility remains a key issue across Africa. The WDR (2009) identifies three key sources for effective integration: institutions, infrastructure, and interventions. Infrastructure includes systems that facilitate the geographical movement of goods, services, people, and ideas - such as roads. The reality of a mobile clinic therefore relies heavily on having the infrastructure to support flexibility, mobility, and frequent movement.  Mobile clinics still won’t be able to reach all patients that need their help; public investment is required into infrastructure such as roads and railways first. The project can only work if mobile clinics are able to be mobile. Further, even if they are mobile it doesn’t necessarily ensure people become ill when the medical officer happens to be visiting.


Taking healthcare beyond basic needs  Not only does VDP improve access to primary health care but the networks developed between different health advisers mean changing health demands can be met. Across Africa there is now a shift in the type of diseases prevalent. Increasing rates of non-communicable disease are being recorded - for which advisers can provide ongoing support. Additionally, there remains a need to improve understanding and treatment of mental health issues within rural areas in particular. Concern with mental health requires greater recognition across Africa. Finally, data can be collected on health issues affecting rural areas for targeted intervention.


Tackling access: working in rural areas  Zambia’s human resource crisis in healthcare is most prominent in rural areas. Poverty remains widespread and despite Zambia’s high economic fortune as a result of copper during the 1960s it has become a heavily-indebted poor country. The World Bank (2013) classifies 76% of Zambia’s poor as residing in rural areas. With disparities in access to health prevalent, Zambia needs to train new doctors and nurses to ensure the population can access health care. The VDP is therefore tackling the issue of access within rural, and remote, areas.  Access to health is a human right, and the VDP is ensuring such rights are become a reality in rural areas and rural populations. Mortality and morbidity can be reduced as rural health workers are able to diagnose and treat a wider range of conditions.


Zambia needs to improve its health care system in general, not work on implementing a virtual programme. Physical contact is still necessary for diagnosis and treatment.  Alternative schemes are being used to meet health needs and improve the structure of Zambia’s health system. For example, the Clinton Foundation and DFID [1] have invested in the provision of community health workers. These programmes invest in training community health workers across Zambia’s rural regions. The health workers trained are therefore physically located within the regions. This is much more important than having virtual doctors on call.  [1] See further readings: Clinton Foundation, 2013.


Can the VDP go beyond basic needs and rights when the scale, and scope, of basic need is so large? Figures show a negative image not only of physical health, also the environment in which people live in. The maternal mortality ratio is calculated at around 590 per 100,000 and infant mortality (under 1) stands at 53 per 1,000 live births. However, only 61% of the population have access to improved drinking water; and 48% are able to access improved sanitation facilities (UNICEF, 2013).  Can we rely on NGO’s providing the VDP to fulfil basic needs when the challenges are so large?


A study carried out by Masiye (2007) indicates only around 40% of Zambia’s hospitals can be defined as efficient. There remains a significant problem of resource wastage in Zambia’s hospitals and the hospitals are technically inefficient in producing, and delivering, services. Health goals cannot be achieved in Zambia if hospitals continue to function inefficiently. This raises concern as to how the hospitals cope once referrals are sent? Is the wider health system adequate?  Outsourcing of medical professions into rural areas, and making improvements in the speed and quality of referrals does not resolve the issue of hospital quality. Although VDP’s can act to significantly reduce the number of inappropriate referrals investment, training, and improved management, is still required within Zambia’s hospital system. Additionally, improved access to drugs is needed. Drug shortages have been reported due to corruption scandals - funding provided to supply drugs in the health sector have previously gone missing [1] . Generic drugs are in short-supply, and high demand. Without doctors being able to access vital drugs, whether they are located in hospitals or remote areas, treatment cannot be provided.  [1] See further readings: IRIN, 2011.


Flexibility of mobile clinics  The use of mobile clinics and ICT in health not only tackles issues around location accessibility to health, by travelling into remote areas, but also the flexibility provided through the clinics mobility means a larger population can be seen and treated.  Virtual doctors are flexible; one doctor can be providing his or her expertise through numerous local doctors and nurses at any time. They can help staff with much less training make the correct decisions. By using mobile clinics the location is flexible - and can be altered depending on variations in social need and seasons -, and the time individuals can access the clinic is flexible. Mobile clinics are more responsive to demand.


Speeding up referral  Each mobile clinic will be equipped with vital tools and equipment, and staffed with a medical assistant, a midwife/nurse, and project officer. Furthermore, the presence of a medical staff team means a number of services can be provided for women, men, and children. The team are able to carry out tests on the ground, and if required refer the patient to a hospital. Referrals are made by the staff, with all required information passed on to the hospital and an appropriate appointment made.  The VDP makes each actor within the referral and treatment process aware of their position and role. The VDP appropriately delegates jobs; thus improving the system of hospital referrals and minimising unnecessary costs from inappropriate referrals.


Technology will only be required within the mobile clinics, to enable the VDP networks to be used. It is a key component, but not the only foundation of which the VDP is based on. This means that the clinics can carry equipment to ensure access to the internet remains – such as a satellite connection. Furthermore, significant developments have been made in Zambia’s technological revolution. Internet connectivity has improved in rural areas; and pioneering movements across rural areas - such as the implementation of solar-powered internet - means connectivity is spreading into rural, remote, Zambia.


Today the inclusion of private stakeholders in providing access to health is proving to be a sustainable approach. To achieve developmental impact the public sector is no longer the key source or actor. Although increased support by the government - both financial and political - may be required in the future it is not fundamental for the implementation stage. The VDP can continue to grow and be sustainable through the work of private organisations and funders. The state can later step in and expand the system nationwide when it is fully demonstrated. Private partnerships are changing how health-care is provided and its sustainability.


Resolving the health service crisis?  To what extent does the VDP resolve the lack of health service professionals in Zambia? Two caveats emerge.  Firstly, the project shows how intervention from international organisations can work against trade union demands and employment issues. The project is introducing a model of outsourcing. The medical staff do not need to be based in hospitals so reducing government costs and decentralising employees. Recent strikes by nurses [1] shows dissatisfaction with work conditions and overwork. It raises concern over the motives of the VDP. Is the VDP encouraging social protection and an ethical work environment for all medical professionals? Or is the VDP an escape mechanism to keep wages low and neglect demands made by working nurses? A majority of the expert ‘virtual doctors’ employed are volunteers. Ultimately then the government might consider the VDP a good excuse not to invest in training Zambian doctors.  Secondly, does the VDP resolve the issue of brain drain? Improved incentives and increased salaries are required for trained medical professionals, to motivate them to stay. The VDP may help educated doctors but it does not provide them with reasons to remain in Zambia, rather it gives them contacts with outside healthcare systems where their skills will be much better rewarded.  [1] See further readings: Kunda, 2013.


Will virtual doctors be used?  Even if VDPs do improve access to health services we cannot assume the health services will be used. The use of traditional healers, and practices, remains popular across rural Zambia [1] . If the population is unwilling to use modern medicine then providing better access to that medicine will be of little benefit. If formally trained doctors and medicines are not accepted, or trusted, by communities then the resources being spent on VDPs would be much better spent on education to encourage people to make better use of the facilities they already have than introducing new technology based solutions that will simply be more likely to be rejected.  [1] See further readings: Bansal, 2012.


A dangerous reliance on technology?  ICT is providing innovative solutions to resolve many social problems across Africa. However, is there now a dangerous reliance on technology? Not everyone has access to mobiles and signal remains precarious. When answers, diagnosis, and treatment, are reliant on using technology in the field it needs to be ensured that the service fitted in mobile clinics will remain reliable for field health workers. Additionally, it needs to be ensured that the network of global professionals frequently check messages for updates and respond as quickly as possible. The quality of health service cannot be improved if the response time remains low due to insufficient technology or connectivity. The scheme requires partnerships to telephone and information technology companies.  The reliance on technology is also danger when we consider what information the technology used is actually providing. The VDP will mainly involve text-based emails and messages to provide patient information. Expanding to use images and videos - such as through Skype - will ensure the virtual doctor is more involved in the process, reducing error.


How sustainable?  A key issue that needs to be raised is funding. Currently the VDP is funded by a range of corporate partners - including Microsoft and Google. However, for the project to be sustainable in the long-run investment is required from a wider range of bodies, and further partnerships need to be formed with the public sector. The government needs to be included as a funder and supporter. The neglect, and exclusion, of the government within discussion on health projects - such as VDP - only acts to remove their responsibility and obligation to tackle the social dilemma. Healthcare is the responsibility of government, not the NGOs and private firms that are providing VDP.


Figures showcasing the popular use of traditional practices, and medicine, do not show the reasons behind use. It fails to recognise the degree of choice and the nature of treatment provided. If people don’t have access to modern medicine then they will go to that which is available. The answer then is to increase access to modern medicine to provide the alternative.


The VDP is providing a number a solution to the lack of human resources within Zambia’s health sector. VDP is enabling the growth of local jobs, for Zambian nationals. Although there are no current figures to estimate the amount of jobs that will be provided within the health sector, the VDP has currently been rolled out into six sites and continues to expand. New clinics will be set-up across Zambia, as well as Tanzania, Malawi and Kenya. A growing body of health workers will be required to maintain the VDP network; reducing the doctor to population disparity in Zambia.


The added cost to public healthcare that comes as a result of diseases brought upon by smoking is vastly outweighed by the amount of money governments around the world receive in taxes on tobacco. The UK currently takes around 60% of the cost of a pack of cigarettes in tax duty. In 2008, the US took over $16 billion in tobacco tax revenue1. Such high tax duties and revenues can hardly be justified if smokers are not even to get healthcare for their money. And without the taxes, cigarettes would be much cheaper, encouraging more people to smoke. Moreover, because smokers tend to die earlier than non-smokers, per head the average health care costs are lower than those of non-smokers2. 1 Tax Policy Centre, US Tobacco Revenue Statistics, 2 USA Today, 15 Jul 11, Do smokers cost society money.. Accessed 15 Jul 11.


Smokers are a drain on economic resources  Smokers contribute a disproportionately large amount to the cost of healthcare. They are a drain on resources. In the UK it is estimated that up to 9,500 beds are blocked daily by smokers, and that up to eight million doctor consultations are required on their behalf each year. A well-informed smoker, unable or unwilling to quit, might assume an increased risk for himself but he would also be indirectly increasing the likelihood of others being unable to access necessary healthcare and this is not fair. Allowing smokers to take scarce beds or organs needed for transplants - that could otherwise go to those suffering from genuine misfortunes - is an unjust allocation of resources.


Many smokers do not choose to harm themselves, they simply can't help it. The 1988 US Surgeon General's report on the addictive nature of cigarette smoking provides proof of what is now widely accepted – smoking cigarettes is highly addictive. Moreover, there are high correlations between people smoking and being under stress or having parents that smoke. All of this suggests that people do not necessarily choose to smoke and may not be able to choose to give up. Given that smokers can therefore be portrayed as suffering from involuntary addiction, it would seem sensible to tackle this addiction alongside physical health issues, as oppose to dismissing smokers altogether.


As smokers have a higher chance of harm from surgery due to complications arising from their habit, it is more efficient to prioritize non-smokers  Failure to quit smoking before surgical procedures increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections and other complications at the surgical site. For example, in a study of wound and other complications after hip or knee surgery, no smoker who quit beforehand developed a wound infection compared with 26% of ongoing smokers and 27% of those who only reduced tobacco use. Overall complications were reduced to 10% in those who quit smoking compared with 44% in those who continued1. This means that surgery costs more on average for smokers and is also less likely to be effective. Treating more smokers means devoting more resources for lower results. Therefore, prioritizing non-smokers, at least in certain areas of healthcare, would be beneficial to society as a whole. 1http Peters, M.J. (2007) Should smokers be refused surgery? British Medical Journal,


The law would act as a deterrent against attempts to conceal a smoking habit to procure healthcare  There are realistic ways a policy of denying healthcare access to smokers could be carried out. Insurance companies already ask lots of health-related questions, often including whether their client is a smoker, when assessing life insurance premiums. In these cases, you are required to give details of your lifestyle by law. Of course, some people do not, however this is to be expected since no law is one hundred per cent effective. Sanctions exist to discourage dishonest behaviour. A similar model could be put in place requiring a declaration of smoker status to the health authority. Indeed, many doctors already enquire about their patients' smoking statuses on an informal basis. It is also particularly hard to lie about being a smoker for two reasons. First, other people inevitably see you smoking. This means an abundance of witnesses in the case of a dispute, and thus a disincentive to lie. Second, people require doctors to undertake detailed examinations for treatment purposes, thereby allowing them to see obvious outward signs of smoking: tar deposits, tar in cough, yellowed fingernails, etc.


Denying, or even reducing, access to healthcare for smokers is impractical, and therefore an unrealistic policy goal. First, the extent to which care is denied is questionable. Does the proposition model include denying palliative care? If it does, this literally means leaving people to suffer agonising pain in emergencies while they try to locate private prescription painkillers, if they can afford them. Further, does it include denying emergency procedures such as resuscitation in the case of a heart attack? If it does, where are patients supposed to go? Private emergency rooms are few and far between, or non-existent, in many countries – never mind private ambulances. Second, in order to encourage smokers to stop smoking, the process needs to involve reactivating access to healthcare if smokers quit. But any cut-off point at which the right is re-activated will necessarily be arbitrary. Some studies have suggested that, for instance, teenagers do irreparable damage to their respiratory systems even if they stop smoking young. If all citizens make an informed decision to smoke, as the proposition argues, isn’t it the case that teenagers make an informed decision to do inordinate damage to their bodies? If it is, then why should there be an absolute cut-off point at which one reassumes healthcare rights? Should there be a relative scale? Wouldn’t this be impossible to construct on a scientific basis?


Smokers may have a higher chance of harm from surgery due to complications arising from their habit, but this is not a phenomenon specific to them. Cardiovascular disease, or heart disease to most people, is the number one killer of men and women in the United States1. It is caused by the build-up of fatty deposits that clog the vessels - those at risk are often smokers, but can just as often be those who are overweight, have diabetes or simply high blood pressure. As such, it is not justified to single out smokers when those with unhealthy diets can just as easily cause complications in their surgeries.  1. Daily News, 13 Jul 11, Cardiovascular disease: Defend yourself by lowering the risks.Accessed 14 Jul 11.


There is no evidence that limiting access to healthcare would act as a deterrent. In fact, in the developing world, where a smoker would on average have worse access to healthcare, tobacco consumption has increased significantly over the last decade.1 Furthermore, governments have indeed acted to discourage smoking through a variety of methods. These have included advertising campaigns and banning smoking in public places and they seem to have worked. Cigarette use in the developed world has declined over the last 50 years. In the UK, smoking rates have dropped by half between 1974 and 2009, from 45% down to 21%2. A majority 59% have never taken up the habit3. 1 World Health Organization, The Tobacco Atlas, 2 Daily Telegraph, 22 Jan 09, Lowest ever number of smokers after public ban and health campaigns.Accessed 14 Jul 2011. 3 Daily Telegraph, 22 Jan 09, Lowest ever number of smokers after public ban and health campaigns.Accessed 14 Jul 2011.


The added cost to public healthcare that comes as a result of diseases brought upon by smoking is vastly outweighed by the amount of money governments around the world receive in taxes on tobacco. The UK currently takes around 60% of the cost of a pack of  Many people have to wait for surgery when they have fallen ill or gotten injured through no fault of their own. Many of the people they are waiting behind have fallen ill out of choice. This includes smokers who have contracted diseases as a result of their habit. There is a vast array of information, easily available to smokers, on the dangers of cigarettes. If despite this, a person chooses to smoke anyway then it is unfair that others who have fallen ill out of genuine misfortune should have to wait in line behind them for healthcare. This problem is particularly in acute in states that have universal healthcare, where non-smokers are forced to wait in a queue for treatment behind those who have negligently made themselves ill smoking. In Britain for example, they have attempted to avoid this by establishing standards under which surgery is denied to obese patients1. Thomas Condliff, the patient, was denied gastric band surgery due to having a body mass index lower than the threshold under which they believed the surgery would be effective2. The priority in such cases is and should be with those who have made a conscious decision to develop an unhealthy habit. 1 BBC News, 11 Jul 11, Man appeals for NHS gastric bypass surgery. Accessed 14 Jul 11.


Denying access to healthcare for smokers would act as a deterrent, discouraging smokers  Governments should do everything they can to discourage smoking. They already attempt to do so in a number of ways, such as through ensuring graphic health warnings are present on all tobacco packaging. Many states have also introduced legislation banning smoking indoors in an attempt to discourage the habit. However, smoking is still a massive problem - millions of people still do it. The refusal of medical treatment to smokers would surely be a massive deterrent to current/potential smokers from continuing/starting the habit. The safety net of modern healthcare being pulled from underneath them would be a powerful incentive to give up the habit, and reduce the estimated $100 billion that the White House believes smokers cost the economy annually through loss of productivity1. 1 USA Today, 15 Jul 11, Do smokers cost society money.. Accessed 15 Jul 11.


Denying access to healthcare for smokers will not hurt the economy, for the health care costs of smokers are substantially larger than those of non-smokers. In fact, 'health care costs for smokers at a given age are as much as 40 percent higher than those for non-smokers' . Furthermore, though the opposition points out that because smokers die younger, average health costs are in fact lower than non-smokers, denying access to healthcare will have two effects which will cancel each other out: more people will give up smoking, increasing gross medical costs for the state, but those who don't will die younger for they won't get treatment, which will offset the previous rise.


There are realistic and practical ways in which the policy of denying healthcare to smokers could be carried out. Smoking is a habit that has clear and demonstrable physical effects, which often correlate with the regularity and longevity of the habit; doctors are trained to recognize such symptoms and do not need patient confirmation. Furthermore, if the bill made it quite clear that healthcare was to be denied to present smokers, the hypothetical presented by the opposition is easily negated. The goal of such a bill would to be to ensure that both smokers gave up the habit and non-smokers did not take up the habit. In this case, the man taking up smoking is in the wrong and is acting contrary to the law. He would have little room for complaint.


Denying access to healthcare for smokers will lead to thousands of people being turned away and potentially dying from preventable illnesses  The denial of access to healthcare for smokers is a policy that will directly lead to the turning away of millions of people, merely for making one perfectly legal, if ill-advised lifestyle choice. In a state like France, where 20 per cent of the population, 12 million people, are smokers, such a policy would leave a large minority unable to access basic healthcare for issues that may be unrelated to their smoking habit . Furthermore, it may lead to the ridiculous situation whereby smokers are dying from preventable diseases despite hospitals being under-utilized, as a fifth of the population is no longer allowed in.


Denying healthcare to smokers is a restriction on people's liberties  Whether or not you believe it should be, smoking tobacco is legal. At the same time, healthcare is regarded as a fundamental human right, alongside rights to education, food and water. Denying someone healthcare is to impede upon his/her basic liberties and this cannot be justified when, in the eyes of the law, they have done nothing wrong. Criminals have the right to healthcare – it is often that you hear that the trial of a war criminal is being delayed while they receive treatment. Take the cases of Ratko Mladic or Slobodan Milosevic for example 1. If healthcare is given to men who have committed genocide then surely it should be given to smokers. Also, if a Government adopts the line that one's behavior determines the kind of health service one receives then what is to stop that Government applying such a mantra beyond smoking and controlling the practices of those they govern in any number of ways?  1.  and


Denying healthcare to smokers alone is victimization  The denial of healthcare, an established right, without the citizen doing anything either immoral or wrong is pure and simple victimization. Suppose you are a doctor and you have two patients waiting for a heart transplant. Patient A is 65. He does not exercise, has never had a job and has committed a series of crimes throughout his life. Patient B is in his 20s, with a first class degree from a good university. He is a trained doctor himself and wants to go and work in the developing world, to help people suffering from leprosy. But Patient B is a heavy smoker. Should you therefore prioritize patient A? It seems problematic to victimize smokers, particularly considering smoking is legal. If you are going to discriminate against smokers then surely you should discriminate against alcohol drinkers and people who do extreme sports as they are also knowingly endangering themselves. Smoking reduces life expectancy by 2.5 years for men, but obesity reduces life expectancy by 1.3 years and if high blood pressure is added to that by a total of 2.8 years all are preventable so why should only smoking be discriminated against?1 Maybe you should discriminate against people who choose to live in polluted cities. And then there are drug users. What about people who could afford private health care? Should age, occupation and past convictions be taken into account? It seems arbitrary and unfair to single out smokers. Yet, if we start to take into account all the factors that determine who "deserves" to be prioritized for healthcare, then we are left with the unsavory, illiberal practice of Social Darwinism. 1 Harvard School of Public Health, "Four Preventable Risk Factors Reduce Life Expectancy in U.S. and Lead to Health Disparities", 22 March 2010, accessed 24 August 2010.


Denying access to healthcare for smokers will hurt the economy  Economically, the healthcare of the nation is important for maintaining a productive workforce. Do we really want to lose otherwise functional members of the workforce the first time they contract an aggravated throat infection and cannot afford, or delay for financial reasons, a simple course of antibiotics? Quite apart from productivity, as The Guardian notes, smokers in the United Kingdom also contribute over £10 billion to government coffers through the tobacco tax 1. To lose this source of revenue will do more to hurt national health services than the occasional complication in surgery granted to a smoker. Lastly, because smokers die younger than non-smokers, though they cost more per year, over their lifetime their average health costs are lower than those of longer-living, non-smokers.  1.


Goods provided by the state, like healthcare, are often, and necessarily, subject to certain provisions. For example, in order to get unemployment benefits, a person must prove that they are regularly looking for a job and a means to get themselves off benefits. Denying access to healthcare for smokers does not mean denying them healthcare access forever; they can regain unlimited access if they stop smoking. Therefore, prioritizing non-smokers for healthcare in certain cases is not impeding upon smokers' basic liberties but a recognition that those who care about their own health enough to not smoke should be prioritized.


Denying healthcare to smokers is impractical  There are several reasons why limiting access to healthcare for smokers could prove impractical. Ultimately they surround the issue of how you define who is a smoker. One man might have chain smoked for 20 years but given up for a year, since a bill limiting access to healthcare for smokers was passed. Meanwhile, another might have been smoking cigarettes now and again just for the past year. Who would be prioritized if the two were on a waiting list for the same operation? If the law penalizes anyone who has ever smoked then it would not provide nearly as strong an incentive to stop smoking. But, if the law does not penalize anyone who has smoked, then choosing whom to punish would seem quite arbitrary. Furthermore, what is stopping people from simply lying about how much/whether they smoke? They might not show any obvious signs of being a smoker. Even if they do, they could claim to have given up, work around fumes or be a victim of passive smoking.


In practice, it is both viable and beneficial, in certain cases, to prioritize non-smokers for healthcare. Where there is more chance of a transplant being successful in a non-smoker for example. It is true that people can knowingly damage their health in other ways, such as drug taking or alcohol abuse and it may well be viable to limit access to healthcare in these cases also. This does not mean that every factor in a patient's life must be scrutinized in order to decide where they are placed on a doctor's waiting list. In public policy, the line must be drawn somewhere. Prioritizing non-smokers can mean that more people can be helped with same amount of resources and, where this is the case, it should be practiced.


The opposition fails to recognize the impact that such a policy will have on smokers. Access will only be denied to smokers who continue to smoke once the bill is in place, if it is proven that they have given up, they will be free to access healthcare. Therefore, the only smokers who will be turned away, and who will potentially die from preventable illnesses are those who place their habit above that of their life.


To not promote abstinence is not a neutral position, it is a position the implicitly encourages sexual promiscuity. Children are at risk of severe psychological and physical harm from having sex too young, and should be encouraged not to do so. Promoting ‘safe sex’ is implicitly encouraging sex by implying that it is safe and a normal thing to be doing. This will encourage young people to believe that there is no risk when this is not the case even if they do follow the prescriptions they have been taught about sex.


Abstinence is an outdated view, based on religious teaching, which may be a personal choice but is not to be expected as the norm for everyone  Young people express their sexuality as part of their development to adulthood. It is not having sex that is a problem, but having unsafe sex or hurting people through sexual choices. Refusing to promote safe sex would mean not moving with the times. Just because schools do not promote safe sex does not mean that adolescents will not experiment with sex. They will already be exposed to sexual imagery and ideas of sex so it is necessary that they are taught properly how to remain safe.  Schools may also want to talk about abstinence at the same time; it is a way of keeping sexually safe. However schools have to recognise that the majority of pupils are unlikely to stick to abstinence regardless of how much the school promotes it. It is therefore necessary for the school to also promote and educate about safe sex.


The problem with mandatory sex education is precisely that it presents that information in an organised fashion – by the state. In doing so the right of the parents to raise their children in accordance with their structure of beliefs is usurped.


Ignorance about sex is the primary cause of the spread of sexually transmitted diseases (STDs)  The spread of AIDS in the 80s and 90s showed that education and information is more important than ever as exemplified by the slogan in the British 1980’s advertising campaign to prevent AIDS ‘AIDS: Don’t Die of Ignorance’. The campaigns were credited with credited with changing behaviour through warnings on adverts and informing through an information leaflet. [1] This shows that education can work even when starting from scratch. Giving sex education in schools is crucial to the spread of information to each successive generation, and may be supplemented by frank discussion at home.  [1] Kelly, Jon, ‘HIV/Aids: Why were the campaigns successful in the West?’, BBC News Magazine, 28 November 2011,


While a serious disease, AIDS transmission makes up only a tiny proportion of sexually transmitted infections each year. [1]  Firstly the harm of these infections has always been satisfactorily low before public Sex Education, and secondly even if mandatory public education did have a substantive benefit it would not outweigh the infringement on the moral freedom of the parents.  [1] Health Protection Agency, STI Annual Data Tables


True, but nor does it make sense to make the classes mandatory once the child reaches an age where it is legally able to decide whether it wants to partake of them. Nor does this mean that these classes need to be promoting safe sex rather than simply teaching the facts and encouraging abstinence.


The information age makes attempting to hide information on sex impossible  The internet provides a vast amount of easily accessible information about sex, of varying degrees of quality. Most children in the west now have access to the internet and are therefore likely to have access to this information on sex, or at least educational materials on sex even if the child’s access to the internet is controlled.  Given that it is impossible to prevent children from accessing this information if they really want to, it makes sense to present it to them in an organised and accurate fashion. Rather than allowing children to find information on their own through what may well be unreliable resources it is necessary that they should get good reliable information. That this information when there is safe sex education comes from the school means that the children know that they information is reliable. They can then use this information to help them decide how reliable any further information they may find from other sources is.


Restricting information to children is inconsistent with the age of consent  With the age of consent being 16 and with young people being able to vote at 18, it does not make sense for parents to have control over whether their children attended sex education classes right up until the age of 19 or whenever they finish full time schooling.  The age of consent means that there is clearly a need to be taught about sex from that age of consent. This is something that cannot be guaranteed to happen in all individual households if left to the parents whereas it can be ensured in schools.


Parents often know nothing (or worse, are armed with dangerously naive delusions) of the sexual state of their children. The picture painted by abolitionists is inaccurate – the process of deciding what is taught in schools involves parents’ groups and school governing bodies on a school-by-school basis, so parents do have a role in deciding what is taught. But ultimately, the state should be involved in educating the whole child, not just in doling out academic ideas – and should work hard to safeguard sexual health of youngsters, a field near-impossible to separate from sex education.  This is a subject just as important for the development of young people as the conventional subjects such as maths and English. The role of ‘teacher’ has to change with time. Once, teachers only instructed the children of the well-off or acted as a branch of the church, now they teach everyone in a secular society. As their role changes, they must remain responsible and obey the law: thus, the scaremongering of suggesting teachers will abuse their students or lure them into relationships is irrelevant, as both sides believe that is wrong, and should be prosecuted.  Rules banning discussions of sex in schools can deny teachers the ability to deal with real problems. When an individual student comes to a teacher with a problem, a rule against discussing such things in the classroom will probably mean that this outlet of help the troubled adolescent has sought out, often because he feels the family isn’t the place to get help, will be denied to him, will turn its back on him. Like it or not, in today’s fractured society teachers have taken on the role of counsellor, and this rule will indirectly curtail their ability to fulfil it. The result of that will be appalling.


Our children are sexually active. They are making decisions that can affect the rest of their lives. They should be able to choose responsibly and be well-informed about the likely outcomes. They should know about sources of free or cheap contraception, who to turn to when pregnant or if they suspect they have a venereal disease, how to use contraception to avoid both, and, contrary to the impression of abolitionists, they should be told the benefits of abstinence. How can you tell people about that if you refuse to discuss sex? How can you imagine they will take you seriously if you turn a blind eye to something so many of their peers are doing?  They need an external source of support to resist peer pressure, and have sex later rather than sooner: lamentably, it is presumed amongst many young people that having unprotected sex with many partners at an early age is the norm and they encourage others to do it (and attempt to humiliate those that don’t). We need mechanisms to support those that want to resist that pressure: sex education is such a mechanism. Sex education is part of a package of provisions needed to help our teenagers avoid the terrible pitfalls of unwanted pregnancy and venereal disease. This problem is here – pretending that it isn’t won’t make it go away. How else do opponents of sex education propose to deal with the huge problems of STDs and teen pregnancy? Effective and widely supported sex education programs can achieve real results. For example, in the Netherlands, amongst people having intercourse for the first time, 85% used contraception – compared to 50% in the UK.


Children are bad decision makers  Sex education informs children about sex, and then invites them to make a choice. But as demonstrated all the time, children are bad decision-makers, often choosing what is bad for them. That is why adult society often needs to decide for them – what they should eat, what they should watch on T.V., when they are mature enough to be able to choose whether or not to drink or smoke. Surely sex is just as important as those things – just as dangerous, just as potentially destructive. The abdication of our responsibility in the sexual arena is shameful; we should be unafraid to simply tell children this is something they cannot do, aren’t mature enough to consent to yet – a responsibility we seem to shrink from even though it is reflected by the stated aim of society enshrined in the law of the age of consent. Lessons implicitly lauding the pleasures of intercourse are entirely contrary to that aim.


Sex education for underage children undermines the law  Sex education classes for those under the age of consent undermines the law. It says, ‘don’t do this – but given that you are, do this, this and this.’ This sends a terrible message about the law – that breaking it isn’t serious, that authority (as represented by teachers) tacitly approves of that illegality, will tolerate it and even encourage it.  Sex education fails to tell our children clearly what is right and what is wrong. And remember that these are children, who need clear boundaries to guide their behaviour, and who may not understand the subtleties appreciated by liberal educationalists. In any case, so few teachers want to teach this subject that the quality of teaching is awful. Those that do end up teaching it are often the oddest characters in the teaching establishment. Many teachers happy to ‘cover’ other subjects are uniquely embarrassed by this one, or object to it on moral grounds and will not do so, leaving it to the most liberal members of staff.


Responsibility for children's moral and sexual upbringing is not the responsibility of schools  This is none of the state’s business. Teaching this subject en masse in a classroom reduces it to biological notions, group embarrassment and crude jokes. Furthermore, children have never needed this from the state: left alone, they learn from their family and surroundings and grow naturally into adults without the state’s involvement. Few things are responsible for parental disaffection with education more than the teaching of sex and sexuality in ways contrary to their wishes.  Parents have a right to determine the moral environment in which their children develop and this is a huge intrusion into that right. That moral environment has been manipulated again and again over the last forty years by a liberal teaching establishment set on undermining traditional values and beliefs. Sex education has been a prime weapon in that social engineering. That tool should be taken away from teachers, who as a body have proven themselves undeserving of it. As for the tedious idea that children somehow need the nanny state to look after their sexuality – who knows children and their needs better than parents? Schools are responsible for so much that is wrong with our children, and by giving them free licence to delve into students’ sexuality, things become so much worse, blurring the line between teacher, adviser, confidante, and sometimes in extremes, between teacher and lover – an abuse of power that bringing sex into the classroom makes so much easier.


Sex education leads to experimentation and early intercourse, and indirectly encourages promiscuity  Sex education leads to experimentation and early intercourse, and indirectly encourages promiscuity. The most moral form of Sex Education says ‘you shouldn’t do this, but we know you are,’ thus pushing children to consider their sexual existence before they need to or indeed should. Thus sex education’s message is invariably confused – on the one hand, by saying ‘here are the perils of teen sex – so don’t do it,’ and on the other hand, ‘here is how to have teen sex safely.’  Less moral forms start by saying, ‘the best form of a relationship is a loving, constant relationship’ and then say, here are the ways to use protection if you’re not in such a relationship’ – a logic which presumes children are in sexual relationships to begin with. The justification for this is that ‘adolescents know all about sex’ – an idea pushed in our permissive society so much it’s almost a truism – but contrary to that bland generalisation, many children don’t do these things early, don’t think about these things – they actually have childhoods, and these lessons stir up confusion, misplaced embarrassment or even shame at slower development. They also encourage children to view their peers in a sexualised context.  The openness with which education tells students to treat sex encourages them to ask one another the most personal questions (have you lost your virginity? – how embarrassing, how uncool, to have to say no), and to transgress personal boundaries – all with the teacher’s approval. Inhibitions are broken down not just by peer pressure, but by the classroom. As pro-sex education people love to point out, children develop in their own time – but that means that some are learning about this too early, as well as ‘too late.’ We in society are guilty of breaking the innocence of childhood, earlier and earlier – and these lessons are a weapon in the forefront of that awful attack on decent life.


Well taught sex education does no such thing. Sex and responsibility classes must tread a fine line, first stressing the importance of waiting until ready before having sex, and pointing to the physical benefits of fewer partners and starting sex later – but must then move on to the reality of modern Britain’s sex-ridden teen culture, without applauding it, and try to decrease the very high levels of STDs and pregnancy. Yes, that’s hard to do – but that doesn’t mean we shouldn’t do it. On the contrary – it’s one of the most important duties society faces today. Arguments about poor teaching apply equally to maths. We often have to try to recruit teachers in unpopular fields – true, difficult, but hardly unique. The answer is to improve teacher training, both for new graduates and for practising teachers, and to bring in outside consultants from the health and social welfare sectors, who have deep experience in this area.


That logic might sound impressive – but it’s the same one that fails to control underage drinking, underage smoking, the watching of rated movies by those forbidden to do so, the eating of bad food – and underage sex. It’s the same poor parental logic that has seen a generation of children grow up divorced from the society around them, children who die from drugs overdoses and whose parents say (honestly), ‘I just had no idea.’ It’s time to talk to our young people about what they do – honestly, frankly, without frightening them into dishonesty and deception. To do otherwise perpetuates the cycle of ignorance about youth society, and perpetuates the status quo of being able to do nothing to change it.


Force feeding is undignified. The World Medical Association considers “Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment.” [1] This is treatment which the European Convention on Human Rights prohibits in Article 3 on the prohibition of torture. [2] The patient’s right to refuse treatment should be respected even if they are mentally ill. (N.B. Anorexia is not recognised as a mental illness in every country).  [1] World Medical Association, ‘WMA Declaration of Malta on Hunger Strikers’, 2006  [2] European Court of Human Rights, Convention for the Protection of Human Rights and Fundamental Freedoms’, 2010, P.4


Anorectic patients are not able to make the decision for themselves.  Anorectic patients are typically treated under mental health legislation (e.g. the UK 1983 Act). They do not make a free choice because they are not rationally able to weigh up decisions and consequences, they ‘feel’ fat when they obviously are not and are irrational as they are willing to starve themselves to the point of death when suicide is not their intent. [1] The patient is not “capable of forming unimpaired and rational judgements concerning the consequences” (British Medical Association 1992). There have been court cases that have confirmed that force feeding should be allowed when a patient is considered mentally ill. For example the case of “B vs. Croydon Health Authority” in 1994 it was judged, that B (a borderline personality disorder patient, which involves suffering from an irresistible desire to inflict-self-harm) can be force fed, even though she did not give consent to the treatment.  The court explained that because she was not aware of the seriousness of her condition and she had found it difficult to break out of the cycle of self-punishment, she was deemed unfit to make decisions about her nutrition. [2]  [1] Fedyszyn & Sullivan, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa’, 2007,  , p.202  [2] Keywood K., B v Croydon Health Authority 1994, CA: Force-Feeding the Hunger-Striker under the Mental Health Act 1983., University of Liverpool,  , accessed 07/22/2011


Far from helping solve the patient’s psychological problems force feeding is just as likely to exacerbate the problems and make them much less willing to seek out treatment, something that they are often already unwilling to do. [1] While it may be the case that when starved people over-estimate their own size those who are anorexic in the developed world did not start out starved so there must have been a different initial cause of the anorexia that will need to be found and solved, there are numerous different types of psychological treatment that can help do this. [2]  [1] Jimerson, Shane R. et al., ‘Eating Disorders: Treatment’, 2002,   [2] NHS Choices, ‘Treating anorexia’, 2010,


Life is more important than dignity  Life is more important than dignity, many medical treatments are unpleasant or painful but they are necessary to preserve life. Without force feeding the anorectic patient will often die. In Australia about 80 per cent of all anorexic children required hospital admission (from 101 cases), and of those, 50 per cent required tube feeding as a life-saving measure to manage starvation. [1] When a patient requires emergency treatment doctors should do what is necessary to save the patient’s life. Psychological problems can only be treated if the person is alive. Treatment for the psychological problem should be considered to go hand in hand with saving the patient’s life as in the B vs. Croydon Health Authority where force feeding was ruled to be complemented the use of other methods to treat her psychiatric problems. [2]  [1] McLean T., Half of anorexic kids need force feeding, 2008,  , accessed 07/22/2011  [2] Keywood K., B v Croydon Health Authority 1994, CA: Force-Feeding the Hunger-Striker under the Mental Health Act 1983., University of Liverpool,  , accessed 07/22/2011


Life is more important than dignity. None the less there is a significant difference between someone who is in an emergency condition being treated without their consent and someone who has previously refused treatment being forced to have treatment. Patients are allowed to make decisions doctors believe are unwise. [1]  [1] Patients.co.uk, ‘Consent To Treatment (Mental Capacity and Mental Helth Legislation)’ 2009,


When it comes to hunger strikes the World Medical Association says that “Forcible feeding is never ethically acceptable.” [1] While there are obviously differences in terms of the objective when it comes to the consent of the patient there is no difference. In both cases the patient does not want to be force fed and understand what the consequences may be.  [1] World Medical Association, ‘WMA Declaration of Malta on Hunger Strikers’, 2006


Force feeding can help psychologically.  A healthier body weight is necessary to be able to treat the patient’s psychological problems. Studies in Minnesota show that when normal volunteers were starved, they began to development anorectic patterns. They over-estimated the sizes of their own faces by approximately 50%. This shows the impact of starvation on the brain. [1]  [1] Fedyszyn & Sullivan, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa’, 2007,  , P.202