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12/16/2014

Notes on the Mill Valley Film Festival, 2014

I saw 19 films at the 2014, 36th Annual Mill Valley Film Festival (MVFF36) this October. After the first five films on my list I realized a pattern which the festival's programmers had not intentionally planned. There were at two major groups that stood out with some that crossed both.

One group of films dealt with people with Enormous Skill, or Promise, Meeting Extraordinary Adversity. They all in some way reflected the relationship between the brain and the mind or how the mind deals with the stress the brain transmits.  The dissolution of the Brain-Mind paradox also reflects ways in which new science, particularly neuroscience, is creating broader social inclusion of individuals with circumstances which previously, historically, would have stigmatized them; autism spectrum traits, physical disabilities, gender differences.

Beneficence - or doing "good" with knowledge, including technology, is Beneficence. I consider these films to illustrate “doing good” with knowledge. I call this set of films 'Promise meets Adversity,' They include: THE IMITATION GAME,  STATES OF GRACE, THE THEORY OF EVERYTHING, IMPERIAL DREAMS and MOMMY.  None of these were comedies but they are all very good.

A second large group of movies at MVFF36 thematically dealt with issues of Proxy Parenting. Who best raises a child? Ethically, we consider that parents represent the best interest of their children, unless proven otherwise.  These films pondered more questions than they answered but Then if not the parent - who? Sometimes the best a parent can do is to select others to act in their stead. Working parents do it all the time, if it can be afforded.  Overwhelmed parents do it also. When parents relinquish parental involvement, temporary or permanently how do we define their right to do so. At what age is a child able to decide on their own about who should parent them?

Medically and legally we have made a value judgment to emancipate children for sexual issues but not for other matters. Should the parameters of emancipation be psychological, cultural, religious or intellectual? Regarding autonomy, do we as bioethicists or clinicians,  “know it when we see it?”  I call this group of films 'Parents and Proxies.'  The MVFF2014 relevant films are: MARIE'S STORY, NATURAL SCIENCES/Ciencias Naturales,  LIKE SUNDAY LIKE RAIN. Li  THE TALE OF PRINCESS KAGUAY/Kaguya-Hime No Monogatari, BLACK AND WHITE and SOLEILS. Many of these films have significant comedic or lighthearted elements though the deal with serious issues.

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12/16/2014

Part I: THE IMITATION GAME meets HOW I CAME TO HATE MATH/Comment j’ai détesté les Maths, Moral Relativism vs Beneficence and Justice: Moral Injury, War and Computer Science

THE IMITATION GAME 
Alan Turing was a Cambridge trained mathematician, wonderfully portrayed by Benedict Cumberbatch (Sherlock) in the WWII bio-historical thriller, THE IMITATION GAME. The film directed by Morten Tyldum and written by Graham Moore was screened at the 36th annual Mill Valley Film Festival 2014. It is an adaptation of a book by Andrew Hodges, Alan Turing: The Enigma 

While a fellow at the MacLean Center for Clinical Medical Ethics in 1990, it was this writer's profound good luck to meet and spend time with the late Dr. Stephen Toulman, a British born physicist, mathematician, philosopher and communications expert. Also Cambridge educated, Stephen knew Alan Touring and his work. Dr. Toulman shared his 1984 New York Review of Books article 'The Fall of Genius,' a critique of the Hodges book, with a digestible explanation of the way that mathematicians minds work. 

Moral relativism is used in arguments about defense of safety and security in times of war. War being defined as “a state of armed conflict between different nations or states or different groups within a nation or state”. In the loosie-goosie world of the noncombatant, war is often used as a metaphor. Dr. Toulman wanted to be sure of what we spoke. Most importantly he looked at the arguments which drive scientific exploration during war and their consequences. 

The plot of THE IMITATION GAME supplies a protagonist who is focused on the work of his mind, to the exclusion of most social contact nearly on the Asperger's Syndrome spectrum. During this period, that work is construction of a machine ultimately able to decode Nazi strategic plans for attacks on allied forces during WWII. The machine historically is known as the Turing Machine and it’s inventor the father of distributed computing.

At its simplest, distributed computing allows the extraction of any single item from a group, for whatever purposes; defining the human genome or spying on citizens. The popular television show, PERSON OF INTEREST provides many fictional examples. THE IMITATION GAME raises important ethical conflicts which plague each of us in science and medicine and become more tense in the circumstance of war. Applied Science, as was the case of the Turing Machine, can be used for good, but in the process harm can also be done, the traditional “double effect” or duplicity of all things. Navigating such conflicts are the life’s blood of practical Bioethics. 

 In the case of THE IMITATION GAME, members of the British Intelligence Service who were endowed with mathematical sensibility, had to make a moral choices which cost the lives of Allied Soldiers. The choice was necessitated because the technology they built worked so well, they “had to,” let their comrades die. 

“Had to,” is a phrase which always risks moral relativism. All moral frameworks are relative, except the one conveniently determine to be absolute at the moment. There is a plethora of popular television which justifies torture despite article 5 of the Universal Declaration of Human Rights. Immoral actions may be taken, but one shouldn’t fool one’s self with the idea they are the results of absolute moral choices. 

Often in the case in War and triage, “the greater good” doctrine wins as the absolute morality model of the day. In the IMITATION GAME, each mathematician involved believes ending the war sooner, rather than later, is justifiable at the cost of many Allied lives. If they could not choose, they simply could follow the commander’s orders, sounding strikingly like the struck down morality of the Nuremberg defense. Justice, by weighing burdens and benefits is an intellectual as well as an emotional norm. Yet, in the film, though at least considered, the decision is portrayed primarily as emotional. 

Hodges book was written thirty years after Turing died of cyanide poisoning and vicious immoral hormonal castration of his person, his homosexuality being odds with then vile British law and anti-gay bias. One cannot discount the role of “having to “let people die, playing in the psyche of depression and suicide. Those who care for Veterans of active combat dying in hospice, are aware of soldiers' attempts to reconcile moral injury from military obligations with their own humanity. 

Mathematicians generally know the difference between correct and incorrect answers, valid and fallacious arguments. Math and philosophy are intrinsically linked by logic, among other things. It could be argued that the burden of the Turing Decoders inaction to protect Allied soldiers, in THE IMITATION GAME was higher than would be for others, because as mathematicians they could calculate the risks as they were creating them. 

Further watching and reading: 

The Imitation Game (35mm) directed by Morten Tyldum ( 2014) Black Bear Pictures ( UK) 114 mins 

The Imitation Game trailer http://www.imdb.com/video/imdb/vi3398414105/imdb/embed?autoplay=false&width=480 

The Universal Declaration of Human Rights http://www.un.org/en/documents/udhr/ accessed December 11, 2014 

Toulman, S. The Fall of a Giant, Andrew Hodges, Alan Touring: The Enigma. http://www.nybooks.com/articles/archives/1984/apr/26/turing-the-system/accessed October 15, 2010 

National Center for PTSD, Moral Injury in the context of War. http://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp accessed November 11, 2014. 

Miles, S.H. Oath Betrayed: Americ's Torture Doctors. University of California Press. 2009. 312p. 

Beneath the Blind Fold (Digital Political Documentary) Directed by Ines Sommer and Kathy Berger Somers ( 2012) Sommer Film Works seehttp://beneaththeblindfold.com/about-the-film/ 

 Person of Interest (2011-) TV Series. imdb.com/title/tt1839578/?ref_=ext_shr_tw_tt 

H.T. King, Jr., The Legacy of Nuremberg, Case Western Journal of International Law, Vol. 34. (Fall 2002) https://litigation-essentials.lexisnexis.com/webcd/app?action=DocumentDisplay&crawlid=1&doctype=cite&docid=34+Case+W.+Res.+J.+Int%27l+L.+335&srctype=smi&srcid=3B15&key=db0b2e01ff75ee68ea576eec125e7c37 accessed December 11, 2014.

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12/16/2014

Part II: THE IMITATION GAME meets HOW I CAME TO HATE MATH/ Comment J’ai Détesté Les Maths Moral Relativism vs Beneficence and Justice: Maths and Economics

HOW I CAME TO HATE MATH/ Comment J'ai Détesté Les Maths is a film Directed by Olivier Peyon and written along with Amandine Escoffier. It  is a documentary whose initial purpose seems hijacked by historical events. Its parallel to the fictional historical biopic thriller, THE IMITATION GAME, screened at the Mill Valley Film Festival 2014, need be made. 
 
The MATH story, like in THE IMITATION GAME, begins lightly with young people who are awkward. Some of them, like Alan Turing,  grow into the lovely eccentricity that those who both love and understand maths often bear. Peyton’s film tours the world of elite global mathematics prize winners and its retreats. The viewer has the feeling of watching young Einsteins. The film is initially a celebration of Maths. 

After showing the rarefied air which the theoretical mathematicians breathe, MATHS eases viewers into the world of technical applications of maths. Finally, the story leads to the economic crisis of our current millennium and the misleading mathematical modeling which wrought it. 

Mathematicians, on camera, own the horrific results of their science.  It is reminiscent of Einstein after the the theory of relativity was weaponized. A nausea is shared by many clinicians and other applied scientists as they wade through memory of disasters sometimes mediated by applied theory, particularly when ethical parameters were absent. 

 “Is there any definable method for deciding whether any given mathematical assertion is true or not?”  The procedure for seeking this answer required stating a hypothesis, like any other science.  "If it were true," Toulman paraphrased  Alan Turing,  ”Any method of 'routinizing' mathematical proof can be thought of as a mechanical process.” Then the question was one of 'simple' technology “What sort of a “machine” would be needed to carry out such a proof?”   This was how the computer was theorized and developed.  It happened that the resources to build the machine arrived in the form of WWII.  However, the drive, well before the War, was Turing's theory needing proof. It happens that  the military remains one of a few venues where mathematics gets funded. The use of science and medicine in war is a bioethical issue.

“What happened with mathematical modeling?”  the last third of HOW I CAME TO HATE MATHS asks.
When Scientific theory jumps to technology, there is always a risk that those who best know the Science will loose or relinquish control of it. It is the fundamental basis of Bioethics that Scientist and Applied Scientist should resist the temptation to abandon their work to those less knowledgeable of their fields. Bioethics is not only a field for medical doctors, clinical medical ethics is only a subset. 

HOW I CAME TO HATE MATH asserts, mathematicians recognized errors in economic mathematical modeling earlier than has been admitted by financiers. In the blame game, the common person's behavioral finance is often pointed out while financiers and maths models are ignored.  As in other situations of bioethical conflict, the first step is recognizing a conflict and then exploring it. Taking responsibility is  requisite for the minds knowing the field to explore the  conflict, as happens in the film HOW I CAME TO HATE MATH.

Not too far away from the applications of the Turing Machine, or mathematical economic models we have seen similar loss of control of the fields of medicine and public health. Misuse of the technology ( knowledge) related to quarantine, perhaps for political capital, during epidemic scares,  come to mind. The murder of polio vaccine workers by extremist when the vaccine program was used as a shield for covert military activity also is an example. 

The logic of immorality is always flawed and bears consequences. However, detailed moral analysis may also bear negative results. The difference is made,  as in all science and ethics,not only by intention of but attention to details.  The people watching have to be able to recognize what they see. Biological Science receiving federal funding requires those learning to use it  have some training in Bioethics that is, graduate students. Apparently,  maths departments have no ethical educational obligation imposed by financiers. Maths and computer science have major bioethical  context in this and the last century.   Recognizing mathematical modeling’s role in a  devastating economic collapse of the world’s economy does not  excuse the greed of financiers, it only recognizes the bioethical issue.  

Even when those who know the science do their best at moral consideration, monitoring of consequences is paramount, in war and in peace. Having spent the last half of his life on Peace, Einstein would agree.  Hats if to the filmmakers of HOW  I CAME TO HATE MATHS, and the mathematicians they interviewed,  for the jerky C- turn made in the last third of this film. Don’t be fooled by the cute beginning. HOW I CAME TO HATE MATHS chronicles a whiplash in history that threatens to break a century’s neck.

References: 

How I Came to Hate Math / Comment j'ai détesté les ma (35mm) Directed by Olivier Peyon.(2013) Documentary. France (103 min)

How I came to  Hate Math  trailer www.youtube.com/embed/QVKtLkNF_PA" accessed October 16, 2014

The National Association of Retirement Plan Participants http://www.narpp.org/

Enstein, A., Nathan, O., Heinz, N. Einstein on Peace. Simon. 1960 

Punjwani, S. K. (2014). Understanding Underpinnings of
Act of Violence against Polio Workers: A Case Study of Pakistan. In I. Needham,
M. Kingma, K. McKenna, O. Frank, C. Tuttas, S. Kingma, et al., Fourth
International Conference on Violence in Health Sector; Towards Safety, Security
and Wellbeing of all (pp. 80-83). Amesterdam: Kavanah, Dewingeloo & Oud
Consultancy.

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12/15/2014

GOING THE DISTANCE SCREENING FUNDRAISER

Dear Readers,   bioethicsscreenreflections has supported the development of the film GOING THE DISTANCE in an advisory capacity. It is a film about Traumatic Brain Injury recovery. I have the honor of co-hosting a fundraising screening&...

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12/15/2014

GOING THE DISTANCE meets SURFING FOR LIFE


Bioethical issues in Traumatic Brain Injury 

GOING THE DISTANCE: JOURNEYS OF RECOVERY is a documentary film about the lives of survivors of Traumatic Brain Injury. Directed by multi-Emmy Award winning filmmaker David L. Brown, the project is seeking funding for its finishing phase. This film has had multiple previews in collaboration with brain injury advocates.  It has also been used in therapeutic TBI groups to gauge the communities' take on their depiction. An earlier film by the same director, SURFING FOR LIFE, reinforces that Brown, like any good film auteur, finds different ways of telling stories whose elements are significant to him. 

SURFING FOR LIFE deals with optimizing life from childhood through aging. It explores our relationship with water or what evolutionary biologists J. W. Nichols calls the ‘Blue Mind.’  GOING THE DISTANCE also deals with maximizing people's potential, after the have acquired brain injury. Not surprisingly, some of the films protagonists also have a restorative relationship with water. 

David L. Brown’s films have a solid optimism to them. That’s right, GOING THE DISTANCE is an optimistic film about TBI. The project follows four people through a narrative spanning roughly eight years. The work has the weight of longevity, diversity and the drama of living on the edges between life, death and rebirth. With four main characters, instead of one, the film is racial, gender, and age cohort inclusive. Permutations and combinations leave every viewer identifying with some part of the story. 

Why is Traumatic Brain Injury of particular bioethical concern?  There are tensions between beneficence, autonomy and justice manifest in issues around the epidemic incidence of TBI. The principle of beneficence, doing good with our science, services medical indications.  We now have plenty of neuroscience to support how these injuries occur at the cellular level and the best ways to prevent and deal with the sequelae. Yet, there are organizational and geopolitical barriers to clinicians and survivors accessing, or utilizing that information. Justice is facilitated by equipoise. Equipoise is the equitable distribution of burdens and benefits. Organizational and geopolitical factors often impede equipoise in the prevention and management of TBI. 

Among the important new science is a better understanding of ‘neuroplasticity,’ Dr. Albert Ray considers neuroplasticity the operating system for the nervous system.  It is the mechanism whereby the physical anatomy and physiological workings of our nervous system happen, both in normal and pathological conditions. It is what makes the brain programmable and re-programmable. 

After a period of intense neurological rest, recruitment and retraining of undamaged brain tissue improves functional capacity.  That recruitment process results from neuroplasticity, or reshaping parts of the brain, to assume tasks abandoned in the aftermath of the traumatic injury. Neuroplasticity fuels the work of occupational, physical and speech therapist and those acting in their stead. When forced to prognosticate, professionals do so within the parameters of the resource stressed systems in which they work. For instance they might cautiously say," A person with this initial assessment, receiving therapy weekly, can expect 'X' amount of functionality in one a year." GOING THE DISTANCE is a story about best chances to exceed those expectations.

Other manifestations of conflicts between beneficence and justice affect veterans returning from war zones with undiagnosed TBI as well as Post Traumatic Stress Disorder, car accidents, repetitive concussions from sports, violent assaults and motor vehicle accidents.  All of these disproportionately affect the young, very old,  poor, and people of color.  Adequate activities of known therapeutic benefit and prevention are often unattainable because of cost and lack of trained resources. Though brilliant acute trauma and neurosurgical care occurs in most urban centers in the USA, the follow up care is lacking. TBI, is a health and healthcare disparity issue. 

Traumatic Brain Injury also results in bioethical tensions between beneficence and the principal of autonomy, or the right to do what is in one’s own enlightened self-interest.  Most agree parents are appropriate surrogate decision makers for their children. Substituted judgment in adults, particularly young adults, with brain injury is wrought with uncertainty regarding extent of damage to a person’s decisional capacity. In this way TBI, like dementia, is a moving target. Dementia and TBI are related in other ways as well.

There is compelling data that negative cognitive effects are among the most disabling of post-concussion symptoms following moderate and severe TBI. These effects unfold slowly, sometimes over years and lead to high incidences of dementia. Deficits occur in attention, memory and "executive function," These deficits show up as impulsiveness, mental fatigue, frustration, depression, pain, self-medication, substance abuse and loss of employment. Justice suggest,” those with the most burden should have the most benefit.” In the most developed nations, minds which operate “like steel traps,” are adored. TBI survivors rarely have those kinds of minds and are often not well accommodated by legislative measures, including the application of the American Disability Act. 

The film CRASH REEL gives a good example of autonomy conflicting with beneficence. An extraordinary athlete, champion snow boarder, struggles with his late stage cognitive and physical limits. The recently completed film, STATES OF GRACE (reviewed elsewhere on this blog) like CRASH REEL, is about another person with uncommon capacity facing extraordinary adversity. There is much to learn from these films but it is not the story of GTD. 
 
GOING THE DISTANCE is about ordinary people riding waves of adversity, while attempting the boring things of daily life. They use “what they’ve got."  What they have is family, friends and advocates.  By example, GTD gently makes the point that those without support have rougher rides and may drown in the surf. GOING THE DISTANCE is a documentary about quiet heroes focused not on what they cannot do in TBI recovery, but what they can.  
Viewing:
GONG THE DISTANCE (Digital) directed by David L. Brown ( 2014) pending release USA.  62 mins  http://www.goingthedistance.info
SURFING FOR LIFE  (Video) directed by David L. Brown (1999) USA  68 min.  http://www.surfingforlife.com/ 
THE CRASH REEL (2013) directed by Lucy Walker http://thecrashreel.com/  HBO Films  USA 108 mins
STATES OF GRACE ( 2014) directed by Helen Cohen and Mark Lipman (USA) distribution pending 71 mins.
Reading: 
Nichols, W. J. Blue Mind. Little, Brown and Company, 2014.
Ray, A. Neuroplasticity, Sensitization, and Pain. in Comprehensive Treatment of Chronic Pain by Medical, Interventional and Behavioral Approaches. ed. Deer, T.R.;Leong,M.S; Ray, A.L. et. al. ; American Acad- emy of Pain Medicine. Springer Inc. 2013.p 759-768,
Shively S1, Scher AI, Perl DP, Diaz-Arrastia R. Arch Neurol. Dementia resulting from traumatic brain injury: what is the pathology? 2012 Oct;69(10):1245-51http://www.ncbi.nlm.nih.gov/pubmed/22776913 accessed December 12, 2014
Carmichael, S. (2010). Translating the frontiers of brain repair to treatments: Starting not to break the rules. Neurobiology of Disease, 37(2), pp. 1-10.



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12/15/2014

Tracey v. Cambridge University Hospital – Duty to Consult

The December 2014 issue of Clinical Medicine (Royal College of Physicians) includes a nice summary of the impact and implications of the UK Court of Appeal's judgment in Tracey v. Cambridge University Hospital.  Under prior UK cases like Aintree a...

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12/15/2014

Is Homo Economicus a Psychopath?

In what academics call neoclassical economics, human beings are largely rational, self-interested decision-makers. This stereotypical human, often referred to as Homo economicus, is a creature of coldly calculated selfishness, dispassionately maximizing its best interests even if that comes at the … Continue reading

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12/15/2014

Ontario Medical Board Seeks Input on Draft End-of-Life Policy

The College of Physicians and Surgeons of Ontario has just posted ’s a revised draft policy for external consultation: "Planning for and Providing Quality End-of-Life Care."  

The draft policy sets out professional expectations of physicians and provides guidance on a range of issues relating to quality end-of-life care, including futility and aid in dying.

The CPSO is inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the draft policy. Comments received by February 2015 will assist in developing a final policy which will be considered for final approval by Council.  Several good comments already appear on the online discussion board.

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12/14/2014

Patients Abandoned—Who is to blame?

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">The vast majority of developed nations in the world provide universal healthcare coverage for its citizens. The only developed nations that do not are “…<a href="http://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/">a few still-troubled Balkan states, the Soviet-style autocracy of Belarus, and the U.S. of A., the richest nation in the world</a>.” </span></p> <p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Yet the United States (US) has the most expensive healthcare system in the world, by far—there really isn’t a close second—spending just under 18% of GPD and around $8,500.00 per person on healthcare. One might assume that given that type of expense, we would be getting a lot more than other countries in return for our investment. According to the research provided by <a href="http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror">Mirror, Mirror</a>, from the Commonwealth Fund, the US sadly underperforms and often fails relative to other developed countries on major measures of performance. </span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>

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12/14/2014

Mass General – Futility Policy Experience

Andrew Courtwright and colleagues at the Massachusetts General Hospital have published "Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial" in the Journal of Critical Care. This w...

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