Brennan offers an interesting strategy in "A libertarian case for
mandatory vaccination," though in form it is the common "devil's
advocate." The apparently least charitable bases for one's own position
(in this case libertarian premises) are granted for the sake of argument;
one's position is nevertheless found defensible (mandatory vaccination);
and thus the harshest critics are answered without having to pay out a
fu...
Brennan offers an interesting strategy in "A libertarian case for
mandatory vaccination," though in form it is the common "devil's
advocate." The apparently least charitable bases for one's own position
(in this case libertarian premises) are granted for the sake of argument;
one's position is nevertheless found defensible (mandatory vaccination);
and thus the harshest critics are answered without having to pay out a
full rebuttal. One need not endorse or condone the "devil" for this to
work; it is not sophistry to pick your battles - if libertarianism is
right, mandate vaccines; if it is wrong, mandate vaccines by a probably
more obvious argument than if it is right. No commitment necessary.
It should be noted, though, that Brennan's intended "devil" is
clearly a pro-vaccine libertarian. The anti-vaxxer audience is lost by
assumptions (A)-(D) that take for granted the efficacy, safety, and
obviousness of vaccines, plus a quip about Jenny McCarthy.
The damage here is not in directly insulting a particular reader (I
would be suprised if many anti-vaxxers read the JME), but in what such
disregard entails. For instance, the author briefly mentions that
libertarians can tolerate government advertisement campaigns, but he does
not feature this as a serious criticism, presumably because the anti-
vaxxer is not only irrational, but unreachable. While it is true that any
attempt to persuade a dogmatic believer can backfire and cause further
polarization instead, this danger applies also when outreach is forsaken
in favor of compulsion. It could be replied that, in the time it takes for
outreach to work, we will fail to stop harm to others, but in the time it
takes to debate each other about a mandate (and eventually to pass it),
there will also be infected. Force is seen as efficacious only after
diplomacy has been discarded.
By disregarding the anti-vaxxer as an agent with potentially
revisable beliefs, this article becomes about what "we" are to do about
"them." "We" are very diverse (so some devil's advocacy is required), but
"they" are demonized with words like "irrational," "stupid," and "self-
destructive." "They" aren't invited to this article, where the "them-
problem" is discussed and resolved (by government policy, no less).
Liberals and libertarians should be the first to get chills, at which
point Brennan also loses the very audience he attempts to court, who are
particularly wary of government-enforced marginalization.
So here is a "demon's advocate" portrait of an anti-vaxxer, based on
close friends of mine who have not vaccinated their children (though I do
not claim how far the portrait can be generalized): They are people. They
are firm in belief, and when I finish talking to them, I do have feelings
of frustration that one might express through name-calling (I have done so
privately). However, they are not those names; they are concerned mothers
and fathers who share many premises in common with me and probably with
you - for instance, a high regard for the welfare of their children. Their
premises diverge from mine on which sources of health information are most
trustworthy, as we have both a different religious and educational
upbringing, and they have felt (not unjustifiably) estranged from the
mixture of impersonal, corporate, and politicized healthcare that differs
strikingly from their intuitions on what "health" or "care" mean. They
prefer personal relationships with small-town doctors who spend time
taking their histories, and who typically engage in preventive, holistic,
minimally pharmaceutical, and minimally invasive forms of care (primum
nocere). Adverse events and side-effects are judged more heavily than
potential gains in health or improvements in one's natural history, so
most drug labels are off-putting and some minor maladies shrugged at;
preferences sometimes align with what evidence-based medicine would
prescribe and sometimes not. Drug and supplement companies who advertise
as being all-natural, small-scale (non-PHARMA) businesses have taken the
time to understand, magnify, and exploit some of these preferences to
share information "that the FDA doesn't want you to know," along with
conspiracy theories about FDA, Pharma, and government agendas (only
marginally more far-fetched when compared to confirmed events like the
Tuskegee or US Radiation studies, which, to use Brennan's phrase, "a
minimal amount of research" can easily uncover for any American worried
enough to look for it).
If we are both clever and patient enough to derive government
mandates from libertarianism, is our rhetorical distance from this
portrait so much greater? Couldn't some of their own premises favoring
preventive care and corporate transparency be used to expose the
misinformation?
*The opinions expressed in this letter are personal and do not
necessarily represent the views of my institution
Dogs have been deliberately bred to be reliant on humans for company as well as to take advantage of their unique skills and intelligence, used in various ways as working dogs , such as sheep herders ,where empathy, attachment and love are blatantly obvious. They are entitled to be cared for , not to be exploited as a substitute for the human guinea pigs of the past. Using dogs which have been discarded by their owners is doubly abhorrent as regarding their lives as even more worthless. It is reminiscent of the recent past again where disabled and ill and people regarded as inferior were used for experimentation. Referring to the dogs, even in quotes, as 'volunteers' is simply disingenuous. Volunteering includes an act of willingness and agreement to procedures,
There is no question of consent of course but ethical issues are inherent in using brain scanning of other groups of often vulnerable people. They have some ethical protection but the urge to 'progress' has often fudged this. Neuropsychiatry is involved in experimentation using scans to diagnose areas of the brain which are claimed to be involved in mental health problems including the highly stigmatising and to some extent catch all label of Personality Disorder. Using scans as a tool for providing treatment designed to change a person's brain ,including psychotherapy ,raises serious ethical questions. How would people give informed consent to having scan...
Dogs have been deliberately bred to be reliant on humans for company as well as to take advantage of their unique skills and intelligence, used in various ways as working dogs , such as sheep herders ,where empathy, attachment and love are blatantly obvious. They are entitled to be cared for , not to be exploited as a substitute for the human guinea pigs of the past. Using dogs which have been discarded by their owners is doubly abhorrent as regarding their lives as even more worthless. It is reminiscent of the recent past again where disabled and ill and people regarded as inferior were used for experimentation. Referring to the dogs, even in quotes, as 'volunteers' is simply disingenuous. Volunteering includes an act of willingness and agreement to procedures,
There is no question of consent of course but ethical issues are inherent in using brain scanning of other groups of often vulnerable people. They have some ethical protection but the urge to 'progress' has often fudged this. Neuropsychiatry is involved in experimentation using scans to diagnose areas of the brain which are claimed to be involved in mental health problems including the highly stigmatising and to some extent catch all label of Personality Disorder. Using scans as a tool for providing treatment designed to change a person's brain ,including psychotherapy ,raises serious ethical questions. How would people give informed consent to having scans taken throughout treatment in order to monitor any change? How would the diagnosis be described initially? With new neuropsychiatric labels? Would 'success' be reliant on a changed brain image? How much would having these scans affect the relationship with a practitioner? How even would they be trained, chosen and allowed to practice in this way? How would the treatment be described in medical notes - which can have serious implications for employment and insurance applications.?
The authors say they have used dogs in experiments themselves but these being relatively benign can be seen as harmless. There is a fudge here even by those who have a genuine concern for the lives of dogs . Severe criticism is directed at those who cross a line into more obvious harmful experimentation but just a little bit of seemingly understood as benign exploitation/experimentation by themselves is acceptable. If only dogs could tell us what they think of us.
In their intriguing 'Plutocratic Proposal' (J Med Ethics 2017), Masters and Nutt note that the 'Matching Agencies' acting as intermediaries between benefactors and the beneficiaries would need to do systematic reviews of all known existing research and commit to publishing full research results, both for their own reputations and for legal protection . Masters and Nutt point out out that these are definitely ethical matters, and that failure to do one or both has had fatal consequences for patients and research participants.
How can it be that Emanuel, Wendler and Grady did not even mention these two vital points concerning publication in their original list of seven ethical requirements? (JAMA 2000:283:701-7011).
Abstract:
The area of consciousness is an ever-evolving discussion particularly in relation to approaches to assessment of awareness. The paper by Wade (2016) further advances the discussion on this complex topic. The purpose of this response aims to put forward alternative views regarding points raised by Professor Wade in his paper “Back to the bedside? Making clinical decision in patients with prolonged unconsciousness” (J. Med. Ethics 2016; 0:1-7).
(67 words)
Overview:
In this response, a number of key issues raised by Professor Wade will be explored. These include assessment modalities, the debate relating to consciousness as a spectrum, and the emphasis- or lack thereof, on the value of rigours clinical assessment in diagnosing awareness.
Assessment Modalities
In his article, Professor Wade alluded to the lack of evidence to support visual tracking as an indicator for the presence of awareness. Despite gaps in the evidence to support the relevance of tracking in making a diagnosis, it continues to be a common bedside screening tool used by both physicians and other clinicians, and has been endorsed by the working party of the Royal College of Physicians (RCP); of which Professor Wade was the co-chair, as an important clinical indicator of awareness (RCP 2013, pg.7 box 1.1). Professor Wade identified the numerous reasons why tracking may be challenging for a person with severe brain injury including oculomotor impairments, visual...
Abstract:
The area of consciousness is an ever-evolving discussion particularly in relation to approaches to assessment of awareness. The paper by Wade (2016) further advances the discussion on this complex topic. The purpose of this response aims to put forward alternative views regarding points raised by Professor Wade in his paper “Back to the bedside? Making clinical decision in patients with prolonged unconsciousness” (J. Med. Ethics 2016; 0:1-7).
(67 words)
Overview:
In this response, a number of key issues raised by Professor Wade will be explored. These include assessment modalities, the debate relating to consciousness as a spectrum, and the emphasis- or lack thereof, on the value of rigours clinical assessment in diagnosing awareness.
Assessment Modalities
In his article, Professor Wade alluded to the lack of evidence to support visual tracking as an indicator for the presence of awareness. Despite gaps in the evidence to support the relevance of tracking in making a diagnosis, it continues to be a common bedside screening tool used by both physicians and other clinicians, and has been endorsed by the working party of the Royal College of Physicians (RCP); of which Professor Wade was the co-chair, as an important clinical indicator of awareness (RCP 2013, pg.7 box 1.1). Professor Wade identified the numerous reasons why tracking may be challenging for a person with severe brain injury including oculomotor impairments, visual field deficits and neglect and this is consistent with the challenges seen clinically. This is a further reason why one might argue that assessments based on ‘uni-modal’ sensory stimulation such as the use of visual tracking in isolation is not an approach of choice. Rather, a multi-modal approach to sensory stimulation would offer a more robust method to assessment whereby patients are given an opportunity to respond to a range of stimuli therefore reducing the emphasis on a single skill.
Professor Wade argues that human judgement plays an important role in the interpretation of behaviours leading to the diagnosis of awareness. This is a valid point, and can be seen as a limitation in the behavioural approach to assessment, using tools such as the Coma Recovery Scale-Revised (CRS-R) (Giaciano et al., 2004), Sensory Modality Assessment Rehabilitation Technique (SMART) and Wessex Head Injury Matrix (WHIM) (Sheil et al., 2000). This reinforces the importance of formal training in the use of these tools as well as the value of mentorship for clinicians who are developing their skills in working with this complex patient cohort. The RCP National Clinical Guidelines advocate this approach to training for assessors (see RCP 2013, Annex 2b). Very few of the authors of the various tools stipulate the need for accreditation in their use. This is an inherent limitation as there are no guarantees that the tool will be utilised in a valid and reliable manner. There is only one available tool to the best of our knowledge that requires both training, accreditation and re-accreditation in its use. This is the Sensory Modality Assessment and Rehabilitation Technique (Gill- Thwaites 1997; Gil-Thwaites and Munday 2004; Gill-Thwaites, Elliott and Munday 2017). Whilst Seel et al., (2010) view these processes as costly, time consuming and challenging to access for geographical reasons it may be argued that such efforts ensure the clinicians who use the tool have the skills to make an accurate diagnosis of awareness.
The recommendation to use other modalities is welcomed but not always possible. The use of functional MRI (fMRI) remains largely accessible for research purposes. Moreover, the generalisation of positive findings into practical ways of interacting in a meaningful manner with one’s environment continues to present as the greatest challenge.
Consciousness as a spectrum
The author’s position as to whether consciousness should be viewed as a spectrum varies throughout the article and he appears at times, contradictory in his position.
Firstly, he proposes that there is no such thing as a clear and definitive diagnosis of any given state of awareness or unawareness. Professor Wade provides the reader with the suggestion that consciousness should be seen as a spectrum and argues that it is impossible to say with any certainty that “someone is and will remain totally unaware at all times” (pg. 5). Secondly, he suggests that the damage can be so profound such that a person can be rendered totally unaware so the idea of them remaining on a spectrum comes into question as he states “some people are severely damaged that they can be considered as being permanently totally unaware” pg.1.
This confusion is introduced from the beginning of the article starting with the title whereby he refers to prolonged unconsciousness rather than prolonged disorders of consciousness which is more typically used in clinical practice. This raises the question as to whether the word unconsciousness is less hopeful and more enduring therefore reflecting on his position that individuals can be “permanently totally unaware” negating a view that consciousness may exist but along a spectrum.
In general, his views are perplexing regarding awareness existing upon a spectrum. This may serve to confuse clinicians and family members of those in pDOC who are looking for clarity on the individuals’ awareness to assist them in their understanding of the person’s condition and to assist in the decision-making relating to the individual’s care. Regardless as to whether the states exist along a spectrum, empirical evidence and best practice guidelines advocate for a longitudinal approach to assessment, a value in detailed assessment over time, along with review of the patients awareness at intervals over their lifetime so as to identify any changes that may support greater functional or communicative engagement (RCP 2013; Yelden et al., 2017). Some assessment and rehabilitative tools such as SMART have evolved over time to acknowledge the likelihood of a ‘spectrum’ of unawareness-awareness with revisions designed to ensure that this is reflected and captures in the prolife of the patient within each modality and with staged re-assessment (Gill-Thwaites, Elliott and Munday 2017).
Summary
Professor Wade’s article provides a rich contribution to the discussion regarding assessment of consciousness and raises important points in relation to making clinical decisions for those with a PDOC. However, the importance of comprehensive assessment of awareness continues to be an integral part in directing the care and clinical management of patients and families affected by prolonged disorders of consciousness.
(973 words)
References
Giaciano J.T., Kalmer K., Whyte J. (2004) The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil 2004; 85:2020-9.
Gill Thwaites H. (1997) The Sensory Modality Assessment and Rehabilitation Technique (SMART): a tool for assessment and treatment of patients with severe brain injury in a vegetative state. Brain Injury. 1997, Oct; 11:723-34.
Gill-Thwaites H., Elliott K.E., Munday R. (2017) SMART- Recognising the value of existing practice and introducing recent developments: leaving no stone unturned in the assessment and treatment of the PDOC patient. Neuropsychological Rehabilitation. DOI: http://dx.doi.org/10.1080/0960002011.2017.1310113.
Gill-Thwaites H and Munday R. (2004) The Sensory Modality Assessment and Rehabilitaiton Technique (SMART): A valid and reliable assessment for vegetative and minimally conscious state patients. Brain Injury. 2004; 1:1255-69.
Royal College of Physicians (2016) Prolonged Disorders of Consciousness: National Clinical Guideline. Available at: https://www.rcplondon.ac.uk/guidelines-policy/prolonged-disorders-consci... (Accessed: 11 July 2017).
Seel, R.T., Sherer, M., Whyte, J., Katz, D. Giacino, J.T., Rosenbaum, A.M., Hammond, F.M., Kalmar, K., Pape, T., Zafonte, D.O., Biester, R.C., Kaelin, D., Kean, J. and Zasler, N. (2010). Assessment Scales for disorders of Consciousness: Evidence-Based Recommendations for Clinical Practice and Research. Archives of Physical Medicine and Rehabilitation 91, pp. 1795-1813
Sheil A., Horn S.A., Wilson B.A., et al. (2000) The Wessex Head Injury Matrix (WHIM) main scale: A preliminary report on a scale to assess and monitor patient recovery after severe head injury. Clin Rehabil. 1 April 2000; 14:408-16.
Wade D. (2016) Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness. J. Med. Ethics. Published online first: August 8th 2016; 0: 1-7. DOI: 10.1136/medethics-2015-103140.
Yelden K., Dupport S., James LM., Kempny A., Farmer S.F., Leff A.P., Playford E.D (2017) Late recovery of awareness in prolonged disorders of consciousness – A cross sectional cohort study. Disability and Rehabilitation. 2017 June 21, 1-6.
This is a thought provoking paper but I wonder if it is founded on a false premise. It strikes me that a conscientious objection only applies if the surgeon has an obligation to undertake a cosmetic surgery procedure. If there is no obligation they are simply declining to carry out the procedure. Presumably this may be because the surgeon decides the procedure is not in the best interests of the patient. Since the surgeon is primarily an expert in physical, bodily function they should base their judgement of best interest on those grounds. Of course, if this reasoning is sound, fewer cosmetic procedures should perhaps be performed than currently are.
Kitzinger et al argued in favor of applying “the ‘holistic’ approach outlined in the Briggs judgment” to ascertain, in Court and ‘on the floor’, what in accordance with the Mental Capacity Act 2005 (MCA) ought to be considered a patient’s best-interest assessment.[1] In Briggs versus Briggs [2016] EWCOP 53 , “all parties were required to address the question of [Paul Briggs’s] ‘best interests rather than seeking to apply the standard of ‘substituted judgment’.”[2] Authors correctly pointed out that the MCA mandates, next to consideration of a person’s past and present wishes and feelings, values and beliefs, the inclusion of other relevant circumstances, i.e., diagnosis, prognosis and ‘sanctity of life’. Kitzinger et al postulated that this holistic approach to the best interest standard not only should be the preferred pathway over that of the ‘substituted judgment’ standard, but, if widely accepted, would make a positive contribution to “the texture and quality of best-interest decision making about these patients [with disorders of consciousness] ‘on the ground’”.[1] They further highlighted the significance of the Briggs judgment because of “the great weight [Mr Justice] Charles J gave the person’s own views, even when set against ‘sanctity of life’.”
There are theoretical and practical problems with Kitzinger et al’s position.
First, it is incorrect to describe the Briggs case as the clash of ‘sanctity of life’ and ‘self-determinat...
Kitzinger et al argued in favor of applying “the ‘holistic’ approach outlined in the Briggs judgment” to ascertain, in Court and ‘on the floor’, what in accordance with the Mental Capacity Act 2005 (MCA) ought to be considered a patient’s best-interest assessment.[1] In Briggs versus Briggs [2016] EWCOP 53 , “all parties were required to address the question of [Paul Briggs’s] ‘best interests rather than seeking to apply the standard of ‘substituted judgment’.”[2] Authors correctly pointed out that the MCA mandates, next to consideration of a person’s past and present wishes and feelings, values and beliefs, the inclusion of other relevant circumstances, i.e., diagnosis, prognosis and ‘sanctity of life’. Kitzinger et al postulated that this holistic approach to the best interest standard not only should be the preferred pathway over that of the ‘substituted judgment’ standard, but, if widely accepted, would make a positive contribution to “the texture and quality of best-interest decision making about these patients [with disorders of consciousness] ‘on the ground’”.[1] They further highlighted the significance of the Briggs judgment because of “the great weight [Mr Justice] Charles J gave the person’s own views, even when set against ‘sanctity of life’.”
There are theoretical and practical problems with Kitzinger et al’s position.
First, it is incorrect to describe the Briggs case as the clash of ‘sanctity of life’ and ‘self-determination’. In this case, there was no self-determination because there was no advance directive that clearly expressed the patient’s preference that, if affected by a disorder of consciousness, assisted nutrition and hydration (ANH) is to be discontinued. It was a third-party determination on behalf of Paul Briggs of the acceptability of future quality of life and judgment what was to be in his best interests. Therefore, Briggs versus Briggs [2016] EWCOP 53 should be referred to as the clash of ‘sanctity of life’ and ‘third-party determination’ of best interests on behalf of a disabled, incapacitated person. Kitzinger et al incorrectly labeled this as a logical extension of self-determination or autonomy. [1] They validated their claim of superiority of the holistic approach to a best-interest assessment over ‘sanctity of life’ by quoting a single article from 1973 calling the concept of ‘sanctity of life’ “impossibly vague and misleading’.” [3] However, the concept of ‘best interests’ is no less vague than the concept of ‘sanctity of life’ in determining and justifying treatment withdrawal. A best-interest assessment of the acceptability of future quality of life on behalf of a disabled incapacitated person is necessarily subjective. Even with today’s dominance of principlism in medical ethics, none of the four principles in this theory (autonomy, beneficence, non-maleficence, and justice) are clear, unambiguous, and uncontested. For instance, the notion of autonomy, which constitutes the foundation underlying the moral and legal notion of the best-interest standard, has evolved over time and continues to do so with significant moral, legal, and social implications.[4] Philosophical issues on the remaining three principles continue to be discussed. The question is not if treatment can be withdrawn but under which circumstances it is justified. In first-person decision-making, individuals have the right to refuse treatment either through in-person communication or, if unable to express their opinion, through clear expression of preferences of that particular treatment in advance directives. Considering the weight of such decision in life-sustaining treatment, it appears that the judgment in W v M & Ors (2011) EWHC 2443 (Fam) requiring clear and convincing evidence that the person had specifically directed not to have ANH administered in case of the presence of a disorder of consciousness is indeed more consistent with the medical principle of first do-no-harm. In absence of an unambiguous, substantive conception of what constitutes ‘the best-interest’ of human beings, mandating clear and convincing evidence of a person’s wishes in matters of life and death reflects without a doubt commitment to both the principle of sanctity of life and that of respect for persons. As it stands, adherence to the ‘sanctity of life’ standard and practicing medicine in accordance with the Hippocratic Oath both uphold the moral obligation of practitioners to avoid inflicting harm on patients.
Second, as the concept of ‘best interests’ in MCA is grounded in a third-party rather a first-person real time determination of acceptability of future quality of life, its interpretation legitimizes also nonconsensual treatment withdrawal in persons with severe disabilities. Many survivors of serious illnesses adapt to their new reality, cope with severe disabilities, and are satisfied with their quality of life even if greatly diminished from the past. [5-8] This means that reliance on previously held opinions can misrepresent real-time or future preferences of individuals with serious disabilities. As has been argued elsewhere, treatment withdrawal decisions based on third-party determination of best interests can result in fatal errors.[9] Although Kitzinger et al endorsed the introduction of a holistic approach to the third-party determination of best interests, they failed to provide a convincing rationale demonstrating that it (1) provides a more reliable (and therefore a superior) instrument for making substitute end-of-life decisions, and (2) results in decisions that are more closely in sync with the principle of respect for autonomy. The basic tenet of “do-no-harm” in medicine appears to provide more practical guidance towards decision-making under these conditions.
Third, some commentators have asserted that the ‘sanctity of life’ value in medicine, commonly associated with commitment to religious values, should not be allowed to stonewall secular determination of best interests.[10] It is clear to many that withdrawing of ANH is the proximate cause of a pre-planned death and, thus, a form of physician-assisted death. In other cases, where a patient is dependent on both mechanical ventilation and ANH (e.g., The Supreme Court In the matter of Charlie Gard https://www.supremecourt.uk/news/latest-judgment-in-the-matter-of-charli... ) withdrawing these life-sustaining interventions will lead, for the same reasons, lead to an act of physician-assisted death. In reality, the observed clash is the consequence of secular intolerance and exclusion of equally respected religious values in a pluralistic society.
From a practical perspective, without additional legislative revisions in the MCA to protect religious values, the best-interest standard and a holistic approach to assessing these interests has now been transformed into a widening of a backdoor approach to justifying nonconsensual euthanasia of vulnerable individuals. The best-interests standard with an expanded domain of potential surrogate decision makers increases the potential for legitimizing a “kill switch” in the MCA.[11] Finally, patients’ religious beliefs and values should be taken into account to ensure that surrogate decisions made reflect commitment to the respect for autonomy.
1. Kitzinger J, Kitzinger C, Cowley J. When ‘Sanctity of Life’ and ‘Self-Determination’ clash: Briggs versus Briggs [2016] EWCOP 53 – implications for policy and practice. J Med Ethics.2017; 43(7):446-449.
3. Clouser K. "the sanctity of life": An analysis of a concept. Ann Intern Med.1973; 78(1):119-125.
4. Saad TC. The history of autonomy in medicine from antiquity to principlism. Med Health Care Philos.2017; First Online:10 June 2017. DOI: 10.1007/s11019-017-9781-2.
5. Antonak RF, Livneh H. Psychosocial adaptation to disability and its investigation among persons with multiple sclerosis. Soc. Sci. Med.1995; 40(8):1099-1108.
6. Lulé D, Zickler C, Häcker S, Bruno MA, Demertzi A, Pellas F, et al. Life can be worth living in locked-in syndrome. Prog. Brain Res.2009; 177:339-351.
7. Demertzi A, Jox RJ, Racine E, Laureys S. A European survey on attitudes towards pain and end-of-life issues in locked-in syndrome. Brain Inj.2014; 28(9):1209-1215.
8. Buono VL, Corallo F, Bramanti P, Marino S. Coping strategies and health-related quality of life after stroke. Journal of Health Psychology.2017; 22(1):16-28.
9. Napier S. Perception of Value and the Minimally Conscious State. HEC Forum.2015; 27(3):265-286.
10. Brierley J, Linthicum J, Petros A. Should religious beliefs be allowed to stonewall a secular approach to withdrawing and withholding treatment in children? J Med Ethics.2013; 39(9):573-577.
Rivera Lopez in his astounding article [1] proposes the duty to kill and is happy not to consider the counter arguments, but just follow his line of thought!!
He is among those prepared to cross the line of taking a life or at least consider such acts in theory. His view demonstrates a very restricted outlook on life, seeing nothing beyond the concrete. It seems a bit drastic or simplistic to get rid of problems by getting rid of the people who have them. If treatment or life itself is burdensome, it can be lightened in many more caring ways. As a GP, I see what a dying person can give to others and the intangible benefits of suffering; in bringing of the family together, acknowledging the heartbreak and drawing out good in others by accompanying and self-giving. I have also seen destruction of the joy in a family by suicide and the feeling of failure among those left behind. Human dignity is found in being supported and loved, not being killed.
Another consideration is that we do not know how those who cross the line will bear up psychologically after many years of this justified killing. Doctors in Ontario, where euthanasia has been permitted by law last year, are backing out as they find that they “go through one experience and it’s just overwhelming, it’s too difficult, and those are the ones who say, ‘take my name off the list. I can’t do any more.’ ” [2] Are we prepared to risk making killing part of the medical practice and wait to see the damage?
Rivera Lopez in his astounding article [1] proposes the duty to kill and is happy not to consider the counter arguments, but just follow his line of thought!!
He is among those prepared to cross the line of taking a life or at least consider such acts in theory. His view demonstrates a very restricted outlook on life, seeing nothing beyond the concrete. It seems a bit drastic or simplistic to get rid of problems by getting rid of the people who have them. If treatment or life itself is burdensome, it can be lightened in many more caring ways. As a GP, I see what a dying person can give to others and the intangible benefits of suffering; in bringing of the family together, acknowledging the heartbreak and drawing out good in others by accompanying and self-giving. I have also seen destruction of the joy in a family by suicide and the feeling of failure among those left behind. Human dignity is found in being supported and loved, not being killed.
Another consideration is that we do not know how those who cross the line will bear up psychologically after many years of this justified killing. Doctors in Ontario, where euthanasia has been permitted by law last year, are backing out as they find that they “go through one experience and it’s just overwhelming, it’s too difficult, and those are the ones who say, ‘take my name off the list. I can’t do any more.’ ” [2] Are we prepared to risk making killing part of the medical practice and wait to see the damage?
Dear Sir,
I thank Dr Holland for his commentary [1] on my article [2]. I am replying to correct a possible misunderstanding he may have about the brain in people with prolonged disorders of consciousness.
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statemen...
Dear Sir,
I thank Dr Holland for his commentary [1] on my article [2]. I am replying to correct a possible misunderstanding he may have about the brain in people with prolonged disorders of consciousness.
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statement on two sentences in the original legal judgement in the Bland case. [3] They say "It is sufficient to say that it arises from the destruction, through prolonged deprivation of oxygen, of the cerebral cortex, which has resolved into a watery mass." and "There are techniques available which make it possible to ascertain the state of the cerebral cortex, and in Anthony Bland's case these indicate that, as mentioned above, it has degenerated into a mass of watery fluid."
Dr Holland has, naturally, interpret these legal statements to mean that there is no residual brain. He therefore argues both that there can be no awareness and that there can be no expectation of any recovery. If his understanding were correct, then his argument would be valid.
In reality people in a prolonged state of unconsciousness including people in the vegetative state still have some structurally intact brain albeit with considerable atrophy, [4] and this brain still shows electrophysiological activity [5] and changes in blood flow associated with stimuli. [6]
I suspect that in 1994 the experts made statements such as "the damaged brain has been replaced by cerebro-spinal fluid, which is mostly water". This simply explains that, within the fixed volume of skull, the space once occupied by the brain that has now atrophied is occupied by water; the statement does not say that there is complete absence of brain. However it has been interpreted to mean that all brain has been replaced by or transformed into 'a watery fluid'. In other words it was not made clear that there was still some structurally intact (albeit abnormally structured) brain present. This would have been known at the time. [7]
This may explain why some people believe it should be easy to determine consciousness. The difficulties in establishing consciousness on the basis of single signs has been shown in another recent publication. [8]
References.
1. Holland S. Commentary on Derick Wade's 'Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness' and Zoe Fritz' 'Can best interests' derail the trolley?' Examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state.Journal of Medical Ethics. 2016;0:1-2 doi:10.1136/medethics-2016-103739
2. Wade DT. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness.
Journal of Medical Ethics. 2016;0:1-7 doi:10.1136/ medethics-2015-103140
3. Airedale NHS Trust v Bland (1993) http://www.bailii.org/uk/cases/UKHL/1993/17.html
4. Guldenmund P, Soddu A, Baquero K, Vanhaudenhuyse A, Bruno MA, Gosseries O, Laureys S, Gomez F. Structural brain injury in patients with disorders of consciousness: A voxel-based morphometry study. Brain Injury 2016;30:343-352
5. Sitt JD, King JR, El Karoui I, Rohaut B, Faugeras F, Gramfort A, Cohen L, Sigman M, Dehaene S, Naccache L
Large scale screening of neural signatures of consciousness in patients in a vegetative or minimally conscious state. Brain 2014;137:2258-2270
6. Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJF, Bruno MA, Boveroux P, Schnakers C, Soddu A, Perlbarg V, Ledoux D, Brichant JF, Moonen G, Manquet P, Greicius MD, Laureys S, Boly M. Default network connectivity reflects the level of consciousness in non-communicative brain- damaged patients.Brain 2010;133:161-171
7. McLellan DR, Adams JH, Graham DI, et al. In: Papo I, Cohadon F, Massaroti M, eds. Le coma traumatique. Padova: Liviana Editrice, 1986:165-85.
8. Fischer DB, Truog RD. What is a reflex? A guide for understanding disorders of consciousness. Neurology 2015;85:543-548
At the frontlines, in the emergency department, clinicians face
multiple challenges. Each patient sees his situation as unique and
quite frightening, although to the clinician, it is commonplace.
Therefore, it is paramount for healthcare providers to empathize with each
individual. Another challenge for clinicians is having self-insight and
viewing each patient in an unbiased manner in order to share meaningful...
At the frontlines, in the emergency department, clinicians face
multiple challenges. Each patient sees his situation as unique and
quite frightening, although to the clinician, it is commonplace.
Therefore, it is paramount for healthcare providers to empathize with each
individual. Another challenge for clinicians is having self-insight and
viewing each patient in an unbiased manner in order to share meaningful
dialogues. Recent publications have focused on these issues 1-5.
Browning, in his recent paper, Sturdy for common things: cultivating
moral sensemaking on the front lines of practice, J Med Ethics.2012;38:233
-235, highlights the importance of clinicians knowing themselves to be
effective. The author also emphasizes that clinicians need to look at each
patient in a new light and realize that this patient and family are
attempting to make sense of their dilemma which from their perspective is
unique. Browning also focuses on the importance of clinicians
comprehending the position of their patients and family members since
clinicians will be called upon to discuss life choices. This requires a
patient-centered approach with sharing of decision making 1.
Chetitih, in, Turning the Lens Inward: Cultural Competence and
Providers' Values in Health Care Decision Making, Gerontologist. 2012.
doi: 10.1093/geront/gns008v also discusses the importance of clinicians
understanding themselves to effectively deal with patients and their
families. As the older population increases in size, in addition, health
care providers will be challenged in dealing with end-of-life care options
for many patients. This will require introspection with awareness of
personal beliefs and prejudices. It will require health care providers to
analyze and understand their own fears and perspectives so that they may
deal capably and honestly with patients and their families. This type of
introspection, the author feels, will allow clinicians to honor their
patient's worldview and be non-judgmental 2.
In addition, effective clinicians require excellent communication
skills. Their conversations with patients and family members lead to
shared decisions regarding complex moral choices. This helps the family
cope with the crisis they are facing 1-5. Effective communication also
ensures that surrogates are accurately informed and able to make
knowledgable decisions. Clinicians with the ability to openly discuss
with families a plan for end-of-life care assist the family in facing
unexpected poor prognoses. Family conferences with shared decision making
also increase the chances for best decisions 1-5.
Ideally, physicians should appreciate the story of each patient and
respect the ill patient's sense of loss of control. This challenge
requires empathy and a patient-centered approach that is humanistic and
compassionate. Healthcare providers that allow older patients who may be
facing long, difficult and serious illness a voice in their care are
appreciating the frightening situation of their patient 1,4,5.
Browning importantly underscores that patients and their family
members see their stressful situation as unique. They also depend on
clinicians, after thoughtful discussion, to help them cope with difficult
decisions and fears 1.
The goals outlined by Browning should be kept in mind by caregivers
on the frontlines to improve patient care and increase clinician
effectiveness.
References
1.Browning DM. Sturdy for common things: cultivating moral sensemaking on
the front lines of practice. J Med Ethics.2012;38:233-235.
2. Chettih M. Turning the Lens Inward: Cultural Competence and
Providers' Values in Health Care Decision Making. Gerontologist. 2012. doi: 10.1093/geront/gns008v.
3.Fisher M, Ridley S. Uncertainty in end-of-life care and shared decision
making. Crit Care Resus. 2012;14:87.
4. Curtis JR, Patrick DL, Shannon SE, Treece PD, et al. The family
conference as a focus to improve communication about end-of-life care in
the intensive care unit: opportunities for improvement. Crit Care
Med.2001;29(2 Suppl):N26-33.
5. Shapiro J. Illness narratives: reliability, authenticity and the
empathetic witness. Med Humanities.2011;37:68-72.
Colaianni cautions that "the long shadow of Nazi medicine" can
engulf the current practice of medicine because of thriving "moral
vulnerabilities in contemporary medical culture" (1). We add to the list
of moral vulnerabilities: the integration of "principlism" as the
dominant, if not the exclusive, ethical model of decision making in
clinical medicine and healthcare policy. Although Beauchamp and Childress
(the main p...
Colaianni cautions that "the long shadow of Nazi medicine" can
engulf the current practice of medicine because of thriving "moral
vulnerabilities in contemporary medical culture" (1). We add to the list
of moral vulnerabilities: the integration of "principlism" as the
dominant, if not the exclusive, ethical model of decision making in
clinical medicine and healthcare policy. Although Beauchamp and Childress
(the main proponents of principlism) (2) , have tried to answer the
charges that principlism is mechanistic and deductivistic, principlism
shares the problem shared by modern theories of ethics in general:
excessive abstraction. Principlism is grounded in four principles:
autonomy, beneficence, nonmaleficence, and social justice. Critics have
argued that principlism has no unifying theoretical moral foundation (3).
However, principlism is intended to provide the "global solution" for
practicing medicine ethically in modern society (4). Anyone can memorize
the list of principles and "apply" them to specific situations--and can
come to any moral conclusion they wish due to the abstract nature of all
formal rules. Lacking intrinsic moral cohesiveness, principlism can serve
as an illusionary moral guardian of life-ending practices in medicine (5).
It has already permitted the integration of a range of life-ending acts
from retrieving transplantable organs by redefining human death (6) to
medical assistance with dying (7) into medical practice. Principlism
represents a form of secular moral reasoning that centralizes respect of
individual autonomy, but which also is embedded within a utilitarian
healthcare system. This presents a moral vulnerability in the medical
culture threatening human dignity and the sanctity of life. The moral
compass of principlism can turn the shadow of the past into the nightmare
of the future in medicine.
Mohamed Y Rady, B.Chir, M.B (Cantab), M.A , M.D (Cantab), FRCS (Edin.
& Eng.), FRCP (UK), FCCM,
Professor, College of Medicine, Mayo Clinic.
Consultant, Department of Critical Care Medicine,
Mayo Clinic Hospital, Phoenix, Arizona, USA.
Joseph L. Verheijde, PhD, MBA, PT, Associate Professor, College of
Medicine, Mayo Clinic.
Department of Physical Medicine and Rehabilitation, Mayo Clinic,Phoenix,
Arizona, USA.
Michael Potts, Ph.D, Professor of Philosophy, Methodist University,
Fayetteville,North Carolina, USA.
References
1. Colaianni A. A long shadow: Nazi doctors, moral vulnerability and
contemporary medical culture. J Med Ethics2012:Published Online First: 3
May 2012 doi:10.1136/medethics-2011-100372
2. Beauchamp T, Childress J. Principles of Biomedical Ethics. 6th ed.
New York: Oxford University Press; 2008.
3. Clouser KD, Gert B. A Critique of Principlism. J Med
Philos1990;15(2):219-36.
4. Engelhardt HT. Critical Care: Why There Is No Global Bioethics. J
Med Philos1998;23(6):643-51.
5. Engelhardt HT. Confronting Moral Pluralism in Posttraditional
Western Societies: Bioethics Critically Reassessed. J Med
Philos2011;36(3):243-60.
6. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical
challenges of end-of-life organ procurement in emergency medicine.
Resuscitation2010;81(9):1069-78.
7. Rady MY, Verheijde JL. Distress from voluntary refusal of food and
fluids to hasten death: what is the role of continuous deep sedation? J
Med Ethics2011 October 29, 2011:Published Online First 29 October 2011.
doi:10.1136/medethics-2011-100278
Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a fu...
Dogs have been deliberately bred to be reliant on humans for company as well as to take advantage of their unique skills and intelligence, used in various ways as working dogs , such as sheep herders ,where empathy, attachment and love are blatantly obvious. They are entitled to be cared for , not to be exploited as a substitute for the human guinea pigs of the past. Using dogs which have been discarded by their owners is doubly abhorrent as regarding their lives as even more worthless. It is reminiscent of the recent past again where disabled and ill and people regarded as inferior were used for experimentation. Referring to the dogs, even in quotes, as 'volunteers' is simply disingenuous. Volunteering includes an act of willingness and agreement to procedures,
Show MoreThere is no question of consent of course but ethical issues are inherent in using brain scanning of other groups of often vulnerable people. They have some ethical protection but the urge to 'progress' has often fudged this. Neuropsychiatry is involved in experimentation using scans to diagnose areas of the brain which are claimed to be involved in mental health problems including the highly stigmatising and to some extent catch all label of Personality Disorder. Using scans as a tool for providing treatment designed to change a person's brain ,including psychotherapy ,raises serious ethical questions. How would people give informed consent to having scan...
In their intriguing 'Plutocratic Proposal' (J Med Ethics 2017), Masters and Nutt note that the 'Matching Agencies' acting as intermediaries between benefactors and the beneficiaries would need to do systematic reviews of all known existing research and commit to publishing full research results, both for their own reputations and for legal protection . Masters and Nutt point out out that these are definitely ethical matters, and that failure to do one or both has had fatal consequences for patients and research participants.
How can it be that Emanuel, Wendler and Grady did not even mention these two vital points concerning publication in their original list of seven ethical requirements? (JAMA 2000:283:701-7011).
Abstract:
The area of consciousness is an ever-evolving discussion particularly in relation to approaches to assessment of awareness. The paper by Wade (2016) further advances the discussion on this complex topic. The purpose of this response aims to put forward alternative views regarding points raised by Professor Wade in his paper “Back to the bedside? Making clinical decision in patients with prolonged unconsciousness” (J. Med. Ethics 2016; 0:1-7).
(67 words)
Overview:
In this response, a number of key issues raised by Professor Wade will be explored. These include assessment modalities, the debate relating to consciousness as a spectrum, and the emphasis- or lack thereof, on the value of rigours clinical assessment in diagnosing awareness.
Assessment Modalities
Show MoreIn his article, Professor Wade alluded to the lack of evidence to support visual tracking as an indicator for the presence of awareness. Despite gaps in the evidence to support the relevance of tracking in making a diagnosis, it continues to be a common bedside screening tool used by both physicians and other clinicians, and has been endorsed by the working party of the Royal College of Physicians (RCP); of which Professor Wade was the co-chair, as an important clinical indicator of awareness (RCP 2013, pg.7 box 1.1). Professor Wade identified the numerous reasons why tracking may be challenging for a person with severe brain injury including oculomotor impairments, visual...
This is a thought provoking paper but I wonder if it is founded on a false premise. It strikes me that a conscientious objection only applies if the surgeon has an obligation to undertake a cosmetic surgery procedure. If there is no obligation they are simply declining to carry out the procedure. Presumably this may be because the surgeon decides the procedure is not in the best interests of the patient. Since the surgeon is primarily an expert in physical, bodily function they should base their judgement of best interest on those grounds. Of course, if this reasoning is sound, fewer cosmetic procedures should perhaps be performed than currently are.
To The Editor
Kitzinger et al argued in favor of applying “the ‘holistic’ approach outlined in the Briggs judgment” to ascertain, in Court and ‘on the floor’, what in accordance with the Mental Capacity Act 2005 (MCA) ought to be considered a patient’s best-interest assessment.[1] In Briggs versus Briggs [2016] EWCOP 53 , “all parties were required to address the question of [Paul Briggs’s] ‘best interests rather than seeking to apply the standard of ‘substituted judgment’.”[2] Authors correctly pointed out that the MCA mandates, next to consideration of a person’s past and present wishes and feelings, values and beliefs, the inclusion of other relevant circumstances, i.e., diagnosis, prognosis and ‘sanctity of life’. Kitzinger et al postulated that this holistic approach to the best interest standard not only should be the preferred pathway over that of the ‘substituted judgment’ standard, but, if widely accepted, would make a positive contribution to “the texture and quality of best-interest decision making about these patients [with disorders of consciousness] ‘on the ground’”.[1] They further highlighted the significance of the Briggs judgment because of “the great weight [Mr Justice] Charles J gave the person’s own views, even when set against ‘sanctity of life’.”
There are theoretical and practical problems with Kitzinger et al’s position.
First, it is incorrect to describe the Briggs case as the clash of ‘sanctity of life’ and ‘self-determinat...
Show MoreRivera Lopez in his astounding article [1] proposes the duty to kill and is happy not to consider the counter arguments, but just follow his line of thought!!
...Show MoreHe is among those prepared to cross the line of taking a life or at least consider such acts in theory. His view demonstrates a very restricted outlook on life, seeing nothing beyond the concrete. It seems a bit drastic or simplistic to get rid of problems by getting rid of the people who have them. If treatment or life itself is burdensome, it can be lightened in many more caring ways. As a GP, I see what a dying person can give to others and the intangible benefits of suffering; in bringing of the family together, acknowledging the heartbreak and drawing out good in others by accompanying and self-giving. I have also seen destruction of the joy in a family by suicide and the feeling of failure among those left behind. Human dignity is found in being supported and loved, not being killed.
Another consideration is that we do not know how those who cross the line will bear up psychologically after many years of this justified killing. Doctors in Ontario, where euthanasia has been permitted by law last year, are backing out as they find that they “go through one experience and it’s just overwhelming, it’s too difficult, and those are the ones who say, ‘take my name off the list. I can’t do any more.’ ” [2] Are we prepared to risk making killing part of the medical practice and wait to see the damage?
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statemen...
At the frontlines, in the emergency department, clinicians face multiple challenges. Each patient sees his situation as unique and quite frightening, although to the clinician, it is commonplace. Therefore, it is paramount for healthcare providers to empathize with each individual. Another challenge for clinicians is having self-insight and viewing each patient in an unbiased manner in order to share meaningful...
Colaianni cautions that "the long shadow of Nazi medicine" can engulf the current practice of medicine because of thriving "moral vulnerabilities in contemporary medical culture" (1). We add to the list of moral vulnerabilities: the integration of "principlism" as the dominant, if not the exclusive, ethical model of decision making in clinical medicine and healthcare policy. Although Beauchamp and Childress (the main p...
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