Dangerousness criteria (1) are another source of discrimination against the
mentally ill, but not the greatest.
There is a statistically and clinically significant association
between violence and major mental illness, and some studies have demonstrated that
major mental illness is associated with at least a fourfold increase in
the chances of violence compared to the general population. (2)
Dangerousness criteria (1) are another source of discrimination against the
mentally ill, but not the greatest.
There is a statistically and clinically significant association
between violence and major mental illness, and some studies have demonstrated that
major mental illness is associated with at least a fourfold increase in
the chances of violence compared to the general population. (2)
However, a study showed (3) that the population impact of patients
with severe mental illness on violent crime varies by gender and age, and
that the population-attributable risk fraction of patients was 5%,
suggesting that patients with severe mental illness commit one in twenty
violent crimes.
On the other hand, rates of victimisation for people with severe
psychiatric disorders are shown to be high and far greater than those for
the general population, although men and women with severe mental ill ness tend
to be seen as authors and not as victims of violence. (4)
The media continue to damage a very important part of society, made up of the mentally ill, their families and
friends. News such as these are not unfrequent in the media:
'A mentally disturbed kills her father in Anywhere County'.
'A schizophrenic who stabbed his grandfather declared that he did it
just to scare him'.
'A schizophrenic stabbed eight children and wounded 19 at
a college'.
We should not believe that all people with schizophrenia do such things. Of the thousands of people who are diagnosed with schizophrenia in the world, only a small percentage has criminal behaviour. The rest live and let live. Most suffer from the disease in anonymity while their families and friends are socially discriminated by the community.
There should not be any discrimination in the treatment of people with illness in the media. Compare the previously reported headlines with these ones:
'An asthmatic kills her father in Anywhere County'
'A cirrhotic who stabbed his grandfather declared that he did it just
to scare him'
'A nephrosclerotic kills stabbed eight children and wounds 19
at a college'
Will this be a reality someday?
We declare that we have not conflict of interest.
1. Large MM, Ryan CJ, Nielssen OB and Hayes RA. The danger of
dangerousness: why we must remove the dangerousness criterion from our
mental healthJ Med Ethics 2008;34:877-881.
2. Walsh E, Gilvarry C, Samele C et al. Predicting violence in
schizophrenia: a prospective study. Schizophrenia Research 2004; 67: 247
252.
3. Fazels S, Grann M. The population impact of severe mental illness
on violent crime. American Journal Psychiatry 2006; 163: 1397 1403.
4. Lovell AM, Cook J, Velpry L. Violence towards people with severe
mental disorders: a review of the literature and of related concepts Rev
Epidemiol Sante Publique. 2008 Jun;56(3):197-207.
Physicians have publicly argued that chemically controlling and
surgically altering the natural development of Ashley - who is living with
static encephalopathy – is an ethically acceptable option on the basis
that her parents would be unable to continuously care for her as she
continues to physically mature and that her disability would only lead to
further medical complications later in life. One of the purposes for suc...
Physicians have publicly argued that chemically controlling and
surgically altering the natural development of Ashley - who is living with
static encephalopathy – is an ethically acceptable option on the basis
that her parents would be unable to continuously care for her as she
continues to physically mature and that her disability would only lead to
further medical complications later in life. One of the purposes for such
a radical treatment was based on the logic that Ashley would become an
easy target for abuse and rape as she continued to physically mature. Such
a radical surgery was therefore meant to reduce, if not completely
eliminate, such possibilities. Unfortunately, it would seem that we now
live in a world where we medically mutilate another person in order to
prevent individuals capable of committing sexual abuse and other
exploitative practices from pursuing their ‘interests’. Kind of
counterintuitive, isn’t it?
An additional argument put forth by Ashley’s parents to justify such
a surgery was that reducing her size would be more appropriate for her
developmental level and would make her less of an anomaly to society,
which would assure her of the basic dignity and respect all persons
deserve.
Disability rights activists and their allies have continued to challenge
normative thinking and have argued that disability is not merely a medical
or internal dysfunction rendering the individual disabled, but in fact it
is equally, if not more, a product of one’s physical, environmental,
attitudinal and social context. It would appear that the attitudes towards
Ashley’s physicality were far more ‘disabling’ than whatever limitations
are inherent to her biology.
However, proponents of this treatment have suggested it would provide
the child with a better quality of life and the ability of Ashley’s
caregivers to provide the best possible care for her. Disability activists
argue that healthcare personnel sometimes have an inaccurate impression
when considering the quality of life of persons living with disabilities
since their perspective can mainly encompass a medical model approach.
They arguably presume - in some cases - that it is a life of misery,
worthy of pity, and compromised by the disability itself. In Ashley’s
case, she was perceived to be the ‘victim’ of a personal tragedy and as
someone who required continuous physical and personal care. It is
certainly plausible that Ashley was in need of continuous care; however,
such assumptions may have colored the manner in which treatments were
administered.
Lastly, the choice of Ashley’s parents to pursue the procedures for
their daughter was arguably not a free and informed choice, primarily
because there continues to be both societal discrimination against people
with disabilities, and lack of appropriate supports and services for them.
Yet, we can all agree that the intentions of Ashley’s parents were
benevolent and that they were merely acting out of concern for their
child’s well-being. However, altering Ashley’s physicality and removing
her ability to mature in such a manner does not serve any purpose other
than to control for the innate fears that were felt over the notion of
Ashley developing into a woman (and the lack of available social supports
that were made available to her parents). It is this kind of thinking that
will continue to damage the very core of what human rights activists have
struggled to gain for so long – equality and the respect for the quality
of life for persons with disabilities as full members of society.
In a study on the six due care criteria for lawful euthanasia in the
Netherlands, H.M. Buiting and others found that the requirement that a
physician should convince herself that her patient was suffering
hopelessly and unbearably was by far the most difficult to meet. [1] Of
the physicians who reported to have experienced problems with the
criteria, 79% reported difficulties with that criterion; in particular
they foun...
In a study on the six due care criteria for lawful euthanasia in the
Netherlands, H.M. Buiting and others found that the requirement that a
physician should convince herself that her patient was suffering
hopelessly and unbearably was by far the most difficult to meet. [1] Of
the physicians who reported to have experienced problems with the
criteria, 79% reported difficulties with that criterion; in particular
they found it difficult to convince themselves that the suffering was
unbearable, and only to a lesser extent that it was hopeless. Actually,
the authors locate the difficulties even more precisely. 53% of the
physicians indicated problems in assessing whether they themselves were
convinced that the patient suffered unbearably, whereas 28% reported
difficulties in assessing whether the patient experienced his own
suffering as unbearable. Other criteria that were mentioned to cause
problems relatively often were the requirement that the patient’s request
should be voluntary and well-considered (58%), and that there should be no
reasonable alternative available (33%).
The authors explain their findings by drawing attention to the fact
that these three requirements are framed as open norms; ‘well-considered’,
‘unbearable’ and ‘reasonable’ all three requiring interpretation which has
to take the specific circumstances of the case into account. Moreover,
‘well-considered’ and ‘unbearable’ (and to a lesser degree ‘reasonable’)
refer to subjective aspects and are to a large extent a matter of the
patient’s experience and personal perspective. This implies that
physicians have to adopt an empathising role in order to ascertain whether
the material criteria relating to the request are indeed fulfilled. But
this need to empathise can get in the way of the physicians’ professional
medical role, making their performance on the reasonable alternative
criterion worse than it would be if their task were confined to the their
medical role alone.
As a solution for the physicians’ problems, therefore, the authors
suggest that ‘It should be clearly communicated [by the Dutch government,
HW] that the patient’s suffering and request (apart from judging the
patient’s competency) can be assessed objectively only to a very limited
extent and that, accordingly, these aspects need to be left to the patient
to a great extent.’ Physicians could then concentrate on their medical
professional judgement to assess whether any reasonable alternatives are
available.
What the authors suggest, effectively, is solving the problem by
eliminating it. Since it is difficult for physicians to assess whether a
patient suffers unbearably to confine myself to the most troublesome
criterion it would be better if they were spared the trouble and were
permitted to leave the decision to the patients themselves. But that
suggestion has some unwelcome consequences. It would, in the first place,
turn the suffering criterion into a sham; a physician would satisfy the
criterion simply by asking the patient if he suffered unbearably. If he
answers ‘Yes’ that would be the end of the matter. But obviously, merely
saying so does not make it so. Secondly, it would not turn just any old
criterion into a sham, but the most fundamental one, the one on which the
Dutch euthanasia regulation is actually based. To quote the authors once
more: ‘Although self-determination of the patient is a necessary condition
to justify termination of their lives, in the final analysis the
physician’s responsibility to alleviate the patient’s suffering is the
most important principle underlying the Act.’ Indeed it is, as has been
convincingly argued by Den Hartogh. [2] If it took a physician no more to
satisfy herself that her patient was suffering unbearably than simply to
ask him if he did, if credibility on this score could be had for the
asking, self-determination would be the fundamental moral ground of the
Dutch euthanasia act after all, and not alleviation of suffering.
How, then, can a physician ascertain that her patient was suffering
unbearably? Is it indeed a requirement she can only meet either by leaving
it to the patient to decide or by abandoning her medical-professional role
as the authors claim? That would be the case only if the medical-
professional role is conceived in an inappropriately restricted way. As
Cassell has argued extensively, among other places in the paper the
authors refer to [3], medical knowledge consists of a lot more than
knowledge of physiology, diseases and symptoms. Instead of directing all
its attention to diseases and symptoms, ‘medicine should concern itself
with illness, the set of disordered functions, body sensations and
feelings by which persons know themselves to be unwell.’ [4] No general
practitioner would dispute this view. At the very least, then, physicians
always need to have particular knowledge about their individual patients,
and if they have to assess their patients’ suffering, they have to know
something in general about what makes a life go well, and hence, when it
has deteriorated to a point at which it is conceivably not worth living
any longer. Suffering is not a raw feeling, like pain or shortness of
breath, but a complex state of being dependent on the particular meaning
symptoms and losses have for this particular patient.
If it takes general knowledge about what makes lives go well and
particular knowledge about this individual patient’s biography and
character to assess his suffering, what does it take to know whether his
suffering is unbearable? Does not that requirement draw essentially on the
patient’s own point of view? Is not he the final arbiter on the
unbearableness of his own suffering? No, again, saying that one suffers
unbearably does not make it so. Rather it invokes a norm. The truth
conditions of the sentence ‘I suffer unbearably’ are not met as soon as
the patient believe they are, but when we, the Dutch political community,
do. We determine which suffering we consider to be unbearable and which we
expect anyone should be able to cope with. Such a norm is public, and no
more subjective than any other public norm. Needless to say, what patients
experience as unbearable and what we consider to be so overlap to a very
large extent, but that does not rule out disagreement or conflict. In such
cases, physicians should apply the open public norm, rather than taking
her patient’s request at face value or foist her own norms on him.
In addition, then, to strict medical knowledge, physicians who have
to decide whether to comply with euthanasia requests should have general
and particular knowledge about what makes lives go well, and moreover,
they must be acquainted with the public norm governing the application of
the concept of unbearableness. Only this latter type of knowledge could
possibly be called non-medical, since the norm in question is a societal
norm in the sense that it is laid down in the Dutch criminal code, and
interpreted by the courts and the regional review committees for
euthanasia in which not only a physician, but also a lawyer and an
ethicist serve as members.
References
1 Buiting HM, et al., Dutch criteria of due care for physician-assisted
dying in medical practice: a physician perspective. JME 2008;34;e12.
2 den Hartogh GA, Het Nederlandse euthanasierecht: Is barmhartigheid
genoeg? (in Dutch) Tijdschrift voor Gezondheidsrecht 2007;31:180-198.
3 Cassell EJ, The nature of suffering and the goals of medicine. N Engl J
Med 1982;306:639-45.
4 Cassell EJ, The nature of suffering and the goals of medicine. New York:
Oxford University Press, 1991: 49.
Winburn and Mullen describe a harrowing clinical encounter with a
young woman with a severe personality disorder who risked death refusing a
blood transfusion. The authors argue that her incompetence to refuse
treatment was “on the basis of her personality disturbance”. Their
reasoning is flawed.
If the patient lacked capacity around this decision, it was not
because she had a personality disorder; it was becaus...
Winburn and Mullen describe a harrowing clinical encounter with a
young woman with a severe personality disorder who risked death refusing a
blood transfusion. The authors argue that her incompetence to refuse
treatment was “on the basis of her personality disturbance”. Their
reasoning is flawed.
If the patient lacked capacity around this decision, it was not
because she had a personality disorder; it was because she lacked one of
the essential components of capacity. It was because she could not
understand or retain the information given her, or weigh up the relevant
risks and benefits, or arrive at a clear choice, or clearly communicate
that choice. Her personality style would have contributed to the
difficulties she may have had in these domains, but it would not be her
personality style per se that would impair her capacity.
A psychiatric diagnosis, be it personality disorder, mood disorder or
psychosis, is not the sort of thing that impairs capacity, though features
of the diagnosis may set up obstacles to capacity. A person with
schizophrenia who believes that the CIA has poisoned the blood supply,
does not lack capacity to accept a transfusion because he has
schizophrenia. He lacks capacity because his delusion has rendered him
incapable of weighing up the relevant risks and benefits of the
transfusion. In the case outlined, the patient’s personality style seems
to have made it difficult for her to communicate her desire to have a
transfusion. She says, at one point, ‘‘it’s not that I don’t want a
transfusion, I just don’t know how to say yes.’’ Ideally one would find a
way to help the patient communicate that desire, but if she is to be
regarded as incompetent, she is incompetent because she cannot communicate
her desires, not because of her personality disturbance.
Life-preserving treatment may only be ethically forced upon a person
with a mental illness, if that person lacks capacity to accept the
treatment and if there is good reason to believe that, had the person had
the capacity, he or she would have accepted the treatment. Mental health
legislation around the world conflates the presence of mental illness with
an assumed lack of capacity. We must be clear to separate the two, and
have that separation reflected in our practice, our laws and our ethical
reasoning (1).
1. Large,M, C J Ryan, O Nielssen, R Hayes. The danger of
dangerousness. An argument against the dangerousness criterion in mental
health acts. Journal of Medical Ethics in press. 2008.
Ethics is about choices, but I do not agree that health care workers
do not
have choices. The choices available to us are obviously very varied. Some
may
well be able to change the number of nurses in a hospital (or have the
ability
to lobby for that kind of change). Alternatively in your cancer example,
your
choice may be just to turn the patient or to provide a cushion. The...
Ethics is about choices, but I do not agree that health care workers
do not
have choices. The choices available to us are obviously very varied. Some
may
well be able to change the number of nurses in a hospital (or have the
ability
to lobby for that kind of change). Alternatively in your cancer example,
your
choice may be just to turn the patient or to provide a cushion. The
constraints are mental as well as physical and the Kenyan doctors you
mention who are “working to improve the standard of care”, I would say are
working against the constraints. The constraints could be
teaching/learning
about pressure sores.
It is also not necessarily the individual doctors who are at fault but
that a
social and structural change and shift of thinking are needed to improve
the
situation in Africa.
I am certainly not saying that Kenyan doctors, or any other group, are
unethical and I think it over simplistic to categorize in this way. We
make
hundreds of decisions with a wide scale of ethics. A number of experiences
in
this article actually relate to European doctors working overseas.
It is also not that practices in the UK are better than those in other
parts of
the world. Some are, some aren’t; most are just different.
Accepting the status quo occurs everywhere but the situations tend to be
much worse in the developing world. Not washing your hands between
patients occurs every day in the NHS, but as there are generally less
serious
diseases and the patients are usually better able to cope, so the problems
caused are comparatively less. The scenario is much worse if your
infectious
disease is cholera and your patient is a malnourished infant for example.
I entirely agree that intensive care has a very small contribution to
worldwide
infant mortality. The point of that paragraph was that our target should
be an
IMR of a developed country but to get there is unrealistic due to the very
high
costs of intensive care.
The role of the rich world certainly is important. This does not take up a
large
proportion of the essay because it is not primarily about this issue.
I know it is easy to sit here and pass judgment, but are all
practices/behaviours acceptable just because they occur in a society? I
think
there are universal standards that we, in admittedly very different ways,
should be striving to achieve.
A write up in the form of a filler by an anonymous author in BMJ1
describes with reference to an Italian philosopher who constructed a scale
looking at existence of professional jealousy in different professions and
finding doctors among the top two, second after the actors. Doctors have
this reputation since a long time and most common presentation is by
regarding each other as ‘quacks’. The famous ‘Dr.Alabone’ case as na...
A write up in the form of a filler by an anonymous author in BMJ1
describes with reference to an Italian philosopher who constructed a scale
looking at existence of professional jealousy in different professions and
finding doctors among the top two, second after the actors. Doctors have
this reputation since a long time and most common presentation is by
regarding each other as ‘quacks’. The famous ‘Dr.Alabone’ case as narrated
by Vaile and Gilbert2 indicates the prevalence of this problem often to
the extent vilification leading to ethical concerns. Question arises as to
why the medicos are ranking so high when it come to this type of jealousy?
If the human factor is to be considered, then, this is relatively common
emotion which concerns self perception of an individual and results from
resentfully suspicious nature of human being. It results from a multitude
of factors including feelings of insecurity, disturbed psychodynamics,
personality traits, internal conflicts, personal inadequacies while not
ruling out genetic predispositions3. Psychologists believe that jealousy
is a life long conditioning process and not just instinctive. One wonders
if this is a common human attribute then why the elite medical profession
ranks so high just one step below the actors. Could it be because of
practice superiority of some over others? Or the intense competitiveness
among those choosing this profession or the acquired egoism because of the
glitter and respect that this profession carry? Would this be due to the
fact some people with paranoid traits are lured into this profession and
become the eventual perpetrators? With regard to actors there are
suggestions by psychologists that they may carry histrionic traits and if
so, there is likelihood of medicos carrying narcissistic traits which
manifests itself in sabotaging other colleagues in order to preserve self-
inflated identity. There could also be a tendency for the medicos to
suffer from “narcissistic injury” in the event of challenge in terms of
diagnostic competence, galore of information, high success rates and
superior demeanor among other colleagues. This appears to a pivotal issue
for the manifestation of professional jealousy. The expression of
professional jealousy can be in the form of allegations, defamation,
questioning the credentials, spread of rumours, passing remarks, bullying,
blocking promotions, verbal abuse and even physical attacks3. This type of
jealousy being rampant and widely known needs curbing by means of
education in this subject. There is a need to be aware of this problem, to
develop further self confidence, talk about it with the rival, not to
overreact and be confident. If matters go beyond control, then, the local
regulatory bodies can do something about it, there may be a role for human
rights organizations as this problem can cause emotional and mental
torture among the victims who can even fall prey to physical ailments in
the face of such a stress. Some sort of tailored psychotherapy may be a
good option for both the victims and perpetrators.
References:
1-Anonymous. Filler: Professional Jealousy, BMJ 2004; 328:887, doi:
10.1136/bmj.328.7444.887.
2- Vaile M, Gilbert S. The curious case of Dr. Alabone-heterodoxy in
19th century medicine. J R Soc Med, 2005; 98:281-286.
3- Gadit AM. Professional behaviour of doctors: are we meeting the
criteria? J Pak Med Assoc; 2007; vol 57, no. 8: 425-427.
While I welcome any discussion of the ethics review system in the UK
and how it may be developing into a broader regulatory structure, any
analysis needs to be based on an accurate understand both of the current
academic literature in this area and upon current REC practice.
Unfortunately McGuinness’ recent article has problems in both of these
departments.
Given that one of her main conclusions is that provide...
While I welcome any discussion of the ethics review system in the UK
and how it may be developing into a broader regulatory structure, any
analysis needs to be based on an accurate understand both of the current
academic literature in this area and upon current REC practice.
Unfortunately McGuinness’ recent article has problems in both of these
departments.
Given that one of her main conclusions is that provided processes are
standardised, it is possible for different RECs to reach different
conclusions over the same application, without this being unfair (the
inconsistency claim made against RECs), it is bizarre that she does not
discuss Edwards and colleagues’ well known article from 2004 which makes
essentially the same point at greater length and detail [1].
Similarly, a broader reading of the literature would have shed light
on her belief that “Surely it will be problematic… for a lawyer [on a REC]
to approve a project from which questionable legal issues arise”. The
obvious response to this is, ‘tell that to Derek Beyleveld’ who incisively
skewered exactly this problem within the UK system, where RECs (even those
with lawyers on them) have been explicitly dissuaded from rejecting
illegal research, on the grounds that the committee is not a legally
competent body [2].
An awareness of the historical documentation around RECs would have
led to an avoidance of the apparent belief that formalised opposition to
RECs commenting on scientific issues was introduced by the Ad Hoc Advisory
Group (AHAG): it was of course first articulated by the DoH in the 1991
‘Red Book’. The fact that REC members resist this division of science and
ethics, holding fast to their motto of ‘bad science is bad ethics’, and
the fact that, rather confusingly, the regulations actually require RECs
to think about the science – they are, after all, asked to look at the
research design, often with the help of a statistician-member appointed
expressly for that purpose – raises complex issues for McGuinness’ rather
simplistic belief that ‘technical ethical’ and ‘ethical ethical’ issues
can be divided.
In addition to minor points of error (such as the idea that RECs are
“responsible for projects’ being adequately insured” – they are not. Since
Northwick Park, NRES has made it clear that the responsibility lies with
the research sponsor since RECs are not qualified to judge ‘how much
insurance is enough’) a better grounding in what RECs actually do would
have prevented an over-overemphasis on risk assessment (RECs also spend a
lot of time thinking about informed consent: indeed it is one of the ways
in which they resolve debates over the ‘riskiness’ of particular research
projects) and allowed a paper which spends so much time talking about the
desirability of standardised procedures for RECs to actually acknowledge
that since 2004, NHS RECs have operated using a set of centrally generated
SOPs, Standard Operating Procedures. These explicitly provide committees
with a clear account for their decisions, and to display the correct
degree of conformity to process.
Notes
[1] Edwards SJL, Ashcroft R, Kirchin S (2004) Research ethics
committees: Differences and moral judgement _Bioethics_ 18(5): 408-427.
[2] Beyleveld, D (2002) Law, ethics and research ethics committees,
_Medicine And Law_ 21(1): 57-75
Ponder et al add a useful view to the debate about seeking consent in
clinical research but it is important to correct their view that guidance
for information sheets produced by the National Resarch Ethics Service
might be seen as a proscriptive straight jacket.
The introduction in our guidance states:
"We provide this document to guide researchers and reviewers alike
but there may be times when variation...
Ponder et al add a useful view to the debate about seeking consent in
clinical research but it is important to correct their view that guidance
for information sheets produced by the National Resarch Ethics Service
might be seen as a proscriptive straight jacket.
The introduction in our guidance states:
"We provide this document to guide researchers and reviewers alike
but there may be times when variation will be necessary. We do not wish to
hinder improvement". (1)
We recognise that one size won't fit all, and in such circumstances,
described in this article, we hope RECs and researchers can reach
agreement about sensible, comprehensible information sheets fit for their
specific purpose.
1. http://www.nres.npsa.nhs.uk/rec-community/guidance/ accessed 9th
September 2008
If I understand ethics correctly, it has to do with "oughts" - what
we should do, or ought to do. This assumes that we have a choice. It is
not unethical to "let" someone die of a highly aggressive cancer of
unknown etiology, for example; we have no choice in the matter. We do have
a choice on whether to perform a 1st trimester abortion on demand, or
whether to pull the plug on Karen Quinlan. Ethics implies choice.
Delan...
If I understand ethics correctly, it has to do with "oughts" - what
we should do, or ought to do. This assumes that we have a choice. It is
not unethical to "let" someone die of a highly aggressive cancer of
unknown etiology, for example; we have no choice in the matter. We do have
a choice on whether to perform a 1st trimester abortion on demand, or
whether to pull the plug on Karen Quinlan. Ethics implies choice.
Delan Devakumar suggests that doctors in developing countries have a
choice to either "accept the way things are and work within the
constraints" or "always be battling against the constraints." He suggests
the second is the more ethical choice. Now I cannot control how many
nurses our district hospital has (no matter how much I "battle against the
constraints"), nor the lack of transport and roads to get people to the
hospital, nor the 50% of Kenyans that live on less than a dollar a day,
nor the poor morale that often results from working in overworked
understaffed facilities. Do I really have a choice in these fundamental
matters? If I decide – or rather so many excellent Kenyan doctors decide –
to "work within the constraints", why does that come on the unethical
side? The ethical Kenyan doctors I know who are "working within the
constraints" are working to improve the standard of care. To me, the
unethical choice is to leave.
Of course there are ethical reasons for why things are bad in Africa,
there are choices – but only a minority of these choices are local. Yes,
there is corruption locally, and there has been in Kenya a palpable change
in this regarding health care since the 2003 election. But where is the
equivalent palpable change in the world economy that is stacked in favor
of the North? The author mentions this ethical issue, but only in passing:
"It is equally not acceptable for the industrialised world to contribute
to these disadvantages both directly—for example, through the sale of
arms—and indirectly, by keeping countries impoverished through various
biased directives and embargoes." In fact, for those who accept the 4
principles of bioethics (and who assume them to be universal), the 4th is
distributive justice. The fundamental ethical problem in Africa is not
unethical doctors who "work within the constraints".
I can appreciate that the author is troubled by what he sees here. But his
proposals seem very much to be only the good intentions he mentions at the
end. What do intensive care units have to do with child mortality? And he
may have "longed for the much-maligned British social services", but would
they really do a better job than the "traditional practices [which] in the
main have a positive cohesive effect on society"?
To improve the accurate clinical ethics research made by Anderson (1)
about confidentiality in sport medicine, we must take into consideration
the existence of two international codes on the issue.
First, the World Medical Association Declaration on Principles of
Health Care For Sports Medicine (2), adopted by the 34th World Medical
Association General Assembly in Lisbon, Portugal, in 1981 and...
To improve the accurate clinical ethics research made by Anderson (1)
about confidentiality in sport medicine, we must take into consideration
the existence of two international codes on the issue.
First, the World Medical Association Declaration on Principles of
Health Care For Sports Medicine (2), adopted by the 34th World Medical
Association General Assembly in Lisbon, Portugal, in 1981 and revised last
time in the 51st World Medical Association General Assembly, in Tel Aviv,
Israel, in 1999.
In this policy is stated:
‘In sports medicine, as in all other branches of medicine,
professional confidentiality must be observed. The right to privacy over
medical attention the athlete has received must be protected, especially
in the case of professional athletes’.
The second document is the Code of Ethics (3) of the International
Federation of Sport Medicine (IFSM).
There we can read the following sentences:
‘The athlete's right to privacy must be protected. The regulations
regarding medical records in health care and medicine shall also be
applied in the field of sports medicine. The sports medicine physician
should maintain a complete and accurate record of the patient.
In view of the strong public and media interest in the health of
athletes, the physician should decide with the athlete what information
can be released for public distribution.
When serving as a team physician, the sports medicine physician
assumes the responsibility to athletes as well as team administrators and
coaches. It is essential that each athlete is informed of that
responsibility and authorizes disclosure of otherwise confidential medical
information, but solely to the specific responsible persons and for the
expressed purpose of determining the fitness of the athlete for
participation’.
However, as in other aspects of professional practice, the best tool
for solve a problem, is to think about the confronted values.
It is good to have rules, but it is better to reasoning about the
problem and obtain a response.
Then, we can check if my own response is one of the stated rules.
We declare that we have not conflict of interest.
1. Anderson L. Contractual obligations and the sharing of
confidential health information in sport. J Med Ethics 2008;34:e6
2. http://www.wma.net/e/policy/h14.htm (access on 2008/08/30)
Dangerousness criteria (1) are another source of discrimination against the mentally ill, but not the greatest.
There is a statistically and clinically significant association between violence and major mental illness, and some studies have demonstrated that major mental illness is associated with at least a fourfold increase in the chances of violence compared to the general population. (2)
However, a stu...
Physicians have publicly argued that chemically controlling and surgically altering the natural development of Ashley - who is living with static encephalopathy – is an ethically acceptable option on the basis that her parents would be unable to continuously care for her as she continues to physically mature and that her disability would only lead to further medical complications later in life. One of the purposes for suc...
In a study on the six due care criteria for lawful euthanasia in the Netherlands, H.M. Buiting and others found that the requirement that a physician should convince herself that her patient was suffering hopelessly and unbearably was by far the most difficult to meet. [1] Of the physicians who reported to have experienced problems with the criteria, 79% reported difficulties with that criterion; in particular they foun...
Winburn and Mullen describe a harrowing clinical encounter with a young woman with a severe personality disorder who risked death refusing a blood transfusion. The authors argue that her incompetence to refuse treatment was “on the basis of her personality disturbance”. Their reasoning is flawed.
If the patient lacked capacity around this decision, it was not because she had a personality disorder; it was becaus...
In response to your comments:
Ethics is about choices, but I do not agree that health care workers do not have choices. The choices available to us are obviously very varied. Some may well be able to change the number of nurses in a hospital (or have the ability to lobby for that kind of change). Alternatively in your cancer example, your choice may be just to turn the patient or to provide a cushion. The...
A write up in the form of a filler by an anonymous author in BMJ1 describes with reference to an Italian philosopher who constructed a scale looking at existence of professional jealousy in different professions and finding doctors among the top two, second after the actors. Doctors have this reputation since a long time and most common presentation is by regarding each other as ‘quacks’. The famous ‘Dr.Alabone’ case as na...
While I welcome any discussion of the ethics review system in the UK and how it may be developing into a broader regulatory structure, any analysis needs to be based on an accurate understand both of the current academic literature in this area and upon current REC practice. Unfortunately McGuinness’ recent article has problems in both of these departments.
Given that one of her main conclusions is that provide...
Ponder et al add a useful view to the debate about seeking consent in clinical research but it is important to correct their view that guidance for information sheets produced by the National Resarch Ethics Service might be seen as a proscriptive straight jacket.
The introduction in our guidance states:
"We provide this document to guide researchers and reviewers alike but there may be times when variation...
If I understand ethics correctly, it has to do with "oughts" - what we should do, or ought to do. This assumes that we have a choice. It is not unethical to "let" someone die of a highly aggressive cancer of unknown etiology, for example; we have no choice in the matter. We do have a choice on whether to perform a 1st trimester abortion on demand, or whether to pull the plug on Karen Quinlan. Ethics implies choice. Delan...
Dear Sir:
To improve the accurate clinical ethics research made by Anderson (1) about confidentiality in sport medicine, we must take into consideration the existence of two international codes on the issue.
First, the World Medical Association Declaration on Principles of Health Care For Sports Medicine (2), adopted by the 34th World Medical Association General Assembly in Lisbon, Portugal, in 1981 and...
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