O’Byrne et. al raise the important issue of pandemic preparedness in medical students’ readiness to deal with the covid-19 pandemic. Healthcare professionals have a moral obligation to volunteer to help, however, there has been a lack of strict consideration for the preparedness and clinical competency of medical students in these circumstances. The article correctly highlights that medical students’ desire to help is insufficient alone, and there is a need for adequate medical education and training to better prepare students for any potential moral trauma and adverse risks to mental health. However, for those newly graduated students, we feel as though the need for a break from clinical activity is a concept that has been overlooked and may be imperative to true pandemic preparedness amongst this cohort.
The majority of medical students will complete an intensive 5-year curriculum before graduating and applying to the foundation programme to continue their training, 43% of whom will have had no break from education up to this point.(1) As highlighted in the article by O’Byrne et. al, many of these students face problems with their mental wellbeing during medical school and thereon after. These problems regarding mental and emotional wellbeing are heightened in situations where students feel anxious or unprepared, such as clinical placements and rotations.(2) The importance of breaks to aid mental wellbeing are well recognised throughout the curriculum, such as tim...
O’Byrne et. al raise the important issue of pandemic preparedness in medical students’ readiness to deal with the covid-19 pandemic. Healthcare professionals have a moral obligation to volunteer to help, however, there has been a lack of strict consideration for the preparedness and clinical competency of medical students in these circumstances. The article correctly highlights that medical students’ desire to help is insufficient alone, and there is a need for adequate medical education and training to better prepare students for any potential moral trauma and adverse risks to mental health. However, for those newly graduated students, we feel as though the need for a break from clinical activity is a concept that has been overlooked and may be imperative to true pandemic preparedness amongst this cohort.
The majority of medical students will complete an intensive 5-year curriculum before graduating and applying to the foundation programme to continue their training, 43% of whom will have had no break from education up to this point.(1) As highlighted in the article by O’Byrne et. al, many of these students face problems with their mental wellbeing during medical school and thereon after. These problems regarding mental and emotional wellbeing are heightened in situations where students feel anxious or unprepared, such as clinical placements and rotations.(2) The importance of breaks to aid mental wellbeing are well recognised throughout the curriculum, such as time-outs and project periods to break-up clinical activity.(3) The concern is that those deployed early onto the frontline will not have had the adequate break required to replenish their wellbeing in preparation for their lifelong career ahead.
The obligation to patient care and dire need for volunteers will see most graduating medical students quickly enter clinical practice. However, stress, anxiety and burnout are well recognised issues amongst medical students, and may be exacerbated for this cohort.(4) The covid-19 pandemic is likely to cause heightened moral distress for newly graduated doctors, as they are required to make increasingly challenging decisions regarding patient care.(5) This highlights the need to build moral resilience to reduce the chance of moral injury or burnout.
It is well recognised that breaks during work are important to avoid burnout, particularly for healthcare professionals. A study conducted on doctors working in a stressful intensive care environment showed that taking breaks from the intensive care unit environment was one important strategy to rejuvenate from moral distress.(6) However, the concern is that those more junior faced with the existing anxiety of a new job role and responsibilities may have a lower tolerable threshold for morally distressing situations; as a result increasing likelihood of burnout. Additionally, many more doctors are taking time out from foundation training in recent years due to stress and exhaustion.(7)
Reflexivity is important in developing as a practitioner and may be crucial in the period between graduating and becoming a medical professional. Coates et. al(1) showed that this transitional period is an important time for life skill development, such as through increasing confidence, emotional stability and independence; important traits of a medical professional. The importance of a break is recognised throughout, with trainees now opting to take a break during medical training, of which the result has been an addition of valuable experience to the development of their future profession.(7)
Therefore, whilst providing newly graduated students with the invaluable learning opportunity of assisting during a global pandemic, it must also be remembered that students must receive an adequate break from clinical studies in order to develop moral resilience, boost mental wellbeing and reduce the chances of burnout during foundation training.
References
1. Coates WC, Spector TS, Uijtdehaage S. Transition to Life—A Sendoff to the Real World for Graduating Medical Students. Teaching and Learning in Medicine 2012;24(1):36-41. doi: 10.1080/10401334.2012.641485
2. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Medical education online 2018;23(1):1530558-58. doi: 10.1080/10872981.2018.1530558
3. Tolhurst HM, Stewart SM. Balancing work, family and other lifestyle aspects: a qualitative study of Australian medical students’ attitudes. Medical Journal of Australia 2004;181(7):361-64. doi: 10.5694/j.1326-5377.2004.tb06326.x
4. Wang Q, Wang L, Shi M, et al. Empathy, burnout, life satisfaction, correlations and associated socio-demographic factors among Chinese undergraduate medical students: an exploratory cross-sectional study. BMC Medical Education 2019;19(1):341. doi: 10.1186/s12909-019-1788-3
5. Wald HS. Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an ‘integrative resilience’ approach. Medical Teacher 2020:1-12. doi: 10.1080/0142159X.2020.1768230
6. Henrich NJ, Dodek PM, Gladstone E, et al. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. American Journal of Critical Care 2017;26(4):e48-e57. doi: 10.4037/ajcc2017786
7. Rizan C, Montgomery J, Ramage C, et al. Why are UK junior doctors taking time out of training and what are their experiences? A qualitative study. Journal of the Royal Society of Medicine 2019;112(5):192-99. doi: 10.1177/0141076819831872
I read with great enthusiasm the article by O’Byrne. As a senior medical student, my feelings resonate with her discussion. I also believe that medical students are given a further ethical challenge. This challenge is dedicating time towards volunteering during the COVID-19 outbreak or continuing with studies remotely. As stated in the article, the ‘curriculum is not readily compatible with the removal of students from their clinical placements(1). However, the guidance from Medical Schools Council (MSC)(2) state that the student’s first responsibility is to continue education and not jeopardise this with taking on too many additional duties.
As the GMC has not suspended education(3), we attend online tutorials and prepare for exams. However, one could argue that the online tutorials and self-learning from textbooks is not adequate education for such a vocational profession. Furthermore, medical schools have created excellent programmes for students in all years to volunteer and help. This ranges from practical clinical work for senior students to first-year students taking on tasks like the general public. With such well-managed, organised volunteering schemes, it seems that the student body has a duty to help. With students coming forward to volunteer in such large numbers(4) it is suggestive that medical students, just like other medical professionals, feel they have a moral duty to help in healthcare.
I read with great enthusiasm the article by O’Byrne. As a senior medical student, my feelings resonate with her discussion. I also believe that medical students are given a further ethical challenge. This challenge is dedicating time towards volunteering during the COVID-19 outbreak or continuing with studies remotely. As stated in the article, the ‘curriculum is not readily compatible with the removal of students from their clinical placements(1). However, the guidance from Medical Schools Council (MSC)(2) state that the student’s first responsibility is to continue education and not jeopardise this with taking on too many additional duties.
As the GMC has not suspended education(3), we attend online tutorials and prepare for exams. However, one could argue that the online tutorials and self-learning from textbooks is not adequate education for such a vocational profession. Furthermore, medical schools have created excellent programmes for students in all years to volunteer and help. This ranges from practical clinical work for senior students to first-year students taking on tasks like the general public. With such well-managed, organised volunteering schemes, it seems that the student body has a duty to help. With students coming forward to volunteer in such large numbers(4) it is suggestive that medical students, just like other medical professionals, feel they have a moral duty to help in healthcare.
Even though these well-organised volunteering roles exist, medical student duties to their study and difficult exams present a challenge in finding a healthy balance between study and volunteering. There is significant pressure to pass and perform well in exams that students may discover volunteering contradicts their academic output. Hence, I believe that the continuing remote education and examination (which pose their ethical considerations) retract students from being able to volunteer their full potential. Given that a large part of medical training is hands, future clinicians and tomorrow’s doctors need as much clinical experience as possible given the prediction of increasing epidemics(5).
Perhaps the best form of education is to adapt to our surroundings and to be able to engage our students in the present moment. Then we will feel fully educated and wholly resourceful.
The excellent essay published by Wynne et al (2020) in the journal of Medical Ethics 1 provides a timely reflection on the urgent need for improvements in the “provision of palliative care in humanitarian and emergency contexts” emphasized by the current Covid-19 pandemic. Regarding this issue, we would like to add some reflections from a developing country perspective about the death in abandonment that may support the authors proposal.
In 1343 Giovanni Boccaccio wrote about the patients with the Bubonic Plague in The Decameron: “Most of them remained in their houses, either through poverty or in hopes of safety, and fell sick by thousands. Since they received no care and attention, almost all of them died”. It is staggering that these words fit to describe the current situation of many patients with severe forms of Covid-19 that do not find places in hospitals. They are being denied even a palliative care and eventually die in their homes or elsewhere in a state of abandonment. This dramatic situation is unprecedented in modern times in wealthy societies. Unfortunately, it is not a novelty in many developing countries that chronically suffer from inadequate health systems, which are now crumbling with the current pandemic. In 1989, Marcio Fabri dos Anjos, a brazilian bioethicist proposed the term mysthanasia (from the Greek: mys = unhappy, thanathos = death) to characterize the death in state of abandonment (Ferreira & Porto, 2019). 2 It was attributed to the h...
The excellent essay published by Wynne et al (2020) in the journal of Medical Ethics 1 provides a timely reflection on the urgent need for improvements in the “provision of palliative care in humanitarian and emergency contexts” emphasized by the current Covid-19 pandemic. Regarding this issue, we would like to add some reflections from a developing country perspective about the death in abandonment that may support the authors proposal.
In 1343 Giovanni Boccaccio wrote about the patients with the Bubonic Plague in The Decameron: “Most of them remained in their houses, either through poverty or in hopes of safety, and fell sick by thousands. Since they received no care and attention, almost all of them died”. It is staggering that these words fit to describe the current situation of many patients with severe forms of Covid-19 that do not find places in hospitals. They are being denied even a palliative care and eventually die in their homes or elsewhere in a state of abandonment. This dramatic situation is unprecedented in modern times in wealthy societies. Unfortunately, it is not a novelty in many developing countries that chronically suffer from inadequate health systems, which are now crumbling with the current pandemic. In 1989, Marcio Fabri dos Anjos, a brazilian bioethicist proposed the term mysthanasia (from the Greek: mys = unhappy, thanathos = death) to characterize the death in state of abandonment (Ferreira & Porto, 2019). 2 It was attributed to the health systems failures due to insufficient funding, corruption and/or poor management. However, even theoretically unexpected, it is also happening in wealthy societies because their health systems became overwhelmed due to the pandemic. Regardless of its cause, misthanasia should not occur in any circumstances. Borasio et al (2020) 3 appropriately mentioned that “It is an ethical imperative to provide high quality palliative care for all patients who are likely to die from COVID-19, especially given their high symptom burden (dyspnea, anxiety etc.).”
To avoid misthanasia it would initially be necessary to acknowledge its existence and scale. In sequence, the palliative care should be organized for all the patients that need it, even in the eventuality of the local health system being unable to provide the appropriate curative treatment approaches. This is a moral imperative. It is a fundamental medical and humanitarian issue that does not require any major investment. Almost seven centuries after the narrative of the Plague in The Decameron it is embarrassing to acknowledge that humankind remains unable to avoid a pandemic or to provide proper curative treatment for all the patients suffering from it. Nevertheless, more empathy and care towards the ones that are left behind could be shown, because at least this is in our hands.
This study by Saint-Lary et al. was an interesting read and very informative. I commend the authors for uncovering so much regarding General Practitioner attitudes towards payment for performance schemes.
One thing that stood out to me was the use of a €100 incentive for study participants. It is not mentioned within the article whether study participants were aware of this reward before agreeing to participate in the study. This would be useful to know in order to understand whether the opinions and attitudes expressed in this study are truly representative of all French General Practitioners, or rather only of those who tend to be more financially driven. For example, the finding that all General Practitioners within the study considered the maximum bonus achievable to be low, may be explained by the fact that these doctors are particularly financially driven.
Given this possibility, I hope this point may be taken into account when interpreting the findings of this paper.
We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
Priority for limited resource...
We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. (4) It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. (5)
Withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for physicians and some doctors might refuse to do so. For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. (6)
The National Institute for Health and Care Excellence in the UK published on 20 March 2020 the Guideline with clinical decision-making. The basis of the Guideline is to maximize patient safety and appropriate use of resources. Admission to an intensive care unit is based on some assessment of frailty, comorbidities and likeliness to recover from the intensive treatment.
Solnica et al described the Jewish ethical prospective on medical triage in in the allocation of scarce resources. Utilitarian principles should be the basis for such decision. The difficulty, however, arises when it is impossible to triage patients based solely on utilitarian considerations.
The Jewish tradition also recognizes the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (1)
In response to the COVD-19 pandemic, three Fatwas (decrees) were issued by major Islamic Jurisprudence authorities. The first was issued by the Assembly of Muslim Jurists of America which stated that what is to be considered in prioritizing patients over others is the degree of need; so the one in greater need should be prioritized. If they have the same need, the one with a greater likelihood of recovery, based on clinical tools, should be given precedence. If such likelihood is equal, then those with the longer life expectancy should be given precedence. When applicable, service should be provided on a first come, first served basis. If all previous considerations do not give precedence to some over the others, resorting to lottery is a principle that is endorsed by the Islam. (8)
The second decree was issued on 28.3.2020 by the European Council for Fatwa and Research (ECFR) on managing scarce resources during this pandemic. It states: “Muslim physicians are committed to the regulations of the hospitals they work in. If the matter is assigned to the physicians, they must utilize medical, ethical and humanitarian standards. Withdrawal of life-saving equipment in order to treat a patient arriving later is not permitted. If the physician has no choice but to choose between two patients, then the former is offered the ventillator, unless he is deemed futile; the one in need of urgent treatment over the one whose condition allows delay, and the patient whose successful treatment is more likely.” (9)
The third recommendation was issued by The International Islamic Fiqh Academy which held a symposium on 16th April 2020 discussing the ethical implications of COVID-19 and stated that “Physicians should adhere to the medical and ethical standards. In case of excessive number of patients requiring ventilators with the lack of adequate devices, it is left to the discretion of the physician who prioritizes the one who deserves prioritization, and when they are equal, he resorts to lottery between patients”. (10)
The Islamic law permits withdrawal of futile treatment on the basis a clear medical decision by at least three physicians. (11) In futile cases, many Fatwas (decrees) stated that while life support treatment is permissible to stop, ancillary treatment including nutrition, hydration, pain control, and antibiotics should continue. (12)
References
1. Solnica A, Barski L, Jotkowitz A.Allocation of Scarce Resources During the COVID-19 Pandemic: A Jewish Ethical Perspective. J Med Ethics .2020 Apr 10. doi: 10.1136/medethics-2020-106242.
2. Khoo EJ, Lantos JD. Lessons learned from the COVID-19 pandemic [published online ahead of print, 2020 Apr 14]. Acta Paediatr. 2020;10.1111/apa.15307. doi:10.1111/apa.15307
3. Mannelli C. Whose Life to Save? Scarce Resources Allocation in the COVID-19 Outbreak. J Med Ethics. Epub ahead of print: doi:10.1136/medethics-2020-106227
4. Zucker H, Adler K, Berens D, et al. Ventilator allocation guidelines. Albany: New York State Department of Health Task Force on Life and the Law, November 2015 (https://www .health
.ny .gov/ regulations/ task_force/ reports_publications/ docs/ventilator_guidelines .pdf).
5. Kerstein SJ. Dignity, disability, and lifespan. J Appl Philos 2017; 34: 635-50.
6. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 [published online ahead of print, 2020 Mar 23]. N Engl J Med. 2020;10.1056/NEJMsb2005114. doi:10.1056/NEJMsb2005114
7. National Institute for Health Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE guideline 2020;25.
8. www.amjaonline.org/fatwa/en/87747/
9. www.e-cfr.org
10. http://www.iifa-aifi.org/5254.html
11. Al-Bar MA, Chamsi-Pasha H. Contemporary bioethics: Islamic perspective. New York (NY): Springer; 2015.http://link.springer.com/book/10.1007/978-3-319-18428-9
12. Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth. 2020;31(1):29‐46. Published 2020 Mar 22. doi:10.1080/11287462.2020.1736243
It is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intende...
It is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intended and designed to produce action-guiding recommendations to decision makers. That is, unlike other empirical bioethics research, deliberative methods ask members of publics to work together to determine what decision makers ought to do. The normative force of their recommendation, however, is not automatic: it relies on certain conditions being met to ensure the democratic legitimacy of deliberative processes and their outcomes. This is always by degree, and even a process that cannot legitimately prescribe policy action may provide valuable insights into matters of public significance.
What is required to achieve democratic legitimacy is a point of ongoing debate within the deliberative democratic literature. The onus is thus on both researcher and audience to critically evaluate, and continue conversations about, the methodological, epistemological and normative dimensions of deliberative research in empirical bioethics and health policy.
Shahvisi offers cogent arguments for men taking primary responsibility for unwanted pregnancy (1). I do not, in this letter, aim to argue against her conclusion. However, when discussing potential counterarguments to this position, she mentions that it is claimed that perhaps women would not trust men to use long-acting reversible contraceptives (LARCs). Shahvisi does well to point out the relevant data that reveals women in longer term relationships would, in fact, trust their partners to use LARCs (2,3). Yet in discussions of casual sexual encounters, she merely asserts that ‘barrier methods are in any case preferable’(1).
I argue this is not trivially the case. The use of barrier methods is highly inconsistent, particularly in casual sex (4–8). Despite their role in preventing both sexually transmitted infections (STIs) and unwanted pregnancy, I would argue that this data shows that people’s condom preferences are not so clear cut. Preference for condom use is heterogenous and is tied to desires more abstract than seeking to prevent pregnancy, such as the desire to feel masculine or ‘clean’ (8). Additionally, condoms, the most popular barrier method, are 86% effective at preventing unwanted pregnancy in typical use (9). LARCs are more than 99% effective (10).
It is my view that defeating the argument that women would not trust men to use LARCs in casual sexual relations thus needs more work. One argument might be that, in a world where...
Shahvisi offers cogent arguments for men taking primary responsibility for unwanted pregnancy (1). I do not, in this letter, aim to argue against her conclusion. However, when discussing potential counterarguments to this position, she mentions that it is claimed that perhaps women would not trust men to use long-acting reversible contraceptives (LARCs). Shahvisi does well to point out the relevant data that reveals women in longer term relationships would, in fact, trust their partners to use LARCs (2,3). Yet in discussions of casual sexual encounters, she merely asserts that ‘barrier methods are in any case preferable’(1).
I argue this is not trivially the case. The use of barrier methods is highly inconsistent, particularly in casual sex (4–8). Despite their role in preventing both sexually transmitted infections (STIs) and unwanted pregnancy, I would argue that this data shows that people’s condom preferences are not so clear cut. Preference for condom use is heterogenous and is tied to desires more abstract than seeking to prevent pregnancy, such as the desire to feel masculine or ‘clean’ (8). Additionally, condoms, the most popular barrier method, are 86% effective at preventing unwanted pregnancy in typical use (9). LARCs are more than 99% effective (10).
It is my view that defeating the argument that women would not trust men to use LARCs in casual sexual relations thus needs more work. One argument might be that, in a world where male LARCs are freely available, the trust that men are indeed using them would stem from a similar place to the trust that one’s sexual partners do not have any STIs. At present, STI status is not routinely verified (e.g., through the exchange of clinic results) before partners embark on casual sex. If at all, statements of trust, such as verbal assertions of STI status, may be proffered prior to casual sex (11,12). I argue it is plausible that, were male LARCs to become readily available, contraceptive status would be navigated in a similar fashion.
2. Campo-Engelstein L. Raging hormones, domestic incompetence, and contraceptive indifference: narratives contributing to the perception that women do not trust men to use contraception. Cult Health Sex [Internet]. 2013 Mar 1;15(3):283–95. Available from: https://doi.org/10.1080/13691058.2012.752106
3. Glasier AF, Anakwe R, Everington D, Martin CW, Spuy Z va. der, Cheng L, et al. Would women trust their partners to use a male pill? Hum Reprod [Internet]. 2000 Mar 1;15(3):646–9. Available from: https://doi.org/10.1093/humrep/15.3.646
4. Reynolds HW, Luseno WK, Speizer IS. Consistent condom use among men with non-marital partners in four sub-Saharan African countries. AIDS Care. 2013;25(5):592–600.
5. Mulumeoderhwa M. “It’s not good to eat a candy in a wrapper”: male students’ perspectives on condom use and concurrent sexual partnerships in the eastern Democratic Republic of Congo. SAHARA J J Soc Asp HIV/AIDS Res Alliance [Internet]. 2018 Aug 27;15(1):89–102. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30149788
6. Bowleg L, Massie JS, Holt SL, Heckert A, Teti M, Tschann JM. How black heterosexual men’s narratives about sexual partner type and condom use disrupt the main and casual partner dichotomy: ‘we still get down, but we not together.’ Cult Health Sex [Internet]. 2020 Feb 10;1–18. Available from: https://doi.org/10.1080/13691058.2019.1683228
7. Fetner T, Dion M, Heath M, Andrejek N, Newell SL, Stick M. Condom use in penile-vaginal intercourse among Canadian adults: Results from the sex in Canada survey. PLoS One. 2020;15(2):e0228981.
8. Sastre F, De La Rosa M, Ibanez GE, Whitt E, Martin SS, O’Connell DJ. Condom use preferences among Latinos in Miami-Dade: emerging themes concerning men’s and women’s culturally-ascribed attitudes and behaviours. Cult Health Sex. 2015;17(6):667–81.
9. Marfatia YS, Pandya I, Mehta K. Condoms: Past, present, and future. Indian J Sex Transm Dis AIDS [Internet]. 2015;36(2):133–9. Available from: https://pubmed.ncbi.nlm.nih.gov/26692603
11. Smith BD, Jewett A, Burt RD, Zibbell JE, Yartel AK, DiNenno E. “To share or not to share?” Serosorting by hepatitis C status in the sharing of drug injection equipment among NHBS-IDU2 participants. J Infect Dis [Internet]. 2013/10/16. 2013 Dec 15;208(12):1934–42. Available from: https://pubmed.ncbi.nlm.nih.gov/24136794
12. Pfeiffer EJ, McGregor KA, Van Der Pol B, Hardy Hansen C, Ott MA. Willingness to Disclose Sexually Transmitted Infection Status to Sex Partners Among College-Aged Men in the United States. Sex Transm Dis [Internet]. 2016 Mar;43(3):204–6. Available from: https://pubmed.ncbi.nlm.nih.gov/26859810
The COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, stayi...
The COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, staying healthily uninfected whilst we strive for containment remains a cause for celebration.
Albert Camus’ The Plague is balm to the fear-riven tear in the fabric of global society. Just as the decimated inhabitants of Shakespeare’s London outlasted the plaque, without modern medicine and public health interventions, the burgeoning coro-demic is but one of Camus' "many plagues in history…yet plagues and wars (still) take people equally by surprise.“ Camus’ contagion will surely go “unaccountably” when it pleases, the sooner if communities adjust and adhere to “bewildering portents” with care and caution to the lives of others. Camus urges the social distancing and lock-downs that today will mitigate the coro-disruption’s festering tenacity, and encourages that the pandemic threat is not fated to last forever.
As we face the rigours of self-isolation, the consumptive poet -doctor John Keats, exiled in the Bay of Naples as typhus raged, reminds the reader of life coming to a premature stop. The threat of cross-infection in my daily patient encounters incites Keat’s “mortality weigh(ing) heavily on me like unwilling sleep,” yet there is consolation in being “half in love with easeful death.” We should all salute the unsung scores of imperilled, some now dead, doctors and nurses that have risen to the occasion.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Adjunct associate professor, School of Public Health and Social Work
O Block, Room O-D610
Victoria Park Road
Kelvin Grove, Brisbane QLD 4059
Queensland University of Technology, Brisbane
Australia
Mob 0404826650
In Ireland, the Health (Regulation of Termination of Pregnancy) Act 2018 provides 'conscientious objection' for doctors and nurses (and their students and trainees). Conscientious objection under this legislation is not provided for pharmacists, pharmacy students or any other healthcare staff. The Irish state does not respect my inalienable human right to freedom of thought, conscience and religion, in this matter. My 'unavoidable personal beliefs' are unrecognised. As a pharmacist my dignity is not respected in the same way that the dignity of doctors and nurses and their students/trainees is respected in the Act.
As an Irish pharmacist I am deeply concerned at the challenge to my right to freedom of conscience and consequently my dignity as a human being. The Irish State must ensure that I as a human being and a pharmacist can enjoy my human and constitutional right to freedom of thought, conscience, religion or belief on the basis of respect for my inherent human dignity. Pharmacists (and others) can have 'unavoidable personal beliefs'.
The right to conscientious objection is not only based on the right to “freedom of conscience”, but also on Article 1 of the Universal Declaration of Human Rights which recognizes that all human beings “are endowed with reason and conscience.” This includes pharmacists.
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Cle...
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Clever use of rhetoric of nation, blood and land has made subsequent atrocities viewed as a correct course of action and generated what might be viewed as moral blindness. We are at risk of heading the same way.
Furthermore the paradigm of “informed consent” chosen by the authors is lukewarm, as it assumes a level playing field for a social contract between patient and doctor. This is not the case. Assuming the “consent” is the most suitable concept to use, then “valid” consent presents a better way of thinking about the problem. A valid consent demands absence of duress or fear. This may be possible for economic migrants who cross borders out of choice, but is not the case for refugees. As for access, to use the above examples, the ship has to reach a port, a safe haven for migrants to access healthcare. No doctor will refuse to care for a sick patient and the authors note the existence of that ethical obligation. But to require doctors to climb over the fence built by the legislators, paddle in boats into the sea to reach patients against the policy created by the government or go into communities to explain treacherous legal language is inappropriate and misleading. It gives an impression of apportioning the blame for the human rights crisis in evolution to the medical profession alone. The problem we face as a society is bigger than communication, health promotion or policy interpretation. It concerns our existence as moral, compassionate and responsible beings. It concerns the future of humanity.
References:
1. Glennerster R, Hodson N. Confused out of care: unanticipated consequences of a “Hostile Environment”. J Med Ethics Epub ahead of print: 22.01.2020 doi:10.1136/medethics-2019-105634. [Accessed 22.01.2020].
O’Byrne et. al raise the important issue of pandemic preparedness in medical students’ readiness to deal with the covid-19 pandemic. Healthcare professionals have a moral obligation to volunteer to help, however, there has been a lack of strict consideration for the preparedness and clinical competency of medical students in these circumstances. The article correctly highlights that medical students’ desire to help is insufficient alone, and there is a need for adequate medical education and training to better prepare students for any potential moral trauma and adverse risks to mental health. However, for those newly graduated students, we feel as though the need for a break from clinical activity is a concept that has been overlooked and may be imperative to true pandemic preparedness amongst this cohort.
The majority of medical students will complete an intensive 5-year curriculum before graduating and applying to the foundation programme to continue their training, 43% of whom will have had no break from education up to this point.(1) As highlighted in the article by O’Byrne et. al, many of these students face problems with their mental wellbeing during medical school and thereon after. These problems regarding mental and emotional wellbeing are heightened in situations where students feel anxious or unprepared, such as clinical placements and rotations.(2) The importance of breaks to aid mental wellbeing are well recognised throughout the curriculum, such as tim...
Show MoreDear Editor,
I read with great enthusiasm the article by O’Byrne. As a senior medical student, my feelings resonate with her discussion. I also believe that medical students are given a further ethical challenge. This challenge is dedicating time towards volunteering during the COVID-19 outbreak or continuing with studies remotely. As stated in the article, the ‘curriculum is not readily compatible with the removal of students from their clinical placements(1). However, the guidance from Medical Schools Council (MSC)(2) state that the student’s first responsibility is to continue education and not jeopardise this with taking on too many additional duties.
As the GMC has not suspended education(3), we attend online tutorials and prepare for exams. However, one could argue that the online tutorials and self-learning from textbooks is not adequate education for such a vocational profession. Furthermore, medical schools have created excellent programmes for students in all years to volunteer and help. This ranges from practical clinical work for senior students to first-year students taking on tasks like the general public. With such well-managed, organised volunteering schemes, it seems that the student body has a duty to help. With students coming forward to volunteer in such large numbers(4) it is suggestive that medical students, just like other medical professionals, feel they have a moral duty to help in healthcare.
Even though these well-organise...
Show MoreThe excellent essay published by Wynne et al (2020) in the journal of Medical Ethics 1 provides a timely reflection on the urgent need for improvements in the “provision of palliative care in humanitarian and emergency contexts” emphasized by the current Covid-19 pandemic. Regarding this issue, we would like to add some reflections from a developing country perspective about the death in abandonment that may support the authors proposal.
Show MoreIn 1343 Giovanni Boccaccio wrote about the patients with the Bubonic Plague in The Decameron: “Most of them remained in their houses, either through poverty or in hopes of safety, and fell sick by thousands. Since they received no care and attention, almost all of them died”. It is staggering that these words fit to describe the current situation of many patients with severe forms of Covid-19 that do not find places in hospitals. They are being denied even a palliative care and eventually die in their homes or elsewhere in a state of abandonment. This dramatic situation is unprecedented in modern times in wealthy societies. Unfortunately, it is not a novelty in many developing countries that chronically suffer from inadequate health systems, which are now crumbling with the current pandemic. In 1989, Marcio Fabri dos Anjos, a brazilian bioethicist proposed the term mysthanasia (from the Greek: mys = unhappy, thanathos = death) to characterize the death in state of abandonment (Ferreira & Porto, 2019). 2 It was attributed to the h...
This study by Saint-Lary et al. was an interesting read and very informative. I commend the authors for uncovering so much regarding General Practitioner attitudes towards payment for performance schemes.
One thing that stood out to me was the use of a €100 incentive for study participants. It is not mentioned within the article whether study participants were aware of this reward before agreeing to participate in the study. This would be useful to know in order to understand whether the opinions and attitudes expressed in this study are truly representative of all French General Practitioners, or rather only of those who tend to be more financially driven. For example, the finding that all General Practitioners within the study considered the maximum bonus achievable to be low, may be explained by the fact that these doctors are particularly financially driven.
Given this possibility, I hope this point may be taken into account when interpreting the findings of this paper.
We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
Show MoreThe Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
Priority for limited resource...
It is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intende...
Show MoreDear editor,
Shahvisi offers cogent arguments for men taking primary responsibility for unwanted pregnancy (1). I do not, in this letter, aim to argue against her conclusion. However, when discussing potential counterarguments to this position, she mentions that it is claimed that perhaps women would not trust men to use long-acting reversible contraceptives (LARCs). Shahvisi does well to point out the relevant data that reveals women in longer term relationships would, in fact, trust their partners to use LARCs (2,3). Yet in discussions of casual sexual encounters, she merely asserts that ‘barrier methods are in any case preferable’(1).
I argue this is not trivially the case. The use of barrier methods is highly inconsistent, particularly in casual sex (4–8). Despite their role in preventing both sexually transmitted infections (STIs) and unwanted pregnancy, I would argue that this data shows that people’s condom preferences are not so clear cut. Preference for condom use is heterogenous and is tied to desires more abstract than seeking to prevent pregnancy, such as the desire to feel masculine or ‘clean’ (8). Additionally, condoms, the most popular barrier method, are 86% effective at preventing unwanted pregnancy in typical use (9). LARCs are more than 99% effective (10).
It is my view that defeating the argument that women would not trust men to use LARCs in casual sexual relations thus needs more work. One argument might be that, in a world where...
Show MoreThe COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, stayi...
Show MoreIn Ireland, the Health (Regulation of Termination of Pregnancy) Act 2018 provides 'conscientious objection' for doctors and nurses (and their students and trainees). Conscientious objection under this legislation is not provided for pharmacists, pharmacy students or any other healthcare staff. The Irish state does not respect my inalienable human right to freedom of thought, conscience and religion, in this matter. My 'unavoidable personal beliefs' are unrecognised. As a pharmacist my dignity is not respected in the same way that the dignity of doctors and nurses and their students/trainees is respected in the Act.
As an Irish pharmacist I am deeply concerned at the challenge to my right to freedom of conscience and consequently my dignity as a human being. The Irish State must ensure that I as a human being and a pharmacist can enjoy my human and constitutional right to freedom of thought, conscience, religion or belief on the basis of respect for my inherent human dignity. Pharmacists (and others) can have 'unavoidable personal beliefs'.
The right to conscientious objection is not only based on the right to “freedom of conscience”, but also on Article 1 of the Universal Declaration of Human Rights which recognizes that all human beings “are endowed with reason and conscience.” This includes pharmacists.
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Cle...
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