Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options....
Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options.
Most of these patients have conditions such as motor neurone disease or
early dementia in which death within six months would not be expected.
Recently, I was asked to see a patient with purely psychiatric diagnoses
and have thus been thinking very hard about the issues discussed in their
paper.
It seems difficult to argue that intractable mental distress is
intrinsically less worthy of our concern than intractable somatic
distress. Most people who kill themselves do so as a result of
psychological rather than physical distress. Much of that distress proves
to be transient and/or tractable (and frequently aggravated by various
intoxications) but some of it is neither. The largest and most
comprehensive survey of suicides in a single 'western' country during the
entire 20th century [1] concluded that many suicides were due to eminently
'understandable' combinations of circumstance and personality or world-
view. Obvious mental illness was a less important factor.
The present era of DSM-5 imperialism is associated with sometimes
ludicrous claims for the effectiveness of antidepressants, despite
consistent evidence that placebo and non-specific mechanisms are much more
prominent than pharmacological ones. Personality disorders are, almost by
definition, resistant to both drugs and psychotherapy. When someone has
reached their mid-thirties without relief and despite such appropriate
interventions as exist, psychiatry should perhaps show a little
therapeutic humility.
Much of the organised opposition to MARS is religious and I think it
goes back to the Augustinian view that suicide is a worse sin than
homicide because it implied criticism of the world that God had created
[2] - a position that led to the ritual desecration of the corpse until
1825 in Britain. Even today, both the main churches officially deny
Christian burial in consecrated ground to suicides, though the Church of
England voted this year to revoke the relevant Canon Law. They get round
the prohibition in practice by claiming that all suicides must have been
suffering from insanity. The official position of psychiatry seems rather
similar.
REFERENCES.
1.Weaver J. Sorrows of a Century: interpreting suicide in New Zealand 1900
-2000.Montreal. McGill-Queen's university press. 2014.
2. Brewer C. Christian attitudes to suicide. In: C Brewer and M Irwin
Eds. I'll See Myself Out, Thank You. Thirty personal views in support of
assisted suicide. Newbould on Stour. Skyscraper. 2015
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases...
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases does PPI (Patient and Public Involvement) in the
research applications we see "adequately reflect the perspectives and
input of ... citizens." The predominant reason for this is a n
unwillingness to go outside the institution and its familiar sources to
the public 'out there'. This is despite the regular requirement to do so
of funding bodies and the law.
If institutions were to comply on a regular and consistent basis, the
need for PLR would be confined to what, in my perception, is the very
limited number of occasions when it would be practicable.
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprise...
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprised by it.
I've been making some effort to understand Islamic medical ethics and its
intersection with Western medical ethics for a couple of years now, as
part of the establishing the policy for King's College Hospital's clinic
in Abu Dhabi, where it has been important to recognise, and apply, both
the ethics of both countries and traditions. Throughout many discussions
of particular practical matters, and ethical decisions, the teachings of
Adab have not been mentioned.
The original sources are the right place to go for an understanding,
but I, and I think others, would find a guide to the field would be
extremely useful. Books that I can find in English on the subject appear
to be either historical, or literary, or to be concerned with non-medical
aspects of adab.
Conflict of Interest:
I am co-chair of the ethics committee of KCH Clinics Abu Dhabi - I'd hope more of a supporting, than a competing, interest, but I should mention it.
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagree...
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagreement and respect can and must co-exist.
Problems arise when conscience impedes the implementation of laws. In
her article, Minerva identifies an example of this in Italy, where a
women's access to abortion services is limited due to the high proportion
of doctors who, for conscientious reasons, forgo involvement in abortion
procedures. Minerva surveys the problem and suggests how it could be
mitigated, after a brief critique of the concepts of conscience absolutism
and what she terms the compromise position.
Minerva defines conscience absolutism as the healthcare
practitioners' right to decline a service, to the extent that it may
"compromise the right of the patient to be cured"[1]. It is possible that
some healthcare practitioners take this view with abortion, even if the
mother's life is immediately threatened. Many, however, as Minerva
acknowledges, hold the compromise position, whereby the healthcare
practitioner's right of refusal is respected, but he agrees to refer the
patient to a willing colleague. To most, this is preferable to conscience
absolutism. It is worth noting that UK law makes a concession for this in
Section 4 of the 1967 Abortion Act, which says, "no person shall be under
any duty... to participate in any treatment authorised by this Act to
which he has a conscientious objection", unless the mother's life is at
risk[3].
However, Minerva argues that such a set-up is inadequate in Italy;
intervention is needed to facilitate access to abortion because, "the
public health system has the responsibility and duty to guarantee to
citizens all safe and beneficial treatments they are entitled to
request"1. In response, I would argue that a woman's legal right to
abortion does not negate a physician's right to conscience. If the state
has a duty to protect both these rights, it cannot use one right to
supplant the other.
Finally, Minerva's second of three recommendations to redress the
issue of abortion access merits comment. She proposes that physicians
should be discouraged from conscientiously objecting by providing an
incentive - she suggests pay rises and holidays - to those who will
perform abortions. The right to conscience is ostensibly respected in
this case, though the moral agency behind it is insulted. At best, it is
profoundly patronising to incentivise doctors to compromise on personal
conscience for the sake of expediency.
In conclusion, regardless of one's view of abortion, the right to
conscientious objection must be maintained in a free society, even at the
expense of unmet requests. The physician is not a slave to the public's
demands. Minerva rejects conscience absolutism; we must reject demand
absolutism.
References:
1. Minerva F. J Med Ethics 2015;41:170-173
2. Trigg R. J Med Ethics 2015;41:174
3. Abortion Act 1697, Section 4
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without...
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without that.
Science is all about "profession" and social well being via technology and
services but yes all these technologies just can't change the fate.
Religion teaches us to how we can spend a good life but science teaches us
best way to use the neccesities around us in the form of technologies.
All religions teach us to be ethical, faithful towards our duties
under legal rules. Who so ever is a patient (birth control based to gays
or lesbians), a doctor must treat him/her as a "subject". The point is a
medical or paramedical staff at "duty" must follow their duty even what
ever religion they follow. But yes, I feel a good religious practicing
medical or paramedical staff will be ethically and morally will be better
than a religious non practicing staff. Religion can make us a better human
if we practice a religion and this will be reflected in our jobs and
strength of our moral ethics in dealing with the patients.
Its not the matter which religion we belong, but it does matter how
the world see us and how we treat the humans ethically and morally and
yes, if a non religious person with no ethics and no morals follow the
regulations and rules concerning with patient and communication skills, he
may be even better doctor than a religious doctor.
Way of passing life (religion) Vs profession must be treated
separately.
Greater transparency and regulatory oversight in disclosing gifts and
payments to physicians from drug and medical device companies could well
reduce their influence on a doctor's prescribing habits and medical
management recommendations. The threat of a very public loss of
professional reputation among peers and patients is likely to discourage a
physician accepting drug and medical device company generosity. However, a
m...
Greater transparency and regulatory oversight in disclosing gifts and
payments to physicians from drug and medical device companies could well
reduce their influence on a doctor's prescribing habits and medical
management recommendations. The threat of a very public loss of
professional reputation among peers and patients is likely to discourage a
physician accepting drug and medical device company generosity. However, a
more positive, potentially more effective and formative approach would be
include in medical school ethics curricula the psychology of gifting and
the adverse influence on clinical practice exerted by pharmaceutical
company incentives and honoraria. Instead of policing behavior to stop
physicians raiding Big Pharma's cookie jar, we should intensively caution
our medical students about inappropriate ties with pharmaceutical
industry. The latter could form the basis of a career-long ethical
approach towards refusing undue gifts and payments.
Careful scrutiny of drug-company sponsored clinical trials could lead
doctors to the conclusion that exciting but expensive new treatments are
not superior to reliable old work horses. Sponsored studies may ignore
comparisons with long-established effective drugs (there's little income
in established patent-expired drugs. By aggressively marketing their
newest products, drug companies would have physicians believe otherwise.
If only doctors had the time at work (preferably paid and without
clinical obligation) and the necessary skills to assess the methodological
robustness of a study, decipher its findings and apply its conclusions to
patients. Such favourable conditions are rarely available outside the
journal club, postgraduate training, teaching hospital and medical school.
If health executives really care about research bearing relevance to
patient care in ambulatory and community practice, they need to fund
doctors to train in appraising the quality of what they read and pay them
for the time spent keeping up to date. Better informed doctors are likely
to deliver better care and dividends in improved care will likely outgrow
remuneration to doctors.
Burgeoning health-care evidence needs to be efficiently delivered to
doctors caring for patients in digestible allotments that will not prove
overwhelming. This involves communicating information relevant to their
clinical practice or specialty, in a format and schedule compatible with
achieving balance in a doctor's work and personal life.
Paying doctors for non-clinical time to learn about the latest
evidence is a good start. Even if one has not assessed the original
studies, investigation and treatment summaries updated with newly emerging
clinical research provides a short-hand way for ensuring patients receive
the best of care, but requires commensurate time to absorb.
The argument for substantial benefit conferred by the placebo effect
in treatment trials has been around for a while. Clinical triallists do
not deny that inactive sugar pills and IV medications or sham surgery have
some quantifiable benefit when compared with doing nothing at all.
Patients who consent to participate in treatment studies tend to be more
motivated and confident that they will get better than those who ref...
The argument for substantial benefit conferred by the placebo effect
in treatment trials has been around for a while. Clinical triallists do
not deny that inactive sugar pills and IV medications or sham surgery have
some quantifiable benefit when compared with doing nothing at all.
Patients who consent to participate in treatment studies tend to be more
motivated and confident that they will get better than those who refuse to
be enrolled, despite only having a one in two chance of receiving a
potentially beneficial therapy. Randomised controlled trials attempt to
discern whether new therapies result in a clinically relevant benefit
(improved survival, reduced symptoms) in addition to that conferred by the
human mind's empowerment to enhance immunological and psychological
defences from participation in studies. Furthermore the awareness of being
closely observed and monitored for clinical progress or deterioration is
an incentive for patients to do better (the Hawthorne effect, aiming to
gain approval from investigators and other participants), regardless of
whether a study subject receive the tested or inactive treatment.
Ebola haemorrhagic fever, with its high case fatality risk, has no
reliably proven effective single drug or immune treatment. Although
several repatriated adults in advanced health systems have survived with
novel immune therapy, it could well have been the excellent critical care
and fluid resuscitation that were responsible for their recovery. The
latter would almost certainly not be available on a day to day basis in
the impoverished West African countries where EHF trials would be
conducted. In addition to placebo comparisons, the study of advanced fluid
resuscitation, immunomodulators and vaccines in vulnerable people who
cannot afford such treatments even if they were found to work remains
ethically challenging.
A substantial proportion of medical research funding in advanced
health economies are diverted to the overzealous policing of low risk
observational studies.
As we plea and wait for the resumption of competitive funding to the
research endeavour so necessary to maintaining Australia's global stature
as a science and innovation based economy, the haemorrhage could be
stemmed re- allocati...
A substantial proportion of medical research funding in advanced
health economies are diverted to the overzealous policing of low risk
observational studies.
As we plea and wait for the resumption of competitive funding to the
research endeavour so necessary to maintaining Australia's global stature
as a science and innovation based economy, the haemorrhage could be
stemmed re- allocating scarce resources from the non-productive and
demoralising barrier imposed by the layer of administration and
bureaucracy that sits on top of, and suffocates, original scientific
research.
I faced months of delays to starting low risk studies that aim to
record current clinical care practices to establish a baseline from which
improvements could be identified and assessed further. This included
"behind the scenes" observation of acute pain management and sedation
protocols that aim to calm the acutely agitated. Neither study influenced
clinician behaviour or treatment as would have been occurred during
routine care. Both had already been declared to being above reproach by
reputable regulatory and oversight bodies in Melbourne Australia.
I had to expend numerous hours of tortuous negotiation of a maze of
needlessly imposed complexity mandated by my local hospital ethics and
governance committee. National Ethics Application Forms and numerous other
documents had to be identically filled in with my hospital's mast head and
be re-submitted to await much-delayed adjudication.
Researchers should contest the resource- and labour-intensive
bureaucratisation of research oversight that confers no additional
protection to participants in low risk obervational research in the
advanced economies, including Australia's.
Australia's gutting of science research funding has at least served
to highlight dispiriting barriers posed by administrative processes that
are wasteful withut conferring additional benefit or participant
protection.
A very difficult area indeed. My view is that that, once you have
decided to stop fluids and/or nutrition, then the patient will certainly
die. Whether or not they will suffer whilst starving, or dehydrating, is
unclear. However, prolonging life in such cases extends suffering for
relatives, staff, and possibly/probably the patient.
A lethal injection at this point is surely more humane than extending
life and,...
A very difficult area indeed. My view is that that, once you have
decided to stop fluids and/or nutrition, then the patient will certainly
die. Whether or not they will suffer whilst starving, or dehydrating, is
unclear. However, prolonging life in such cases extends suffering for
relatives, staff, and possibly/probably the patient.
A lethal injection at this point is surely more humane than extending
life and, thus, extending suffering. As a profession doctors should surely
see a 'good' death as a part of the care we should be providing. I can see
nothing good about allowing someone to starve to death, because we feel
that taking an active step, is a step too far. We have already decided
that they are going to die. Why not provide the quickest and most painless
death possible?
Critics of a regulated market in organs have correctly focussed on
its inability to protect the vendor from coercion and exploitation.
However, they have consistently failed to realise that coercion and
exploitation are not immanent in this market. Rather, they are immanent in
the need to even consider selling ones organs (free people do not engage
in such considerations). In other words, the critics have failed to
ackno...
Critics of a regulated market in organs have correctly focussed on
its inability to protect the vendor from coercion and exploitation.
However, they have consistently failed to realise that coercion and
exploitation are not immanent in this market. Rather, they are immanent in
the need to even consider selling ones organs (free people do not engage
in such considerations). In other words, the critics have failed to
acknowledge that a regulated market in organs should, at least
theoretically, be able to protect the vendor from coercion and
exploitation that might occur within the sphere of exchange, but it cannot
protect the vendor, not even theoretically, from coercion and exploitation
that occur universally outside this sphere. Even worse, its ethical guise
would only serve to conceal and reinforce them.
In this light, criticism of any organ market could make sense only if
it were part of the greater struggle against the oppressive social
conditions that have made it a viable option to begin with. This anti-
market argument still awaits refutation.
Dear Editor. I do occasional psychiatric assessments for people contemplating medically-assisted rational suicide (MARS) in Switzerland and broadly agree with Schuklenk and van der Vathorst's arguments. Usually, my role is limited to assessing mental capacity and excluding the existence of a treatable psychiatric condition that might be influencing the patient's decision to include MARS in the list of acceptable options....
The Article states "In health research, funding bodies and academic institutions actively undertake patient and public involvement programmes to ensure that studies adequately reflect the perspectives and input of patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for seven years. I do not recognise this statement, nor would my colleagues. In very few cases...
I think this is a very important article. Well written, well researched and timely.
It seems that there is a large body of ancient wisdom locked away in the Adab writings. I suspect that there will be material of great value to Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing ethic, to Sharia. I'm ashamed of my ignorance, and also surprise...
In his commentary on Francesca Minerva's paper 'Conscientious Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for people who agree", and, "it is against the spirit of democracy to ride roughshod over other's [sic] beliefs"[2]. His point is apposite: in a democratic society an individual's conscience in matters of ethical controversy ought not to be compromised by popular sensitivities. Sharp disagree...
With respect to all authors, I have read the article and the comments made in the e-letter. I agreed with Biggar to little extent. But one of the important point here is the reason of following religion Vs following the science. Religion is not only about the beliefs but also about the practices. It teaches us 24 hours way of passing life by giving us the heavenly or moral knowledge either with a concept of God or without...
Greater transparency and regulatory oversight in disclosing gifts and payments to physicians from drug and medical device companies could well reduce their influence on a doctor's prescribing habits and medical management recommendations. The threat of a very public loss of professional reputation among peers and patients is likely to discourage a physician accepting drug and medical device company generosity. However, a m...
The argument for substantial benefit conferred by the placebo effect in treatment trials has been around for a while. Clinical triallists do not deny that inactive sugar pills and IV medications or sham surgery have some quantifiable benefit when compared with doing nothing at all. Patients who consent to participate in treatment studies tend to be more motivated and confident that they will get better than those who ref...
To the Editor:
A substantial proportion of medical research funding in advanced health economies are diverted to the overzealous policing of low risk observational studies.
As we plea and wait for the resumption of competitive funding to the research endeavour so necessary to maintaining Australia's global stature as a science and innovation based economy, the haemorrhage could be stemmed re- allocati...
A very difficult area indeed. My view is that that, once you have decided to stop fluids and/or nutrition, then the patient will certainly die. Whether or not they will suffer whilst starving, or dehydrating, is unclear. However, prolonging life in such cases extends suffering for relatives, staff, and possibly/probably the patient.
A lethal injection at this point is surely more humane than extending life and,...
Critics of a regulated market in organs have correctly focussed on its inability to protect the vendor from coercion and exploitation. However, they have consistently failed to realise that coercion and exploitation are not immanent in this market. Rather, they are immanent in the need to even consider selling ones organs (free people do not engage in such considerations). In other words, the critics have failed to ackno...
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