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Recent eLetters

Displaying 1-10 letters out of 439 published

  1. PLR - better to boost PPI

    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.

    Conflict of Interest:

    None

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  2. Where should this go next?

    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.

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  3. Rejecting Demand Absolutism

    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

    Conflict of Interest:

    None declared

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  4. Religion Vs Science towards Life and Survival

    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.

    Conflict of Interest:

    None declared

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  5. response to the article : After-birth abortion: why should the baby live?

    In an article entitled "After-birth abortion: Why should the baby live?" the authors, Dr. Francesca Minerva and Alberto Giubilini argued that because the abortion is accepted, it should be legal to kill newborns as well. They claim that a newborn and a fetus are morally equivalent and are not *person* in a sense that they are not able to ascribe any value to their existences and are not subjects of a right to life. How is that for ethics? Where is the standard of morality? If this practice is allowed, where do we draw the line? If human beings have to be able to assign value to their lives, many mentally ill people can be killed. This is nothing but undermining the value of human beings simply because of their station in life. The moral status of a newborn and a fetus are both an opinion rather than fact dependent. It is enough to be a human being to have a right to life. Newborns are independent human beings and their right to live is a moral axiom. They hold an unconditional value and they are related to the world around them. So, their human rights and dignity should be fully respected.

    Conflict of Interest:

    None declared

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  6. response to ( After-birth abortion: why should the baby live?)

    A Letter to the editor

    In an article entitled " After -birth abortion: Why should the baby live?" the authors, Dr. Francesca and Alberto Giubilini argued that both fetuses and new born don't have the same moral status and the actual person and concludes that what we call 'after-birth abortion' (killing a newborn) should be permissible in all the case where abortion is, including case where the new born is not disabled. What are our ethical boundaries? Is it not enough to be human being to live a life? The newborn babies can't defend themselves, they are yet not capable of raising their voice doesn't mean we shouldn't value their existence. There are many disorders that can only be diagnosed 18 months after birth, should they be killed as well? They also said "we also need to consider the interest of the mother who might suffer psychological distress from giving her child up for the adoption." There are many adaption system that are in practice like "open adaption", where adoptive parents hold all the rights as the legal parents, yet the individual of the biological and adoptive families can contact each other and the child in various way, by sending emails or face to face visit. I think instead of making an abortion as option, we should significantly improve the process of the adaption and meet the requirement of the both biological and adaptive families.

    Conflict of Interest:

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  7. Does religion deserve a place in secular medicine? Brief comment on Biggar (2015)

    In the latest issue of the Journal of Medical Ethics, Professor Nigel Biggar--an Oxford theologian--argues that "religion" should have a place in secular medicine (Biggar, 2015).

    Some people will feel a shiver go down their spines--and not only the non-religious. After all, different religions require different things, and sometimes they come to opposite conclusions. So whose religion, exactly, does Professor Biggar have in mind, and what kind of "place" is he trying to make a case for?

    When one thinks of stories like the 2012 death of a woman in Ireland due to septicemia after being denied an abortion ("This is a Catholic country," she was reportedly told by medical staff; see Quinn, 2012), one is reminded of the ways in which some people's religious beliefs can have profound (even fatal) consequences for others who may not share those same beliefs. As Mother Jones reported in 2013:

    "A growing number of patients are finding their health care options governed by [religious] guidelines as Catholic hospitals, long major players in the health care market, have been on a merger streak, acquiring everything from local hospital systems to medical practices, nursing homes, and health insurance plans" (Mencimer, 2013).

    In the U.S. context, at least, Catholic hospitals are required to follow health care directives handed down by the US Conference of Catholic Bishops--a group described as "celibate older men who have become increasingly conservative over the past few decades" by the author of the Mother Jones piece.

    What are the implications? What does this mean--in other words--for individuals who, say, reject Catholic doctrine on principle, but don't have feasible alternatives for personal healthcare as a result of the "merger streak" described above? Stephanie Mencimer (2013) lays out some of the concrete effects:

    (1) abortion services disappear,

    (2) doctors may be prohibited from prescribing birth control (and hospital pharmacies won't sell it),

    (3) emergency contraception may be denied to rape victims,

    (4) tubal ligations and vasectomies are prohibited,

    (5) patients' requests to be removed from feedings tubes or life support -- as expressed in living wills -- may be ignored,

    (6) hospitals are permitted to discriminate against gays and lesbians, whether they are employees or patients ... and so on.

    So there seems to be some cause for concern. At least, there is if you don't agree with the moral worldview of the "celibate older men" we've been talking about. But when you actually read the article by Professor Biggar, you may find yourself detecting a certain hint of a bait-and- switch. This is because (or so I'll suggest) the word "religion" in the title of Professor Biggar's piece ends up meaning something not so very different from "philosophy"--which is a lot less controversial.

    Here is some evidence for my view:

    First, Biggar begins by ruling out the "irrational" parts of religion (since he doesn't see irrationality as being uniquely the province of religions, and he thinks we should stay away from it whatever its source, so long as our goal is to make a convincing argument), as well as all appeals to authority, "whether to that of the Bible or of the Pope or of the Qur'an" (Biggar, 2015, p. 230).

    Then, he goes on to suggest that religious people cannot just force their views on others, but instead must attempt to "persuade" them using, well, all the ordinary tools of philosophical debate. So, to illustrate, he says that: "If I, a religious believer, am going to succeed in persuading you, an agnostic or atheist or different kind of religious believer, of my moral view [about abortion, as he discusses in this passage], then I will have to show you that your view has weaknesses or problems, that these cannot be adequately repaired in your terms, but that they can be repaired in mine" (Biggar, 2015, p. 230).

    Ok ... but so what? How is that different from just doing philosophy? You can imagine a slight adjustment to the phrasing: "If I, a utilitarian, am going to succeed in persuading you, a Kantian, or Rawlsian, or different kind of moral philosopher, of my moral view, then I will have to show you that your view has weaknesses or problems, that these cannot be adequately repaired in your terms, but that they can be repaired in mine."

    Other moral frameworks could be slotted in as well. The point is, we all have certain meta-ethical commitments (whether explicit or implicit)-- religious or otherwise--and we all have to try to convince those we disagree with that our meta-ethical commitments make more sense than theirs do, or do a better job of explaining a shared moral intuition, or whatever. That's just "doing philosophy."

    So what does religion, specifically, have to do with Biggar's argument? His answer is this:

    "Religion has the following to do with it. As a Christian monotheist, I esteem the lives of human individuals very highly: all individuals are equally the creatures of one divine Father, and each has a special vocation in their time and place. As a consequence, even if I believe that it can be morally right for one individual to take another's life, I think that killing is a morally and socially hazardous business and that it should never be done casually and without cogent reason" (Biggar, 2015, p. 230).

    I'm not sure that answers the question. After all, any number of non- religious philosophies or moral worldviews could end up reaching the (seemingly obvious) conclusion that "killing ... should never be done casually and without cogent reason" without having to avail themselves of such premises as there being a "divine Father" (of which we are all "equally the creatures") or similar.

    In other words, if P entails Q, and Q is true (here, "Q" means: we shouldn't kill people willy nilly without good reason), we have little reason to think that P (Christianity?) is true, too - simply on account of the fact that A, B, C, and D (and all the rest of the alphabet for that matter) could just as well entail Q, and one of those might be the one that's correct. Biggar actually concedes this point a little later on.

    Accordingly, it is about as persuasive to say "As a Christian monotheist" before delivering a moral argument as it is to say "As a Marxist" (or whatever else you please): what matters is whether your premises are reasonable, and whether your conclusions follow from your premises. Whether your premises are reasonable is, yes, the million-dollar question--and to convince me, you'll have to do some meta-ethics. But that doesn't have anything to do specifically with religion.

    To be sure, Biggar does have some additional arguments up his sleeve, and his paper goes on for a while longer. Nevertheless, I still didn't get the sense that "religion" meant anything different from "philosophy" by the end of it--although perhaps I missed a crucial point. I must say that I am reminded of Sam Harris's recent attempt (Harris, 2011) to argue that "science can determine human values," where by "science" he apparently means "moral philosophy plus facts" (as I argue in a forthcoming paper: see Earp, in press).

    When you grab your reader's attention by saying "religion" (in Biggar's case) or "science" (in Harris's case) -- and all you apparently mean is "moral philosophy," your reader could be forgiven for feeling a little bit misled.

    * Note: this e-letter is adapted from a blog post by the author originally published at the Journal of Medical Ethics blog on 26 February, 2015. This post is available at the following link http://blogs.bmj.com/medical-ethics/2015/02/26/does-religion-deserve-a- place-in-secular-medicine/.

    References

    Biggar, N. (2015). Why religion deserves a place in secular medicine. Journal of Medical Ethics, 41: 229-233.

    Earp, B. D. (in press). Science cannot determine human values. Think: A Journal of the Royal Institute of Philosophy, in press. Available at https://www.academia.edu/10290501/Science_cannot_determine_human_values.

    Harris, S. (2011). The moral landscape: How science can determine human values. New York: Simon and Schuster.

    Mencimer, S. (2013). Do bishops run your hospital? Mother Jones. Available at http://www.motherjones.com/politics/2013/10/catholic- hospitals-bishops-contraception-abortion-health-care.

    Quinn, B. (2012, November 13). Scandal in Ireland as woman dies in Galway 'after being denied abortion.' The Guardian. Available at http://www.theguardian.com/world/2012/nov/14/ireland-woman-dies-after- abortion-refusal.

    Conflict of Interest:

    None declared

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  8. Teaching medical students rational prescribing and improving opportunities for doctors to appraise new treatments enhances rational prescribing

    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.

    Conflict of Interest:

    None declared

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  9. The use of placebos in Ebola treatment trials

    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.

    Conflict of Interest:

    None declared

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  10. Is it ethical for scarce research funding to be diverted to overzealous policing of low risk observational studies?

    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- 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.

    Conflict of Interest:

    None declared

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