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Displaying 1-10 letters out of 454 published

  1. After Birth Abortion: Three Years On

    To the editor.

    Three years ago, on February 23rd, 2012, the Journal of Medical Ethics pre-published electronically the paper by Alberto Giubilini and Francesca Minerva, which proposed the new term "after-birth abortion" as a key concept for re-interpreting an old debated issue, i.e. the moral relevance of birth for the right to life of fetuses/newborns. As is well- known to the readers of this Journal, a few days afterwards media and web- sites around the world raised a storm on such paper, deploying such titles as: "Slaughter newborn kids, say academics. Fury at call to legalize 'after-birth abortions'", "Academics - Who Else? - Call for the Killing of Babies", "Infanticide as a Right: Killing Babies No Different From Abortion, "Experts" Say". The editor of the JME promptly rebutted the attacks, highlighting the cultural and liberal line of the journal and of academic discussion in general. This, however, was not enough to stop the wave of offences and insulting criticisms to the authors, editors and anyone showing interest in the issue. In particular, Giubilini and Minerva received death-threats and were exposed to other forms of ostracism, such as being classified as "insane" and needing psychiatric support or being intellectually dumb and philosophically immature, along with serious consequences for their professional life.[1]

    One of the aims of this strong reaction was to make clear that the new term as well as the corresponding idea was so outrageous that it shouldn't have deserved any discussion at all, and that the whole issue had to return to a complete oblivion. It was courageous and wise of the Journal of Medical Ethics to publish in 2013 a double issue discussing the various aspects of the story. But with the exception of a few other important academic journals (such as The Hastings Center Report, Bioethics, and Monash Bioethics Review), the problem appeared to be carefully avoided and set aside in public discussion, since stupid ideas are to be forgotten and leave space to more interesting ones. In this general scenario it may be interesting to notice that this trend was recently reversed by cardinal Angelo Bagnasco, one of the most authoritative figures in the Catholic Church, president of the Conference of the Italian Catholic Bishops since 2007 and vice-president of the Conference of European Catholic Bishops since 2011. Already in 2012 Bagnasco showed interest in the issue, and in his official Address for the opening of the Permanent Committee of the Italian Bishops (March 26, 2012), he remarked that "another thesis has emerged in the last few weeks concerning the legitimization of infanticide absurdly presented in an international scientific journal: something that is aberrant in itself, if not also monstrous. For these scholars, of Italian origin, what is permissible to do to the foetus - that is abortion - is also permissible to do to the newborn child. And why not also even later?"[2]. After this outcry of disgust for the thesis, a thick veil of silence was hanged down the issue, even with some forms of boycott (for example some invitations to conferences were withdrawn or withheld, as were some job offers).

    Recently, at the end of January and early February 2015, Bagnasco came back again with three official speeches on the issue, using the term "post-partum abortion" [aborto post-partum] to refer to what Giubilini and Minerva had called "after-birth abortion". Of course, Bagnasco mentioned the issue in order to denounce it as a terribly immoral idea, but by insisting on it he seems to think that it is a lively and timely issue to be discussed. While three years ago it was simply to be discarded and immediately rejected, now he thinks that it has to be seriously considered and examined, not least because, according to him, it appears to be supported "at the European level" (whatever this means). This step is crucial and shows how relevant academic freedom of discussion is, as defended by the Journal of Medical Ethics and other journals: reflection and discussion at the academic level has the potential to shape public debates and to prompt people to reflect on important, neglected issues. Bagnasco spoke for the first time on the issue during the opening Address of the Permanent Committee on January 26, 2015: in presenting the next conference of the Italian Church, titled "In Jesus Christ the new humanism", which will be held in Florence the next November, Bagnasco said that it is important to think over again on the issue because nowadays there is an "anthropological challenge", whereby some want to "overturn the alphabet of the human and redefine the bases of the person and of society". In this context he explicitly said that "in Europe some want abortion declared as a basic right so to bar any "conscientious objection", and urge that so-called post-partum abortion be recognized" [3].

    A few days later, Saturday 31st of January 2015, Bagnasco was the keynote speaker in Brescia at a conference on the Encyclical Humanae Vitae organized by the local bishop in honour of pope Paul VI, who was born in Brescia. In the middle of his speech, Bagnasco said that "we do not know if Paul VI had imagined to what extent the principles that he had stated would have become so relevant for the new challenges that we have to face today. We do not know this. We can only hint to genetic manipulation, to the possibility of patenting human embryos as well as of freezing and destroying them, up to the so-called post-partum abortion that some want to be legalized at European level" [4].

    Again, on February 6, 2015 at a Conference organized in Montesilvano by the bishops of two Italian Regions, before over 500 delegates cardinal Bagnasco was criticizing the moral "desert" created by secular ideologies, repeating the same words pronounced at the Address to the bishops: "in Europe some want abortion declared as a basic right so to bar any "conscientious objection", and urge that so-called post-partum abortion be recognized" [5].

    More recently, on May 30 Bagnasco was invited to open the Conference for the 10th Anniversary of Scienza&Vita, a prominent pro-life Association closely connected to the Italian bishops waiting for directions. The first part of the discourse was devoted to criticize so-called "proportionalism", a moral theory spread in Catholic moral theology. Bagnasco remarked that such a theory has good intentions since it aims at preventing human suffering. But it is wrong, because it justifies many actions against life, like abortion and embryo experimentation, going "up to abortion post-partum, a definition used to sweeten infanticide", he added speaking off the cuff [6].

    Not only is it very interesting that Cardinal Bagnasco in the last months came back on the issue of post-partum abortion several times as something worth discussing, but he even suggested that "in Europe some [...] urge that so-called post-partum abortion be recognized". I had no information about this claim to "recognition" before reading Bagnasco's speeches, but if confirmed, it would be a real revolution. Giubilini and Minerva presented their ideas as a logical hypothesis to be explored, without any practical implication nor any proposal for public policy. Now cardinal Bagnasco informs us that that hypothesis is going to be recognized at some European Union level. This is really surprising. I can only explain it by recalling that sometimes a new word forces us to create a new category, and that, as Hegel said, "all cultural change reduces itself to a difference of categories" [7]. This alone, however, does not account for the rapidity of the cultural change in this case: in only three years a new category - afterbirth abortion- passed from being an academic, logical proposal to being a topic of public discussion In any case, we have to acknowledge that cardinal Bagnasco's statements inform us that the debate has entered now a new phase. It is no longer in the field of the "absurd" that shouldn't even be considered or mentioned, but it is jumped into that of the "debatable" that needs to be taken seriously and analysed. We have to acknowledge as well that it is a merit of the Journal of Medical Ethics to have started this debate and promoted this new discussion, and it would also be desirable that for Giubilini and Minerva the form of ostracism of the last years come to an end.

    Maurizio Mori

    Professor of Bioethics

    Dipartimento di filosofia e scienze dell'educazione

    Universita di Torino, Italia

    References

    1. Minerva F. New Threats to Academic Freedom", Bioethics, (2014): 28(4); 157-162

    2. A. Bagnasco, Prolusione "Un'altra tesi ? emersa nelle ultime settimane, la legittimazione dell'infanticidio, assurdamente presentata in riviste scientifiche internazionali: in s? qualcosa di aberrante, se non addirittura di mostruoso. Per questi studiosi, di origine italiana, quello che secondo loro si pu? fare sul feto, ossia l'aborto, sarebbe possibile anche sul bambino appena nato. E perch? anche non successivamente?"

    3. A. Bagnasco, Prolusione, 26 gennaio 2015: "In Europa si vuole far dichiarare l'aborto come un diritto fondamentale cos? da impedire l'obiezione di coscienza, e si spinge perch? sia riconosciuto il cosiddetto aborto "post partum"!".

    4. A. Bagnasco: words available on the web at: https://www.youtube.com/watch?v=mrPz43xCT40. Last access on February 5, 2015. They are at minute: 48-50. There is no written text available so far. In Italian the words are the following: "Non sappiamo se paolo VI abbia immaginato fino a che punto i principi da lui affermati sarebbero divenuti attuali, nelle nuove sfide che oggi siamo chiamati a fronteggiare. Non sappiamo questo. Possiamo qui solo accennare alla manipolazione genetica, alla possibilit? di brevettare degli embrioni, di crioconservarli e distruggerli, di praticare l'aborto, fino al cosiddetto aborto "post partum" che si vuole legalizzare in sede europea".

    5. The words of Bagnasco are reported in inverted commas in an article of P. Greco, "Si vuole capovolgere l'alfabeto dell'umano", Avvenire, 7 marzo 2015, p. 17.

    6. The full text of Bagnasco's discourse is published in Avvenire, May 30, 2015, pp. 14-15. The sentence I quoted is reported in a complementary paper by L. Liverani, "Bagnasco: difendiamo l'uomo da pretese di interessi e ideologie", Avvenire, May 30, 2015, p. 13: ?Fino all'aborto post-parto - aggiunge a braccio al testo del discorso -, definizione usata per addolcire l'infanticidio?. For an analysis of Bagnasco's views, cfr. M. Mori e D. Neri, "Editoriale", Bioetica. Rivista interdisciplinare, xxiii (2015), no. 1.

    7. "All revolutions, whether in the sciences or world history, occur merely because spirit has changed its categories in order to understand and examine what belongs to it, in order to possess and grasp itself in a truer, deeper, more intimate and unified manner" GWF Hegel.

    Conflict of Interest:

    None declared

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  2. Ancient conceptions of dignity. The secular sacred.

    Dignity need not be coupled with theology. The South African offence of 'crimen injuria' is the offence defined as the act of "unlawfully, intentionally and seriously impairing the dignity of another."

    It is based on the 'Latin phrase crimen iniuriae, which should mean 'accusation of abusive behaviour' ( https://en.wikipedia.org/wiki/Crimen_injuria ).

    The search for an understanding of a secular basis for the notion of 'dignity' could benefit from an examination of Roman and South African case law.

    The word itself goes back to the Roman 'dignitas', a strongly related notion, that also may be worth examining to gain a secular picture (https://en.wikipedia.org/wiki/Dignitas_(Roman_concept) ).

    This article ( http://athensdialogues.chs.harvard.edu/cgi- bin/WebObjects/athensdialogues.woa/wa/dist?dis=22 ) on three types of dignity considers, inter alia, the Ancient Greek model, which would have informed the Roman.

    In support of the universality of the notion if dignity, it is wirth noting that it also appears in the Chinese and Japanese constitutions: http://www.chinahumanrights.org/cshrs/Developments/t20130206_1037860.htm

    The specific question of how dignity relates to the treatment of the dead is, I think, related, but separate. A corpse, in Roman law, is a res nullius, a thing that belongs to nobody, which attracts only duties, not rights. Organ transplant from corpses, of course, complicates this because a human organ can be possessed, and has value, possibly even monetary value, but this does not relate to dignity.

    The inarticulate, or instinctive, belief, or feeling, that corpses are special, and must be treated with respect, relates more to the notion of the 'sacred', which also exists in a secular sense. This sense relates to aesthesics and sentimental preciousness, rather than to dedication to the gods, but is a real and important human universal.

    The question of the treatment of the deceased might be considered as part of the wider question of what, in a secular world, is sacred - a question that most certainly does not have the answer 'nothing'.

    Conflict of Interest:

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  3. For Drugs that Save Lives, a Steep Cost

    This represents a thoughtful analysis of costly drugs. Recently, the potential overpricing of a device that allows safe bystander delivery of the established staple narcotic antagonist naloxone bears closer examination. As an emergency physician, I am cautious to avoid needle stick injuries when reversing overdoses in patients who are at high risk of HIV or hepatitis B/C. No matter how careful one is, the clinician still incurs significant occupational exposure. I once accidentally stabbed myself in the hand with a central line finder needle used to treat a shocked woman with hepatitis C who became acutely agitated after naloxone. Months of distress and serological testing followed. Economic analyses of medical care should include safety concerns of frontline paramedics, police and hospital staff. Expensive non intravenous and non intramuscular devices that allow the opiate dependent patient to breath effectively reduces bystander and occupational exposures to life changing infections and could avert the need to transport to hospital emergency rooms.

    There is no doubt that cost effectiveness assessment of medical and surgical treatment improves the distribution of limited health care spending more equitably across a range of competing demands for funding. As adjudicated by patient focused outcomes (and now clinician safety), these analyses maximize overall health maintenance and gain in society by ensuring that scarce resources are deployed to patient cohorts that will attain the most benefit from a moderate to expensive intervention. The focus goes beyond living longer to living better with enhanced quality of life, social engagement, symptom and pain control and sustaining emotional wellbeing, factors important in cancer care.

    Further steps are required to exert material influence on how health dollars could be better spent. Publicly funded clinical trials could be obliged to examine and report cost implications of health gains when a treatment proves to be effective. Medical school curricula and residency programs should emphasize cost effectiveness assessment as much as the magnitude of therapeutic benefit. Clinical practice guidelines promulgated by specialist groups need to be rid of industry sponsors that bias recommendations towards favoring new expensive treatments that are no better than established options. It is also high time that we also critically appraise the health impact and cost-overruns from excessive and inappropriate medical and screening tests ordered by doctors with a vested interest in using them as much as possible.

    Conflict of Interest:

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  4. Should Obesity Be a 'Disease'?

    Obesity being designated a disease recognizes its adverse effects on physical and psychological health. Pleas on behalf of the corpulent to not being judged and regarded without compassion are timely. However, obesity's classification as a disease could devolve the self-control needed to assume personal responsibility for the unhealthy dietary and sedentary choices we make. Dieting, weight consciousness, anxiety about body weight/shape and widespread hostility to obesity are fundamental themes in contemporary life. There is tension between trying to control our body weight in the midst of unprecedented access to unhealthy foods. The impulse to ridicule and publicly monitor the body shape has its basis in the highly visible markers of overweight transgressing aesthetic standards and signalling pathology and disease. Seeing fatness leads to the negative reading of fat bodies. More than ever, judgements about our own and others' worth is based on the morphological body as compared to the ideal. Although there is psychological toil from discrimination meted out to the obese, being insulated from the externally-imposed assessment of our weightiness imposes the inertial foundation to stay as we are. There is indeed a fine line between a stern reprimand that could avert a burgeoning public health disaster and abuse and derision that debases the esteem of others. Aside from being susceptible to more serious iterations of a whole range of chronic medical problems, the obese sustain higher risks of anaesthetic, pregnancy and post operative complications. They are more difficult to resuscitate in trauma and critical illness. Life- sustaining procedures such as intubation and central venous access pose an anatomical challenge. Due to their thickset habitus, even the longest chest drains could fail to reach large clots pressing on lungs in major trauma. The treat of loss of life and limb with acute injury and serious illness could be far more effective message than low grade hazard spread over years to decades .

    pleas on behalf of the corpulent to not being judged and regarded without compassion by society. Dieting, weight consciousness, anxiety about body weight/shape and widespread hostilty to obesity are fundamental themes in contemporary life. There is tension between trying to control our body weight in the midst of unprecedented access to unhealthy foods. The impulse to ridicule and publicly monitor the body shape has its basis in the highly visible markers of overweightedness transgressing aesthetic standards and signalling pathology and disease. Seeing fatness leads to the negative reading of fat bodies. More than ever, judgements about our own and others' worth is based on the morphological body as compared to the ideal. Shriver rightly protests the psychological toil from discrimination suffered by the obese. On the other hand, being insulated from the externally-imposed assessment of our weightiness imposes the inertial foundation to stay as we are. There is a fine line between a stern reprimand that could avert a burgeoning public health disaster and abuse and derision that debases the esteem of others.

    Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.

    Clinical senior lecturer, Division of Anaesthesiology and Critical Care, University of Queensland Medical School, Brisbane.

    Acute Care Programme, Mater Research Institute, The University of Queensland, and Division of Critical Care and Anaesthesiology, Mater Health Services, South Brisbane, QLD 4101.

    TEL : +61 07 3843 2541

    CELL: 0404 826 650

    Conflict of Interest:

    None declared

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  5. The Unrealized Horrors of Population Explosion-Increased longevity and enhanced reproductive capacity

    To the Editor: The threat posed by human "population explosion" goes beyond that capable of being supported by the earth's diminishing food and natural resources. The long standing but recently dormant debate on the sustainability of population growth is an integral topic that complements recent media focus on global warming and catastrophic weather events. There needs to be balanced discussion on the societal and health impact of overcrowding, water and food depletion as well as heightened risk of conflict fueled by competition for limited resources. Beyond mass starvation, environment degradation, critical destruction of animal habitat and accelerated loss of biodiversity needs to be foregrounded. When all living beings are interdependent and inextricably linked, this omission is remiss.

    Proponents of human population growth contend the declining impetus to have children jeopardizes human prosperity and societal well-being. The dilemma lies in matching the subsidized needs of a burgeoning number of retirees and the long living elderly (the demand) with children raised to tax-paying independence (the supply). However, this co-dependency holds potential to generate an accelerating demand-supply loop. Today's children will grow old and in turn seek their due from generations raised to adult productivity that come after them. The cost of raising a child to independence, an increasingly deferred milestone, is not just met by the parents and families but also the rest of society.

    Exponential human population growth is not just constrained by the depletion of food stocks and rapid environmental degradation. Although food production has kept pace with recent population growth through better yield crops, improved farming practices and more efficient food distribution, shortage of safe drinking water in many parts of the inhabited world remains a threat to all life. The successful cultivation of crops and animals for human consumption are contingent upon adequate supplies of water. Water is the font of life on earth; no life (including sources of human food) can take root without it. Indeed we search for it in outer space as a harbinger of life.

    Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.

    Clinical senior lecturer, Division of Anaesthesiology and Critical Care, University of Queensland Medical School, Brisbane.

    Acute Care Programme, Mater Research Institute, The University of Queensland, and Division of Critical Care and Anaesthesiology, Mater Health Services, South Brisbane, QLD 4101.

    TEL : +61 07 3843 2541

    CELL: 0404 826 650

    Conflict of Interest:

    None declared

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  6. Research fraud thrives in today's competitive science endeavour

    It does us all well to recognize that despite only a minority of scientists engaging in dishonest means to achieve academic gains, their disrepute will unfortunately taint the hard work of the honest majority. The greater harm will be loss of faith in publicly funded research and the waste of resources on non-credible work. Provided one evades detection, contemporary academia's unbridled publish or perish imperative breeds and rewards ethical lapses, leading to an irreparable breach of trust.

    Deliberately misleading research could be unwittingly adopted into daily life and even be incorporated as detrimental advances in medical treatment, putting all of us at risk. The issue should be deemed to go beyond research misconduct to the material risk of harming people. This occurs by giving false hope, patients receiving non-beneficial treatment and forgoing therapies that do work, and incurring unnecessary side- effects. When standards are not adhered to, we depend on personal ethics and morals to avoid research misconduct. It is high time that all researchers were trained in ethical approaches to career advancement, preferably in their formative years.

    Science fetishes the published paper as the gold medal of prestige and achievement, more so if it is headline grabbing, hosted in a top journal and concentrates on a hot topic such as sex and race. The perverse academic promotion and incentive system that view high-profile journals as the pinnacle of success corrupt us by rewarding those who cut corners, or worse, cheat for a shot at glory. The pressure to publish or perish has become the sole currency of tenure, grants, prestige and promotion. The scientific endeavour is dysfunctional with cheating in scientific papers growing ever deeper roots. Recent headlines of misdemeanours suggest exaggeration, fraud and manipulation to enhance academic standing and competitive funding have only has gotten worse, or that we are better at detecting problems that would have gone unnoticed in the past.

    Falsified or erroneous results have forced authors and editors to retract papers from journals whose peer reviewers have failed to detect conclusion-altering biases and misrepresentations. In the same week that gay marriage was legalised by popular vote in Ireland, Science retracted a paper that purportedly showed gay political canvassers to be better at influencing conservative voters' views on same-sex marriage. Diederik Stapel's sensational findings that garbage-strewn train platforms made racial prejudice worse made for great press. The hope that cleaning up our environment could set free the better angel of our natures was dashed when a whistle blower revealed the social psychology experiments to have never taken place. Tilburg University defended him to the last, and Stapel continues to defend his actions as being driven by "a quest for aesthetics, for beauty-instead of the truth." Yoshiki Sasai, a senior author of a 2014 Nature paper that claimed to have developed an easy method to create multipurpose stem cells, was found hanging in his office stairwell. Vaccination rates tumbled and a rash of measles cases followed Andrew Wakefield's published contentions that thiomerisal vaccines could lead to autism. Wakefield is now in jail and deregistered as a medical practitioner. Authors submit fake peer reviews under assumed false identities, often ones they themselves have written in praise of their own work.

    The dog-eat-dog competition to be published in prestigious journals, weak oversight by supervisors or study monitors, the rush by journals to publish ground-breaking press-worthy studies, cursory appraisal by reviewers juggling the demands of their own wor, the secrecy and unavailability of original data for inspection all lead to sloppy or even unethical research. However, most researchers are honest to their calling, despite the career and competitive gains that become their due from disseminating their work in high profile journals. Of 2 million papers published each year, only a single paper a day is withdrawn from journals because of misconduct, ranging from plagiarism to fabrication of results. If we accept that only 2% of researchers commit deliberate or false misrepresentation, then 98% of the scientific research remains above board. However, the rare occurrence of fraud taints the whole scientific community, incurs loss of public trust on whom most funding depends, embeds erroneous findings in health care (resulting in patient harm), incurs the adoption of ineffective social policy and undermines future research underpinned by false premises.

    There are ways to minimise fraud, but it will require changing the process, from how scientists share their data to how their peers review it and who is allowed to enforce academic standards. Surveillance and regulatory oversight, such as that provided by Retraction Watch and Office of Research Integrity in the United States, police for fraud after it has occurred. Although sanctions, official reprimand and even jail serve as deterrents for potential offenders, could the problem be weeded out at an earlier stage, when a study manuscript is appraised by peer reviewers for suitability to be published? A journal's peer reviewers are supposed to detect errors, but they often do not have the critical data needed to check the findings, nor the time to do so, particularly since they are seldom paid.

    The scientific community clearly needs to build a better safety net, more so in biomedical research involving human subjects. Institutional review boards are only delegated to assess and approve a clinical trial protocol for participant safety and methodological validity, with no remit to monitor a researcher's adherence to safety standards during the conduct of the study. Although misrepresentation of findings leading to biased, exaggerated and fraudulent claims can be discerned by independent re- evaluation of full outcome data that are made available after publication of a clinical trial, this process does not protect a patient from harm and coercion for the duration they are enrolled in a clinical trial.

    I have previously advocated for the important role of data monitoring and safety committees in conferring protection to participants and detect fraud whilst the trial is in progress. With their in depth understanding of the study objectives and protocol, as well as access to fully disclosed results as they accumulate, these committees are well placed to gauge breaches in safety mechanisms, coercive recruitment and fraudulent behaviour from the start of a trial to its completion. Data monitoring committees are independent and widely perceived to be extremely competent. Using these committees to review and approve the completeness of outcomes reported before publication would also enhance the trustworthiness and credibility of clinical studies. The DAMOCLES Study Group recommends that data monitoring committees "ensure that trial results are published in an unbiased, correct and timely manner" and that the committee discusses final data and their interpretation with study investigators. The ability to monitor for errors, whether deliberate or not, while the study is being conducted improves the validity and credibility of submitted manuscripts, eliminates the need for resource intensive post-publication re-evaluation, and averts disseminating erroneous studies to journal audiences in the first place.

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  7. When Doing Everything Is Way Too Much

    To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they became really sick. If they were previously housebound with significant cognitive impairment, I would be reluctant to start aggressive treatment and then have to deal with the difficult decision of whether to continue. To do everything for a non- communicating bed-ridden patient confers legal protection to the treating team but does the patient fearful of meeting his maker a gross disservice. Such measures prolong physiological viability at the expense of meaningful life.

    Unlike the inhumanely excessive and overly aggressive treatment demanded by desperate patients, and complied with by the ICU, there is often all-round agreement that symptom alleviation, with a focus on pain reduction, maximising physical comfort and support of the psychological well-being of both patient and family, is the clinically rational and humane course to pursue. Before the acute worsening, and in consultation with their usual treating physician, partners, children and families will have had to opportunity to discuss and contemplate at length a fundamental shift of objective to comfort care, preservation of dignity and symptom palliation.

    There is usually time to come to a realization that premorbid or disease-related quality of life is poor and more aggressive treatment would be futile. Most of us believe that dying at an old and infirm age is not something to be raged against or resisted at all cost. For all of us and every day, life dies at a varied pace. Some race into the abyss of oblivion and the healthy are inching towards the precipice. Alastair Reid yields a truthful rebuttal to Dylan Thomas' "Do not go gentle into that good night." "Curiosity", alluding to a cat's nine lives and a dog's contentment with its allocated years, is an enjoinder to life as the prelude to death.

    "...to tell the truth; and what cats have to tell

    on each return from hell

    is this: that dying is what the living do,

    that dying is what the loving do,

    and that dead dogs are those who never know

    that dying is what, to live, each has to do."

    We need to bear in mind Kafka's "The meaning of life is that it stops." The question arises of health resources wasted in futile clinical care being made available elsewhere, and the substantial opportunity costs entailed in expensively futile critical care.

    The algorithm for equitable distribution of expensive health care should include probability of meaningful survival, quality adjusted life years of remaining alive from medical treatment, and the loss of scarce critical care beds to a competing patient with better prognosis.

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  8. Freedom of speech risks inciting race based abuse and vilification

    To the Editor: The rights to unrestrained free speech in Australia, including the abolition of the ban on hate speech in the Racial Discrimination Act that makes it it unlawful to "offend, insult, humiliate or intimidate" a person or group on the basis of their "race, colour or national or ethnic origin," could incite race based abuse.

    Racial discrimination and vilification remains a prescient worry for the recently arrived, with children at higher risk of its long-term adverse effects. As a child growing up in 1980s Australia, I was daily branded ''ching chong Chinaman''. As an intern in the early 1990's, I looked after the child of a fellow student who had repeatedly hurled racial abuse and spat at me as I left for home from school on the bus. During the week of typhoon Haiyan in late 2013, a man mimicked paddling a kayak to a Filipino colleague while heckling him to ''row back to where you came from''. A would-be parliamentarian declared that asylum seekers were clogging up traffic in western Sydney in the lead up to our most recent Federal Elections (2013).

    None of these personal or very public instances of race-based vilification were taken seriously enough to court on the basis of injury to reputation and defamation. The effort and expense required to instigate and follow through legal proceedings compels most non-majority non-white Australians to take such insults and threats on the chin. This aids and abets strong electoral support for Australia's already curtailed foreign aid to be redirected from Indonesia if it did not allow boats to be turned away from Australian shores. The inhumane treatment of asylum seekers remains the biggest elephant in the room, racial prejudice implemented in a systematic rollout.

    How is an immigrant child to deal with unbridled permission to express hateful abuse? Would its vehemence not be seared into his soul, just as the vilification 30 years ago at a bus stop remains fresh and alive in my memory? I am all for free speech, but racially motivated abuse is threatening and hurtful to the progress of hardworking minorities who just want to make a go of it in a new country.

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  9. Lost in Clinical Translation: Difficult communication in futility

    Getting your message across to a patient and their family is difficult and fraught with misunderstanding. Aside from not having enough time and patience to explain complex diagnoses and sophisticated treatment plans as well as ensuring that understanding has occurred, English may not be the patient's first language.

    As a hospital doctor, even when using non-technical terms, I wonder whether a family member or a professional interpreter is capably relaying acute concerns and nuances of complicated discussions to patients from a non-English speaking background. The medical team cannot be sure that questions posed by a patient in return are being faithfully rendered.

    As communication is an iterative and interactive process, far more is "lost in translation" in health care encounters when the several spoken languages are necessary. Body language can be misinterpreted, with cross- cultural diversity in health-seeking behavior and beliefs pose further obstacles to effective communication.

    There is no doubt that the ethical, moral and legal quandaries of whether to withdraw ventilator-support from a child and pregnant adult clearly dependent on machine-assisted breathing are stressful for, indeed provoke strong emotions in, families and critical care staff.

    Ongoing physiological support as decisions on treatment withdrawal are being deliberated in courts of law necessarily delay the availability of scarce intensive care beds to other seriously ill or injured patients with far better prospects of meaningful recovery. These patients cannot afford to wait for all-round resolution between families, clinicians and courts. Surely the high cost of intensive care and the diversion of hundreds of thousands of dollars from other health care programs bears serious thought even in times of immense crisis. The health system cannot afford the thousands of dollars spent each day in the support of a brain- stem damaged person for whom futility is the eventual outcome. In the unlikely event that one is weaned off the ventilator, the patient is still condemned to full nursing care for the rest of her natural life.

    I recently cared for an elderly man who had sustained a large brain hematoma. The son, who had cared for an ailing father for years, stroked his shock of white hair as he declined neurosurgical treatment on his father's behalf. As he tearfully looked upon the face of his uncomprehending father, the son was unwavering in his refusal. He believed that the great man his father had once been was no longer there. We agreed that surgery was not going to change that and they went home.

    A truthful rendition of diagnosis, treatment and prognosis, as well as ensuring that the family has understood, were necessary for my patient's son to confidently make a decision aligned to his father's wellbeing and priorities. My job was easier without the self-imposed burden of trying to dictate treatment trajectory. I was satisfied that I had not, by deception or persuasion, imposed what I believed to be in the best interest of the patient. Doctors are human after all, with even our most well-intentioned recommendations susceptible to the the beliefs and values we hold dear.

    Conflict of Interest:

    None declared

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  10. Patients with psychosis should not be disqualified from assisted dying on grounds of mental incompetence.

    Dear Editor.

    Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.

    Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying more generally, wherever intractable severe mental distress pertains. This point is also made by psychiatrist Colin Brewer in his letter in response to the paper [1].

    In establishing the case that patients with depression should not necessarily be considered incompetent, Schuklenk and van der Vathorst's paper contains the assumption that mental competence is a prerequisite for access to assisted dying. While most prochoice ethicists take this position to be axiomatically correct, I suggest that an insistence on competence - at least as it is usually conceived in medicine - may lead to unfair discrimination and unnecessary suffering amongst patients suffering from a particular class of psychiatric disorder, namely those deemed to be 'psychotic'.

    As Schuklenk and van der Vathorst describe, even the most prochoice jurisdictions stipulate mental competence as a prerequisite for assisted dying. So in the Netherlands, while patients suffering from TRD can obtain assistance in dying, those with psychotic depression do not qualify, because treatment decisions by these patients are considered to be often 'not arrived at competently and should be overridden/ignored'. The fundamental assumption here - and it is a commonplace notion in medical ethics - is that psychosis equates with mental incompetence. Presumably, the basis for this position is that psychosis entails disordered or delusional modes of thought.

    TRD can be very severe, as is made very clear by Schuklenk and van der Vathorst's paper; however, various forms of intractable psychosis can be at least as -and in some cases possibly even more- difficult to endure. Psychotic depression, as above, might be one such case; treatment- resistant severe schizophrenia would also appear to be an extremely difficult to endure form of psychosis, entailing great suffering - indeed many of those affected end up committing suicide. While such patients (by definition) suffer from disordered or delusional thinking, it is not clear that the desire to end their lives should be deemed irrational.

    As with TRD, denial of assisted dying to patients enduring intractable psychosis is responsible for a great deal of unnecessary suffering and amounts to unfair discrimination. I suggest that the assumption 'psychotic = incompetent' should no longer be accepted axiomatically. Prochoice medical ethicists ought to explore principled ways by which our conceptions of 'competence' may be refined such as to permit fair access to assisted dying for those afflicted by intractable psychotic disorders.

    REFERENCES. 1. Brewer, C. Depression is not the only treatment-resistant psychiatric condition. eLetter, Journal of Medical Ethics, 2 June 2015.

    Conflict of Interest:

    None declared

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