485 e-Letters

  • Expanded terminal sedation in end-of-life care (Gilbertson et al. doi:10.1136/jme-2022-108511)

    As a retired palliative care physician, I am puzzled by several aspects of this article. First, authors’ choice of terminology: ‘terminal sedation’ and ‘expanded terminal sedation’. It is more than 20 years since the use of the former began to be discouraged because of perceived ambiguity, and replaced by ‘palliative sedation’ (PS)[1] – as reflected in current professional guidelines.[2] And despite dissenting voices,[3] most clinicians would probably consider ‘expanded terminal sedation’ to be ‘slow euthanasia’.
    PS was used to describe a deliberate switch from escalation of symptom management to a deliberate reduction in a patient’s level of consciousness in order to ease otherwise intolerable refractory suffering in ‘imminently dying’ patients. The sedation varied from light to deep depending on individual need. Some guidelines refer to ‘intermittent’ as well as ‘continuous’ sedation. Recently, because of the lack of clarity in many reports, there’s been a trend towards limiting discussion to ‘deep continuous sedation until death’ (CDSUD) – the most contentious aspect of sedation near the end of life.
    Second, it may be correct that ‘the Doctrine of Double Effect (DDE) continues to shape much of the ethical and legal literature concerning end-of-life care’ (EOLC), but what about the medical literature? Would it surprise the authors if I say that, when a practicing clinician, I never agonized about ‘double effect’? As they noted, DDE was originally formulate...

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  • Some negatives of generative AI

    The article on the ethics of generative AI should be read in tandem with the recommendations on “Chatbots, ChatGPT, and Scholarly Manuscripts” issued by the World Association of Medical Editors (https://wame.org/page3.php?id=106).

    While acknowledging the positive contribution chatbots can make to the development of texts on ethics and other academic fields, I would cite a few key negatives:

    1) Chatbots like ChatGPT appear to be biased in favour of what they are proposing. This bias is evidenced in the references they provide, which uniformly support the point of view expressed by the chatbot. References opposing the point of view are not provided. This is probably inherent in the instructions in the algorithms applied by a chatbot, which must be along the lines of “provide an argument and supporting evidence”. No doubt this tendency to bias can be cured in future editions of the chatbot.
    2) Chatbots have been found to invent references where there are none. This is puzzling. Why did the programmers allow that? This should be an easy fix.
    3) Chatbots are only as up to date in their references as their programming (their “training”). For ChatGPT, the cut-off date is sometime in mid-2021 – anything that appeared later than their training material that is simply not in their universe. In fast-moving fields, thus, there is a strong risk that what is asserted in the chatbot’s output has been superseded by...

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  • The Right to Safety and Freedom of Association

    This author agrees with the claim that freedom of association is a basic moral right and that the right to have visitors stems from this freedom. This author also agrees that the discussion around visitor policy should be framed as a discussion about rights infringement. However, this author suggests that the discussion around restriction is best described as a potential conflict between two rights: freedom of association and the right to safety. Accordingly, the rights infringement could go either way.

    It is reasonable to claim that people have a moral right to safety (or something like it), and it is reasonable to say that this right should be highly protected in a hospital, where the sick and injured seek treatment. If people do have a right to safety, then it follows that this right would be infringed if hospitals did not take reasonable precautions to reduce hospital-acquired infections. Limiting visitors during COVID-19 should be seen as an example of such a precaution.

    To be clear, McTernan recognizes that safety is an important consideration, but she does not state that it is a right. This affects the framing of the issue. Appealing to something as a right makes it substantially harder to act against that which is protected by that right. It is for this reason that McTernan correctly argues that restricting visitation is harder when we appeal to freedom of association.

    The issue, then, is one in which patients have potentially two conflicting...

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  • Need to consider other benefits of COVID-19 vaccine boosters in university students

    We read with interest this risk-benefit and ethical analysis of the utility of SARS-CoV-2 vaccine boosters in university students. We have some major concerns about the choice of hospitalization as the primary measure of benefit. From the onset of the pandemic, healthcare providers, scientists, and public health experts in higher education have been learning from shared experiences, research, and evolving medical knowledge about the best way to safely populate college campuses with students, faculty, and staff. Hospitalizations averted is not the only marker of morbidity that is relevant to the college student population and given the rarity of severe disease requiring hospitalization in young, generally very healthy adults, hospitalization is not a good choice for a marker of COVID-19 related morbidity. We have also strived to minimize the risk of missed classes, severe illness, and need for prolonged medical leaves of absence given the potential adverse academic consequences of illness for students. Colleges and universities have been trying to balance infectious disease mitigation efforts with the need for in-person learning, social interactions, and the increased mental health challenges caused by some of these efforts that furthered the experience of isolation.

    Much has changed since early 2020 and most schools have continued to evolve their protocols and policies to reflect new information and relevant data. We are dedicated to learning and contributing to th...

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  • The proportionality principle is the wrong ethical standard for vaccine mandates

    The article does not engage with the objections (published in this journal and also in response to the previous article by the same lead author) to the applicability of the ‘proportionality principle’ to ethical judgment when the considered intervention violates the right to life and discriminates on the basis of healthy, innate biological characteristics of the human race. In particular, the proportionality principle is irrelevant to coercive policies (mandates) if the associated procedure is known to kill a small percentage of people and therefore amounts to a mandated killing of a minority for the benefit of the majority. The right to life cannot be taken away in the interests of others, even if the majority would greatly benefit from the killing, without negating the very concept of human rights: if being born human is not a guarantee of the right to life, then there is no right to life. On this view, vaccination mandates can no longer be considered healthcare but democide.




    Any claims by psychiatrists1 to be able to improve people morally should be extremely modest. It is helpful to be reminded that psychiatrists have attempted to do this and still do so, nowadays usually unconsciously or implicitly. In fact where therapeutic approach embodies moral positions, as clarified for the psychoanalytic tradition by Edward Harcourt2, it is important for these to be made explicit so that they can be scrutinised.
    People coming to see a psychiatrist are often in a personal crisis, whatever its cause (which may include the effects of mental disorder as well as factors in their lives contributing to that disorder). They may as a result may be driven to re-evaluate their lives, their choices and their relationships (there are parallels with the impact of serious physical illness and confrontation with disability and mortality). In fact any serious illness or intimation of mortality may generate the same kind of self-questioning. Such people are clearly faced with moral questions, whether that be regarding specific decisions, balancing their own needs with those of others, making hard choices or making amends. How they address these things will form part of their recovery and shape it. An important difference between physical and mental illness is that people living through the latter are more likely to be lonely, relatively unbefriended, isolated and short of support from family, friends or other social circles, or indeed alienated from them. They a...

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  • A laudable but currently unfeasible goal

    McConnell et al. provide a cogent argument that psychiatrists should influence the moral development of their patients in a limited substantive approach.
    What interests me, as a practising psychiatrist, is how to achieve this task. The penultimate paragraph of the paper recommends a “pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth”. This recommendation follows a vignette of a woman with autism with “underdeveloped moral conceptions”. It’s worth noting that moral reasoning differs between autistic and neurotypical individuals despite similar moral judgements (Dempsey et al.). I suspect that, for a sustained change in interpersonal function and moral development, the patient would require more than an explanation of social reciprocity by a benevolent and well-meaning psychiatrist.
    An earlier vignette describes a man with a possible antisocial personality disorder and unwelcome views about the acceptability of violence. There is an unfortunate paucity of evidence to suggest psychological interventions result in significant change in specific antisocial behaviours (Gibbon et al.). There are experimental therapies that may cultivate moral development in these individuals (Tuck & Glenn), however these are far from accepted in clinical practice.
    The article sensibly notes that the needs of people with serious mental disorders should take priority over the flourishing of...

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  • Trust is dead, long live trust

    I had difficulty with the Goldacre report, when it starts with the apparent contradiction of dismissing trust (in no uncertain terms). yet then proposing these TREs. (Trusted research environments). Where do the authors actually stand?

  • One cheer for trust

    Eyal is correct that ethicists’ speculations about how the public may respond to human challenge trials are often made without a whisper of evidence.

    This is not a new problem. The Institute of Medicine titled a 2001 monograph Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. One might think that a book with this title would demonstrate that the IRB system preserves public trust, but the title is merely an ornamental flourish. The book is devoted entirely to the accreditation of IRBs; public trust is neither analyzed in depth nor is there any attempt to show that accreditation improves trust.

    We all agree that trust is important, which is what earns it one cheer. Assertions about its future trajectory merit additional applause only when they are are supported by evidence.

    Cite: Institute of Medicine (U.S.). Committee on Assessing the System for Protecting Human Research Subjects. 2001. Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. Washington, D.C.: National Academy Press.

  • Re: Vaccine mandates for healthcare workers beyond COVID-19

    While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in he...

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