62 e-Letters

published between 2017 and 2020

  • Critique of Good Reasons to Vaccinate: Mandatory or Payment for Risk?

    The author asserts that coercion to vaccinate is ethically analogous to mandatory seatbelts or the use of physical force to remove a dangerous substance from a child. This is a false analogy. Wearing seatbelts while driving or removing a dangerous toy from a child does not alter anyone’s individual constitution, but vaccines do, permanently, and with largely unknown long-term consequences. Vaccination is an intimate, deeply invasive and permanent medical procedure, not just a behavioural preference. The same flawed comparison could be used to support mandatory abortion or coercive organ harvesting if these procedures were deemed in the interest of public health: a repugnant conclusion.

    Regarding seriousness of Covid-19 as a public health issue, the author ignores the fact that Covid-19 deaths are recorded in a non-standard way which precludes meaningful assessment of the true public health impact of this disease in comparison to other respiratory infections. Acording to the WHO https://www.who.int/classifications/icd/Guidelines_Cause_of_Death_COVID-... guidelines, “A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness [...] COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.” The Office of Nat...

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  • Placebos can still work when patients are told, honestly, that they are placebos

    This study, https://doi.org/10.1126/scitranslmed.3006175, showed that the placebo effect still worked when patients were informed that they were receiving the placebo.

    If this is generally true, there is no need to move from honesty.

  • Why a selective lockdown of the elderly would be unjust: A response to Savulescu and Cameron

    On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
    I shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
    Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
    ‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, th...

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  • Safe, effective, proportional and necessary?

    While the authors are right to conclude that any compulsory medical intervention/vaccination could only be justified if the intervention is safe, effective, proportional and necessary, the moral dilemma really only starts here.

    Who should have the right to determine what is proportional and necessary? Furthermore, the safety and efficacy in themselves will be disputed. We know this from existing vaccine controversies that lead parents to decline vaccines for their children. They do not trust the data produced by the manufacturers and they do not trust anyone who has industry funding or other potential conflicts of interest. Clearly the only reason why a parent would decline a medical intervention is because they fear that it could harm their child.

    Although a Covid19 vaccine would not mainly be aimed at children, as in routine childhood immunisations, but at everyone, the question of safety and efficacy remains and invariably determines the question of proportionality as well. In fact it will be even more difficult, due to the shorter development times, shorter trial lengths and shorter follow-ups we can expect, as well as the limited time the virus is expected to be around in sufficient parts of the population that would allow for meaningful field trials.

    Safety and efficacy have always been at the heart of the debate. We know from our work with parents at Consent (https://consent-charity.org.uk) that any...

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  • Do newly graduated medical students require a “break” from clinical responsibilities to truly be prepared to cope with the covid-19 pandemic? A response to O’Byrne et. al

    O’Byrne et. al raise the important issue of pandemic preparedness in medical students’ readiness to deal with the covid-19 pandemic. Healthcare professionals have a moral obligation to volunteer to help, however, there has been a lack of strict consideration for the preparedness and clinical competency of medical students in these circumstances. The article correctly highlights that medical students’ desire to help is insufficient alone, and there is a need for adequate medical education and training to better prepare students for any potential moral trauma and adverse risks to mental health. However, for those newly graduated students, we feel as though the need for a break from clinical activity is a concept that has been overlooked and may be imperative to true pandemic preparedness amongst this cohort.

    The majority of medical students will complete an intensive 5-year curriculum before graduating and applying to the foundation programme to continue their training, 43% of whom will have had no break from education up to this point.(1) As highlighted in the article by O’Byrne et. al, many of these students face problems with their mental wellbeing during medical school and thereon after. These problems regarding mental and emotional wellbeing are heightened in situations where students feel anxious or unprepared, such as clinical placements and rotations.(2) The importance of breaks to aid mental wellbeing are well recognised throughout the curriculum, such as tim...

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  • A Response to After-Birth Abortion: The Necessary Distinction Between Fetus and Newborn

    The article titled, “After-birth abortion: why should the baby live?” argues that after-birth “abortion” should be permissible in all cases where abortion is, “including cases where the newborn is not disabled.” I would like to begin by addressing the obvious oxymoron used in the expression of the authors ‘after-birth abortion’. The authors address this issue also by proposing to call the practice ‘after-birth abortion’ rather than ‘infanticide’ or ‘euthanasia’. They argue that to call it infanticide would be incorrect because the moral status of the individual killed is comparable with that of a fetus rather than of a child/person; to call it euthanasia would be incorrect because “the best interest of the one who dies is not necessarily the primary criterion for the choice, contrary to what happens in the case of euthanasia.” To re-iterate this second point, euthanasia is practiced with the self-interest of the individual in mind, usually to end a life of suffering, after-birth abortion, on the other hand, can be practiced even if it is only a burden to the family and the child is in full health.
    The authors define a person, in the sense of ‘subject of a moral right to life,’ as “an individual who is capable of attributing to her own existence some (at least) basic value such that being deprived of this existence represents a loss to her. This means that many non-human animals and mentally retarded human individuals are persons, but that all the individuals who are...

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  • NIPT is the only ethical test

    Medethics-2020-106709 – see decision 23-July-2020

    NIPT is the only ethical test

    Bunnik et al and Schmitz interchange about the public funding of NIPT surprisingly lacks consideration of Wilson’s and Jungner’s classic principles of screening as well as broader issues relating to women’s autonomy. In addition, overall healthcare costs must be considered no matter the system of their financing (public purse, private insurance or direct cost to families).

    I have followed the interchange between Bunnik et al and Schmitz [1 – 3] because NIPT is a topic I have published on for 5 years now, most recently in English [4].
    The most important reason for making NIPT publicly funded and for it to replace First Trimester Combined (FTC) in screening is that NIPT is a much better test than FTC [4]. According to the principles laid down by Wilson and Jungner in their classic essay [5], in this situation screening should be done with a test with as low a false negativity as possible so that the pregnant can truly trust the message that she does not carry a foetus with a genetic abnormality. NIPT misses far fewer cases than FTC and is a classic rule-out test.
    Where it has been studied, the biggest unease with NIPT among pregnant women is the risk of sex-selection, that is that female foetuses are selectively aborted only because they are female [4, 6, 7]. Notwithstanding, Schmitz raises the spectre of “unease with NIPT causing discriminatory mes...

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  • Financially driven study participants?

    This study by Saint-Lary et al. was an interesting read and very informative. I commend the authors for uncovering so much regarding General Practitioner attitudes towards payment for performance schemes.

    One thing that stood out to me was the use of a €100 incentive for study participants. It is not mentioned within the article whether study participants were aware of this reward before agreeing to participate in the study. This would be useful to know in order to understand whether the opinions and attitudes expressed in this study are truly representative of all French General Practitioners, or rather only of those who tend to be more financially driven. For example, the finding that all General Practitioners within the study considered the maximum bonus achievable to be low, may be explained by the fact that these doctors are particularly financially driven.

    Given this possibility, I hope this point may be taken into account when interpreting the findings of this paper.

  • Dying in abandonment during the Covid-19 pandemic: the silent tragedy of misthanasia and the urgent need to avoid it

    The excellent essay published by Wynne et al (2020) in the journal of Medical Ethics 1 provides a timely reflection on the urgent need for improvements in the “provision of palliative care in humanitarian and emergency contexts” emphasized by the current Covid-19 pandemic. Regarding this issue, we would like to add some reflections from a developing country perspective about the death in abandonment that may support the authors proposal.
    In 1343 Giovanni Boccaccio wrote about the patients with the Bubonic Plague in The Decameron: “Most of them remained in their houses, either through poverty or in hopes of safety, and fell sick by thousands. Since they received no care and attention, almost all of them died”. It is staggering that these words fit to describe the current situation of many patients with severe forms of Covid-19 that do not find places in hospitals. They are being denied even a palliative care and eventually die in their homes or elsewhere in a state of abandonment. This dramatic situation is unprecedented in modern times in wealthy societies. Unfortunately, it is not a novelty in many developing countries that chronically suffer from inadequate health systems, which are now crumbling with the current pandemic. In 1989, Marcio Fabri dos Anjos, a brazilian bioethicist proposed the term mysthanasia (from the Greek: mys = unhappy, thanathos = death) to characterize the death in state of abandonment (Ferreira & Porto, 2019). 2 It was attributed to the h...

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  • The ethical dilemma of medical students during COVID- study online or volunteer.

    Dear Editor,

    I read with great enthusiasm the article by O’Byrne. As a senior medical student, my feelings resonate with her discussion. I also believe that medical students are given a further ethical challenge. This challenge is dedicating time towards volunteering during the COVID-19 outbreak or continuing with studies remotely. As stated in the article, the ‘curriculum is not readily compatible with the removal of students from their clinical placements(1). However, the guidance from Medical Schools Council (MSC)(2) state that the student’s first responsibility is to continue education and not jeopardise this with taking on too many additional duties.

    As the GMC has not suspended education(3), we attend online tutorials and prepare for exams. However, one could argue that the online tutorials and self-learning from textbooks is not adequate education for such a vocational profession. Furthermore, medical schools have created excellent programmes for students in all years to volunteer and help. This ranges from practical clinical work for senior students to first-year students taking on tasks like the general public. With such well-managed, organised volunteering schemes, it seems that the student body has a duty to help. With students coming forward to volunteer in such large numbers(4) it is suggestive that medical students, just like other medical professionals, feel they have a moral duty to help in healthcare.

    Even though these well-organise...

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