57 e-Letters

published between 2019 and 2022


    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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  • Fundamental values are not defeated by utilitarian calculus

    Utilitarian ‘ethics’, as employed in this article, implicitly rejects all absolute values and associated rights, allowing for limited transgression of rights (including the right to life) for the sake of contemporaneous ‘benefits’ outweighing the ‘costs’. I maintain that this is a self-defeating paradigm; without absolute values there is no objective measure of benefits and costs, therefore no rational basis for the judgement of proportionality. In short, the utilitarian argument is logically circular and vicious. Once the veneer of proportionality is revealed as objectively ungrounded, utilitarian ethics amounts to little more than a public relations strategy for legitimising arbitrary exercises of power.

    The argument from proportionality (benefits vs costs) cannot justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.

    1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).

    2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social op...

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  • Heroism is a harmful misconception

    One of the most enlightening statements for me from the report of the WISH patient safety forum 2015 is, "The idea that saving patients’
    lives demands heroism is a harmful misconception about health and medicine seen in popular culture. In the real-world, the true heroes are not just rescuing patients, they are voicing their concerns and taking proactive measures to reduce the risks, before a patient is potentially put in harm’s way".
    We shouldn't need to rely on heroic rescue or expect it to be a normal part of our every day clinical practice. The idolisation of heroism damages attempts to improve systemic approaches to improving patient care because it neglects and belittles the under-appreciated grind of change to reduce the underlying risk of patient harm. Heroism should be less of an aspiration and more of a flag highlighting the need for organisational improvement.

  • In New Zealand Zero-Covid resulted in the best outcome

    The argument Jecker and Au mount against an elimination strategy for Covid-19 fails to account for the New Zealand experience. They discuss the question of excess mortality and suggest that tactics to reduce Covid-19 related deaths inadvertently increase deaths from other causes. Whilst this is intuitively true actual country wide data undermines their argument: https://blogs.otago.ac.nz/pubhealthexpert/mortality-declines-in-aotearoa... New Zealand experienced negative excess deaths for the years 2020-21 as did Australia and Taiwan. Had New Zealand experienced the same rate of excess deaths as the USA we could have expected 19,900 deaths which would have disproportionately affected ethnic minorities and the vulnerable. The elimination strategy in New Zealand was by far the best strategy to address health disparities, without it many more of those suffering disparities would have died.

  • Reconsenting paediatric research

    Murdoch et al. give an excellent account of the law in Canada relating to consent to research in children when they mature. Laws must be based on moral principles, which always have a beneficial intention and are everywhere similar for both treatment and research, for both adults and children and for the publication of identifying data.

    A competent adult can accept,reject or discontinue treatment. But a doctor must only provide treatment, which is beneficial physically or emotionally. In a publicly funded service she may need to balance the benefit to the individual against the needs of the community. The .patient is always free to consult a different doctor. A patient's personal details must not be revealed without express permission.

    An adult can also accept, reject or stop participation in research intended to benefit others. Again he must not be identified without permission. He cannot require the eradication of data obtained because that would harm others.

    A guardian, on behalf of a child, consents to treatment or research with the same rights and restrictions. As far as possible the informed consent of the child should be obtained.. When the child reaches maturity he must be fully informed and assumes responsibility for his own care. He can discontinue beneficial treatment but cannot demand that the doctor reverses it, because that would require her to cause harm. He can change doctors. He can stop participation in research but he cannot hav...

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  • Fifty years later: the significance of the Nuremberg Code

    Fifty years later: the significance of the Nuremberg Code
    E Shuster 1 Affiliations expand, PMID: 9358142 DOI: 10.1056/NEJM199711133372006
    Veterans Affairs Medical Center, Philadelphia, PA 19104, USA.

    The prosecution of doctors guilty of appalling human rights abuses at Nuremberg was achieved on the mistaken premise that the research community already had a code of conduct which, if applied, would have made such abuses impossible. In fact, not only was there no such code but when the 'Nuremberg Code' was published after the trial it continued to be ignored by many doctors for some thirty years afterwards. Indeed its central principle of informed consent has itself been eroded by subsequent international agreements on the ethics of medical research. This review shows that the mechanisms for approval of medical research which have now been promulgated in England and Wales, in practice, are applied on a very variable basis. Research in vulnerable groups unable to give fully informed consent such as children, prisoners and the incompetent elderly require the application of more rigorous standards of ethical control than those currently in operation. The use of vulnerable populations in the developing world and the application of international standards to them is also considered. A number of suggestions for improvements in current proce...

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