480 e-Letters

  • Pharmacists are vulnerable too!!

    The vulnerabilities of pharmacists would appear to be invisible in the euthanasia/assisted suicide debates.

    As healthcare systems and societies are changing, the social positions of doctors, pharmacists, nurses and patients within them were changing too. In the past, clinical experts’ authority and patients’ autonomy have been in conflict. The current patient-centered / person-centered model of medical care, aims to establish egalitarian relationships between patients and healthcare clinicians and providers .

    Vulnerability can be defined as a lack of autonomy and independence, bodily and psychological insecurity, marginalized or deviant status, lack of acknowledgement within the society (1).Vulnerable groups are exposed to discrimination, intolerant attitude, subordination. Vulnerability is usually seen as an inherent quality of certain social groups (but not others). However it has many dimensions and might be attributed to relatively “powerful” groups (2). Doctors, pharmacists and nurses i.e. so called powerful groups, are rarely characterized as vulnerable groups, but within certain circumstances, they can be recognized as “vulnerable”.

    Doctors, pharmacists and nurses are in a situation where they are becoming more controlled by the patients. There is an emphasis on the myth that citizens (patients) should be autonomous and the inevitability and normality of dependency is not recognised (3). Dependency is an unavoidable feature of...

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  • The response to COVID-19 of many countries has been dictated so far by the media, or better by those who control the media, rather than the scientists. To find a solution, scientists should be free of this conditioning

    Dahlquist and Kugelberg (2021) correctly notice as the many non-pharmaceutical interventions (NPIs) which have been introduced to stop or slow down the COVID-19 pandemic through coercion are not publicly justified through a scientific consensus on the factual propositions that are used to support the policies, and as such, they would be illegitimate. It has been an unfortunate circumstance of this pandemic, that not only the NPIs but also the therapeutic approaches have been the subject of media misinterpretation, at the expense of a correct debate in between the scientific community, with scientists expressing opinions not welcomed by the media routinely abused for doing their work. Examples of policies lacking every scientific support, but still approved by the media, are everywhere. To find a working solution to the pandemic, definitively we do need free science “on the top”, rather than “on the tap” or even “on a leash”, limiting the interference by governments and corporations directly and through the media serving their interests. Misinformation by media is what has made the response to COVID-19 less effective than what could have been listening to the majority of the scientists. The response to COVID-19 of many countries has been dictated so far by the media, or better by those who control the media, rather than the scientists. To find a solution, scientists should be free of this conditioning.

    1. Dahlquist M, Kugelberg HD. (2021). Public j...

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  • Words/Nga Kupu

    Words/Nga Kupu*
    The suggestion of a “Words” column focussing particularly on words from a non-western ethical tradition is great. We are journeying through perilous waters and will need to adapt our ethical framework to the new reality. A value of diversity is that we can draw on concepts from other traditions. Of course, a “Word” in a language you do not speak is of no use. The word is part of a language, which is the embodiment of a culture, and ethics is inevitably culture bound. Even words shared between cultures do not necessarily share exact meanings. A consideration of Justice within the bioethical community culture would be incomplete without reference to Rawls. A consideration of Justice within a Māori community would be centred around Te Tiriti o Waitangi/ The Treaty of Waitangi(1). A simple translation is not enough. The definition of Whakawhanaungatanga is a good starting place, but more depth is needed. It is embedded in a Māori concept of health(2), and the richness of the concepts cannot be appreciated without appreciating the context in which it is used. Whilst it is a Māori word it is now also a New Zealand word. A whole generation of medical students have been taught Māori concepts of health, including Whakawhanaungatanga, significantly spearheaded by the work of Pitama and Lacey(3). Parry as a 5th year student wrote a heart-warming case study that illustrated the value of using these concepts(4). The New Zealand ethical landscape is an example of t...

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  • Conversations and Intentional Killing

    We should be careful of the way we talk. Human society can be described as a long conversation about what matters. In this conversation, the language we use to describe our healthcare and social care practices not only reveals our attitudes and virtues, it shapes them. In order to promote self-worth and respect for individuals who use professional services there must be an understanding of how the language used in a profession influences professionals and the individuals with whom professionals work. The term ‘ service user’ or ‘client’ may be one reluctantly used by many healthcare professionals. The language of ‘service user’ or ‘client’ is acceptable at the political level. However it may be potentially detrimental to those it labels in healthcare and may also be damaging to the underlying ethical practices of many healthcare professions.

    Language is a means of communication in healthcare, it can indicate attitudes and it is an integral part of social and professional life and behaviour. The particular meaning we attach to words reveal the underlying values and attitudes we hold about the people or things to which we are referring. Language exerts hidden power as our words may be simple descriptions or they may change lives. This power may not be detected by the vulnerable/underserved in society and by those with less power . Power and status in healthcare and social care interactions determine how each party behaves e.g. The term ‘service user’ or ‘cl...

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  • MAID, social determinants, and the slippery slope.

    In their recent article, Jocelyn Downie and Udo Schuklenk conclude, first, that the Canadian experience denies the existence of a 'slippery slope' expanding medical termination from a limited to a broader medical constituency. Second, they argue a faiure to provide social constituents of health and support is a significant factor in the increased requests for 'medical aide in dying.' (1) It is hard to credit their conclusions on either point.
    As they note, 2016 legislation legalized 'medical assistance in dying" in cases of serious and incurable illness, disease or disability in an advanced state of decline with death an inevitable and foreseeable conclusion. But as they note (pg. 3-4) new legislation has broadened those criteria to include those with 'disabilities' whose death is not reasonably foreseeable as well as others with chronic, non-progressive disorders including mental illness. Indeed, enui seems to now be an acceptable rational for termination among even those without serious chronic illnesses or disorders. (2)
    That is precisely the definition of the slippery slope, a narrow framework of action is broadened to include ever larger classes of peoples.
    Similarly, they give short-shirt to the issues of the social constituents of health, ignoring the complex of predicate failures that may lead one to seek a rapid death. These include the limited availability of expert palliative care, the shortage...

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  • In Defense of Instrumental Value

    The authors argue that when we prioritize healthcare workers for ventilators because of their instrumental value as healthcare workers, we fail to value human lives equally. While they suggest that “it may be ethically justifiable for healthcare workers to receive priority for some scarce healthcare resources” and argue that healthcare workers should have sufficient personal protective equipment (PPE), they do little to explain why granting priority for these resources isn’t also, as they argue with ventilators, a case of failing to attribute equal value to human lives. Indeed, it is not clear that they think prioritizing healthcare workers for vaccines was the right thing to do: “. . . our social fabric has shown signs of unravelling as vaccine roll-outs have pulled on loose threads” and prioritizing vaccines has resulted “in unanticipated frustration, mistrust and strife.” The authors are right in their conclusion about ventilators, but we should reject the concerns their article raises about vaccines and PPE. If saving the most lives is the goal, it is consistent with valuing each person’s life equally to prioritize healthcare workers for preventive measures, particularly at the outset of a pandemic.
    The authors mention three reasons ventilators are different from preventive measures like PPE and vaccines: 1) Efficacy: Those who require a ventilator will not return to work quickly. 2) Lifesaving: While ventilators rescue endangered lives, preventive measures only...

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  • Pharmacists and Assisted Suicide : Thoughts after reading "The Judgment of the German Federal Constitutional Court regarding assisted suicide: a template for pluralistic states? "

    Pharmacists are essential healthcare professionals and are critical members of the whole healthcare team. Pharmacists work in varied settings such as community and hospital, hospice/palliative care industry and regulatory affairs. Regardless of where pharmacists work, and whether their roles provide direct or indirect patient care, all pharmacists contribute to safe and quality health care. Pharmacists may hold roles in many specialty areas of a healthcare system including the emergency department, infectious disease, oncology, pain management and anticoagulation management (1).

    Although effective, medicines are often challenging to manage and use appropriately. This is due to a number of factors, such as increasingly complex pharmacotherapies, polypharmacy, ageing populations with multiple diseases, and limited, or inadequately coordinated resources in healthcare systems. While performing a medication review, many pharmacists work together with GPs/consultants to optimise the patient's pharmacotherapy and reduce the potential risks of polypharmacy. An example of an expected health related goal suggested by a patient during a medication review could be a desire to reduce pain. During the medication review, the patient’s pain medication could be optimised by a pharmacist to achieve this goal (1).

    Pharmacists are pivotal in the lethal drug medication use process. Assisted suicide(i.e. physician assisted) will not take place without the use of medicat...

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  • Paediatric Patient Preference Absolutism?

    Even when there is no reason to doubt the truth of what patients say, it does not necessarily follow that clinicians must do exactly what patients want despite the risks. Is Priest’s line of thought here, in part at least, analogous to that of Minerva (1) and therefore open to a similar critique as that of Saad (2) who coined the term Patient Preference Absolutism to describe such a position?

    1. Minerva F. Cosmetic surgery and conscientious objection. Journal of Medical Ethics 2017;44:230- 233.
    2. Saad T C Mistakes and missed opportunities regarding cosmetic surgery and conscientious objection Journal of Medical Ethics 2018;44:649-650

  • Not a (global) controversy

    This article addresses a critically important topic, but I would not classify it as a 'current controversy'. The UK Animal Welfare and Ethical Review Body (AWERB) task of 'helping to promote a culture of care within the establishment and, as appropriate, the wider community' includes supporting the wellbeing of animal technologists and care staff. There is a good level of understanding that the culture of care includes caring for staff, in the belief that people who are cared for will behave more compassionately towards animals, and that science, animal welfare and staff morale will all benefit [see references in 1]. The AWERB task of 'supporting named persons, and other staff dealing with animals, on animal welfare, ethical issues and provision of appropriate training' can also be interpreted as providing emotional support and ensuring staff feel competent, capable and confident with respect to humane killing.

    Outside the UK, the European Union working document on Animal Welfare Bodies and National Committees also discusses the importance of supporting staff and ensuring mutual respect as part of a good culture of care, including encouraging scientists to work with (and value the contribution of) animal technologists and care staff [2].

    In my experience of working with AWERBs, many of these were (and are) very mindful of the emotional loading exterted on staff who had to humanely kill animals because of the pandemic [3]. The i...

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  • SEMPER ET UBIQUE MEDICUS (physician always and everywhere)

    I read with great attention and not a little emotion the short article of Clinical Ethics by SDTR [1]. The narrative and flat form fails to hide the author's strong ethical commitment. Few points, in my view, deserve a greater focus in the challenging and highly contributing considerations.
    The core of this contribution is the question: “when as a hospitalised medically qualified patient, one sees fellow patients in difficulty, or deteriorating clinically, unnoticed by medical staff, the question of whether it is ethical to intervene arises”.[1]
    The issue is complex and is very much about the mutual assistance that patients (may) give each other, as have often given each other, when confined to a hospital ward, on a desert island, in a prison, in a concentration camp, in a college. This aspect of natural solidarity, observable also in ethology in many animal species, even in captivity, can come into brutal contrast not so much with "education", which concerns cultural and social aspects of shared ethics, but more with "instruction", also intended as training and usual professional activity. Actually, impact of curricular studies of medicine on youngsters is complex, but seems to modify only some and limited aspects of previously acquired thoughts and feelings on health and disease. [2] Are there deontological appropriate rules of conduct for doctors that can be immediately contrary to elementary ethics? Regretfully yes, and without dist...

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