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...
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 any society and it is not a feature that is taken into account from the liberal perspective. The recognition of universal vulnerability suggests that the autonomy model will have to re thought (4).
Ethics has not paid attention to vulnerability for three possible reasons (5):
• Vulnerability is the antithesis of the individualistic ethics predominating in Western societies.
• Vulnerability is not addressed in ethics because philosophy ignores the body.
• Ethics has been prominently rationalist and therefore feelings have been displaced or have not been taken into account.
It is methodologically important not to define certain groups as (not) vulnerable by default (2). There are many potential sources of vulnerability, and each of these constitutes a different, overlapping layer. This metaphor of layers presents a contextual and variable concept of vulnerability, moving away from the fixed and static view (6). The vulnerability of professionals e.g. pharmacists remains invisible as it does not correspond with their social position. The sufferings (existential and moral) of pharmacists in particular are invisible, denied and ignored in the euthanasia/assisted suicide debates.
All forms of euthanasia and physician assisted suicide require lethal medications. The role of pharmacists in the pharmaceutical care/medication use process at the end of life is often ignored, written out or overlooked. In the main doctors and nurses are included in “conscientious objection” legislative protections. Pharmacists are often excluded from protection of their human right to freedom of conscience and the derived right of “conscientious objection”. Pharmacists in all working environments (pharmaceutical industry , community pharmacy, hospital pharmacy, palliative care pharmacy, long term care, care of people with disabilities including intellectual disabilities, general practice pharmacists, etc. ) will be part of the process (7).
We can understand our humanity in a broader sense only by recognizing our universal vulnerability and interdependence (8). Pharmacists and their patients and colleagues are vulnerable and autonomous. The end of life medication use process (natural death or intentional death ) is dependent on the involvement and expertise of pharmacists. Failure to recognise this makes individual pharmacists and the pharmacy profession vulnerable.
References
1. Liamputtong, P. Researching the Vulnerable: A Guide to Sensitive Research Methods; SAGE: London, UK; Thousand Oaks, CA, USA, 2007; 246p.
2. Societies 2020, 10(1), 5; https://doi.org/10.3390/soc10010005
3. Fineman, Martha A., The Autonomy Myth: A Theory of Dependency, New York, The New Press, 2004.
4. Rodriguez, Janet Delgalo. The Relevance of the Ethics of Vulnerability in Bioethics. The Ethics Forum. Volume 12, Issue 2–3, Automne 2017, p. 154–179 https://doi.org/10.7202/1051280
5. Hoffmaster, Barry, “What Does Vulnerability Mean?”, Hastings Center Report, vol. 36, no. 2, 2006, pp. 38-45.
6. Luna, Florencia, “Vulnerabilidad: la metáfora de las capas”, Jurisprudencia Argentina, IV, 1, 2008, pp. 60-67.
7. Flood, Bernadette. Pharmacists and assisted dying. BMJ 2020 https://www.bmj.com/content/368/bmj.m1139.full
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.
REFERENCES
1. Dahlquist M, Kugelberg HD. (2021). Public j...
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.
REFERENCES
1. Dahlquist M, Kugelberg HD. (2021). Public justification and expert disagreement over non-pharmaceutical interventions for the COVID-19 pandemic. J. Med. Ethics, Published Online First: 12 October 2021. doi: 10.1136/medethics-2021-107671
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...
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 the extent to which ethics is culture bound. Whilst traditional ethical principles remain they are increasingly augmented by Māori concepts. The related word Whanaungatanga is one of the principles in “Te Ture Whakaruruhau Code Of Ethical Principles For Public Health in Aotearoa New Zealand”(5). I look forward to further contributions.
* Māori language translation of words.
1. Mutu M. ‘To honour the treaty, we must first settle colonisation’ (Moana Jackson 2015): the long road from colonial devastation to balance, peace and harmony. Journal of the Royal Society of New Zealand. 2019;49(sup1):4-18.
2. Durie M. Whaiora Maori Health Development. Second Edition ed. Melbourne Australia: Oxford University Press; 1998.
3. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor–patient relationship with Māori. Journal of the New Zealand Medical Association. 2011;124(1347).
4. Parry R, Jones B, Gray B, Ingham T. Applying a Māori-centred consultation approach for engaging with Māori patients: an undergraduate medical student case study. Journal of Primary Health Care. 2014;6(3):254-60.
5. Public Health Association of New Zealand Incorporated. Te Ture Whakaruruhau Code Of Ethical Principles For Public Health in Aotearoa New Zealand. Wellington New Zealand2012 [Available from: https://www.pha.org.nz/page-18201.
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...
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 ‘client’ may be described as ‘depersonalising’.
Care of people who are unable to care for themselves and compassion towards people who are vulnerable has been a basic tenet of medicine since ancient times . We need to be aware of our own language, values and attitudes to enable us to create a collaborative relationship with people that is person centred, respectful, non-judgmental, encourages personal responsibility and takes into account ethical and professional considerations.
We need to be particularly careful of language in the care of the dying. Euphemisms are place-holders for important concepts. They may disguise a practice which one might abhor if it were given another name.
Those who use the phrase ‘dying with dignity’, by avoiding the negative connotations of suicide and euthanasia /intentional killing , expect that it will be perceived as less alarming than euthanasia and assisted suicide, and that there is a problem with people being treated with ‘dignity. The use of the term ‘dying with dignity’ creates a halo of benignity and generates greater support for and muted opposition to any proposed law. Similarly, the euphemisms ‘physician assisted suicide’ , ‘medical assistance in dying’ or ‘assistance with dying’ are meant to be reassuring.
The use of ‘detoxifying language’ can lead to a situation where physicians, pharmacists, nurses and others can turn from healers/those who maintain or improve health, to those who intentionally take human life. In Nazi Germany during World War II, euphemisms were used to desensitize physicians, pharmacists, nurses and society to the horrors of a program of intentional killing /euthanasia .
The consistent application of euphemisms for medicalized killing significantly weakens arguments against assisted intentional killing of a human being.
Reference:
Mitchell CB. Of Euphemisms and Euthanasia: The Language Games of the Nazi Doctors and Some Implications for the Modern Euthanasia Movement. OMEGA - Journal of Death and Dying. 2000;40(1):255-265. doi:10.2190/K68E-
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...
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 of hospices across Canada's provinces, and in each provincial health system the limited availability of those resources and the rehabilitative, psychological and social facilities that may make a life lived with chronic conditions meaningful and sustainable.
As a Canadian long engaged in this debate--legal and social--as well as in the care of those with chronic conditions I thus find their arguments incomplete and their conclusions inaccurate. I would, of course, be more than willing to debate their argument in person or in this, or another journal.
Tom Koch
The University of British Columbia, VAncouver, BC, Canada.
Alton Medical Centre, Toronto, ON, Canada.
1. Downie J. and Schudklienk U. Social determinants of health and slippery slopes in
assisted dying debates: lessons from Canada. J Med Ethics 2021. doi:10.1136/medethics-2021-107493.
2. Koch T. Old age alone shouldn’t be considered a justification for physician-assisted death. Globe and Mail 2018 (April 18). https://www.theglobeandmail.com/opinion/article-old-age-alone-shouldnt-b....
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...
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 reduce risk. 3) Urgency: Not being prioritized for preventive measures likely means waiting until they become available, while not being prioritized for a ventilator means not receiving one at all. The point about efficacy should be acknowledged as an important difference between ventilators and preventive measures. If healthcare workers qualify for priority for scarce life-saving resources due to their instrumental value in their roles as care providers, and the need for a ventilator indicates an inability to fulfill this role, then healthcare workers requiring ventilators shouldn’t receive priority for those resources over others.
The authors’ commitment to community solidarity leads them to concern about the results of assigning (or worse, reassigning) the last ventilator to a healthcare worker as opposed to someone in equal medical need. However, if prioritizing ventilators for healthcare workers weakens our social fabric, we must ask whether this also applies to preventive measures. Contra the authors’ last two points about differences between ventilators and preventive care: a) preventive care is lifesaving: The life of a nurse forced to face Covid patients without adequate PPE is endangered. b) preventive measures are urgent: If hospitals are overwhelmed and death rates are spiking, those aware of the virus’s danger and the vaccine’s efficacy in January will find only limited comfort in knowing that they might be able to receive the vaccine if they are healthy by May.
Preventive measures are like ventilators in that they are scarce lifesaving medical resources and their use is urgent. Can prioritizing them be justified? The authors follow James Childress in supposing that any justification for their use on the basis of instrumental value carries a “heavy burden of proof.” Childress made his comments in 1970, while grappling with how to approach extremely limited dialysis or organ transplant opportunities. He argued that the burden for straying from randomness or chance as a basis for allocation demands showing not that someone has positive contributions to make, but that they are literally irreplaceable, that disaster would likely result from that person’s loss. However, in the context of a pandemic, this burden of proof is too heavy. It is possible to be instrumental in saving many lives yet still fall short of Childress’ standard.
The most straightforward justification for prioritizing those who save more lives is the multiplier effect, an instance of instrumental value. If we save the life of a life-saver, more total lives are saved. This is evidence not that we value lives unequally—the life-saver’s life isn’t valued more highly—but that we value saving more lives above saving fewer lives. The authors make the point that many workers, not just healthcare workers, have instrumental value. It is true that healthcare workers aren’t alone in having instrumental value (many are instrumental in keeping the economy running or society functioning, for example) and in fact, aren’t the only ones in roles that might save lives. My argument is that if saving the most lives is our primary objective, then prioritizing those we believe will make that possible is consistent with valuing each life equally.
These judgments are context dependent. Decisions must be judged by the information available at the time. At the outset of a pandemic, we are information poor. No one knows whether the infectious agent in question is as contagious as measles or Ebola, how it spreads, or which groups are most at risk. This is difficult because PPE must be stockpiled in advance, and successful planning for mass vaccine allocation/distribution, although it happens later, isn’t last minute either. We must act on our best predictions. For pandemic disease, it is reasonable to assume that healthcare workers will be particularly vulnerable to death and that more lives will be saved if healthcare worker lives are saved. If we later come to have solid evidence that prioritizing housekeepers for vaccines instead of healthcare workers would actually save more lives (not the same as concluding that housekeepers are dying at higher rates, as mentioned in the article), we should adjust our priorities accordingly.
The authors’ account of unravelling social fabric is overblown. Scarcity brings sorrow; there aren’t enough lifesaving resources to go around. However, this is more a reflection of the pandemic’s toll than our decision to save the most lives by prioritizing healthcare workers. The goal is to save the most lives, not a perfect distribution process. Inevitably an imperfect distribution system will lead to the frustration the authors reference. Many will disagree with which goals are primary or how to achieve them. But frustration isn’t failure. When we come to know more, we can do better. Meanwhile, we save the most lives we can.
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...
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 medications dispensed by pharmacists.
Prescribing > Dispensing > Administration
The two quotes below ( (a.) and (b.)) taken from Professor Urban Wiesin’s very stimulating article (2) will be of interest to pharmacists worldwide.
a. “Nobody can be forced to assist with suicide, this is also the case for physicians”.
b. “Doctors ought to have a role in assisted suicide, simply on considering the facts. No other profession can ………. recognise inadequate pain therapy better. No other profession can provide more adequate information about the options for medical treatment of an illness”.
The pharmacy profession worldwide is regularly excluded from conscientious objection provisions in legislation. This exclusion denies the dignity of pharmacists as human beings and their central role in medication use.
The following questions must be asked
• Are pharmacists less dignified/ less free than doctors?
• Are pharmacists lacking in a conscience/ are they robots?
• Is the complex role of pharmacists in assisted suicide not understood / purposely ignored / not visible?
• Are conscientious pharmacists valued by society / health systems/ other professions?
Pharmacists will be at the vortex of some of society’s most controversial moral dilemmas. Pharmacist are highly trained professionals with moral, ethical and legal accountability. The human rights and dignity of pharmacists must be recognised and protected.
(1) www.fip.org/file/4757 Patient safety .Pharmacists’ role in “Medication without harm” 2020. FIP. International Pharmaceutical Federation.
(2) Wiesing U The Judgment of the German Federal Constitutional Court regarding assisted suicide: a template for pluralistic states?Journal of Medical Ethics Published Online First: 11 June 2021. doi: 10.1136/medethics-2021-107233
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
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...
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 issue of potential staff distress around using particular killing techniques, especially physical methods, is also frequently discussed by AWERBs. Further support for staff is forthcoming from the UK Institute of Animal Technology, which frequently produces materials and holds meetings and workshops to help its members develop resilience and deal with AUB.
However, I can believe that not all AECs, IACUCs etc worldwide are concerned with staff mental health (practice can also vary regarding achieving all the tasks between different AWERBs and AWBs), and it is a shame to think that mitigating AUB might be viewed as controversial by some.
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...
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 disturbing the best systems with our considerations. The recent year 2020, and the current 2021, however, is placing us in front of problems related to the confinement of entire populations, with extreme isolation both for hospitalized patients and for patients in home quarantine. Actually, even patients with COVID-19 are never completely alone, but those who have the fortune, or misfortune, of having to stay in the hospital in recent months find around them as the only possible friends, to watch and, hopefully, to talk to, other equally unhappy patients. Relatives, friends and even the personal doctor, if there is one, are not allowed in for visiting and even for contributing, as more or less was usual everywhere. The patient's only connection with the outside world is a functioning smartphone.
Patients with COVID-19, or non-COVID-19 under current COVID-19 protective measures, stay alone in the hospital, and, at worst, die alone there. I do not want to talk about personal experiences, but I will only talk about the feelings of loved ones, or known ones or, simply, of my patients. The acute sense of injustice that patients and relatives feel concerns precisely this prolonged obligation to suffer and die alone.
The most directly related issue is that younger doctors are trained to proceed along stranded guidelines, which do not at all include interference from other patients, however much they are medically qualified. In general, it can also be justified, by medico-legal considerations: but what leaps to the eye is the annoyance of many doctors in having a patient who is too aware, and sometimes too impatient or with excessive demands for attention. All this seems to be tolerated, and not always, if the concerns and requests, or suggestions, refer to the patient himself: less so if they concern other patients. Perhaps it is an anthropological problem, or perhaps something else, but this situation is at least unusual in the hospitals that I know. Here, as an unwritten rule, nurses and doctors often if not always ask for the collaboration of the concurrently hospitalized health professional to monitor, as possible, on other patients. As always, it is requested to the more lucid and attentive patients in the same ward. Intervening in the diagnostic reasoning, even in urgency, of those who are on-duty is, of course, quite another thing. However, it must be done, without hesitation, gracefully and promptly. Usually our trainees learn to appreciate this real world school. If all this sounds excessive and difficult to implement in a context of ethical directives, it could be better received within a strategy of clinical risk analysis and management, with a focus to processes.
Guglielmo M. Trovato, MD
Professor of Medicine at the School of Medicine of the University of Catania (Italy)
References
1) Taylor-Robinson SD. Personal perspectives: having the time to observe the patient. J Med Ethics Epub ahead of print: [please include Day Month Year]. doi:10.1136/medethics-2020-107041
2) Trovato GM, Catalano D, Di Nuovo S, Di Corrado D. Perception of cultural correlates of medicine: a comparison between medical and non-medical students--the authoritarian health. Eur Rev Med Pharmacol Sci. 2004; 8:59-68. PMID: 15267119.
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...
Show MoreDahlquist 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.
REFERENCES
Show More1. Dahlquist M, Kugelberg HD. (2021). Public j...
Words/Nga Kupu*
Show MoreThe 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...
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...
Show MoreIn 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.
Show MoreAs 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...
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.
Show MoreThe 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...
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...
Show MoreEven 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
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...
Show MoreI 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.
Show MoreThe 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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