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...
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 medical intervention to which they do not give their voluntary and informed consent comprises a huge emotional conflict; one which can become almost an existential threat, psychologically, if they feel forced into allowing or accepting a medical intervention which they have, rightly or wrongly, come to believe to be dangerous. One can imagine the resistance this will induce. People will consider deregistering children from schools and giving up their careers in order to avoid the perceived threat.
How do we address this questions of safety? How can people be made to trust the data? Do we have a moral right to mandate, if we have made no effort to convince? Are we willing to do what it takes? In the long term the answer may well have to be a completely independent body to conduct trials, independent both of industry and politics.
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...
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 time-outs and project periods to break-up clinical activity.(3) The concern is that those deployed early onto the frontline will not have had the adequate break required to replenish their wellbeing in preparation for their lifelong career ahead.
The obligation to patient care and dire need for volunteers will see most graduating medical students quickly enter clinical practice. However, stress, anxiety and burnout are well recognised issues amongst medical students, and may be exacerbated for this cohort.(4) The covid-19 pandemic is likely to cause heightened moral distress for newly graduated doctors, as they are required to make increasingly challenging decisions regarding patient care.(5) This highlights the need to build moral resilience to reduce the chance of moral injury or burnout.
It is well recognised that breaks during work are important to avoid burnout, particularly for healthcare professionals. A study conducted on doctors working in a stressful intensive care environment showed that taking breaks from the intensive care unit environment was one important strategy to rejuvenate from moral distress.(6) However, the concern is that those more junior faced with the existing anxiety of a new job role and responsibilities may have a lower tolerable threshold for morally distressing situations; as a result increasing likelihood of burnout. Additionally, many more doctors are taking time out from foundation training in recent years due to stress and exhaustion.(7)
Reflexivity is important in developing as a practitioner and may be crucial in the period between graduating and becoming a medical professional. Coates et. al(1) showed that this transitional period is an important time for life skill development, such as through increasing confidence, emotional stability and independence; important traits of a medical professional. The importance of a break is recognised throughout, with trainees now opting to take a break during medical training, of which the result has been an addition of valuable experience to the development of their future profession.(7)
Therefore, whilst providing newly graduated students with the invaluable learning opportunity of assisting during a global pandemic, it must also be remembered that students must receive an adequate break from clinical studies in order to develop moral resilience, boost mental wellbeing and reduce the chances of burnout during foundation training.
References
1. Coates WC, Spector TS, Uijtdehaage S. Transition to Life—A Sendoff to the Real World for Graduating Medical Students. Teaching and Learning in Medicine 2012;24(1):36-41. doi: 10.1080/10401334.2012.641485
2. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Medical education online 2018;23(1):1530558-58. doi: 10.1080/10872981.2018.1530558
3. Tolhurst HM, Stewart SM. Balancing work, family and other lifestyle aspects: a qualitative study of Australian medical students’ attitudes. Medical Journal of Australia 2004;181(7):361-64. doi: 10.5694/j.1326-5377.2004.tb06326.x
4. Wang Q, Wang L, Shi M, et al. Empathy, burnout, life satisfaction, correlations and associated socio-demographic factors among Chinese undergraduate medical students: an exploratory cross-sectional study. BMC Medical Education 2019;19(1):341. doi: 10.1186/s12909-019-1788-3
5. Wald HS. Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an ‘integrative resilience’ approach. Medical Teacher 2020:1-12. doi: 10.1080/0142159X.2020.1768230
6. Henrich NJ, Dodek PM, Gladstone E, et al. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. American Journal of Critical Care 2017;26(4):e48-e57. doi: 10.4037/ajcc2017786
7. Rizan C, Montgomery J, Ramage C, et al. Why are UK junior doctors taking time out of training and what are their experiences? A qualitative study. Journal of the Royal Society of Medicine 2019;112(5):192-99. doi: 10.1177/0141076819831872
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...
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 not in the condition of attributing any value to their own existence are not persons.” They go on to say that “those who are only capable of experiencing pain and pleasure (like perhaps fetuses and certainly newborns) have a right not to be inflicted pain. If, in addition to experiencing pain and pleasure, an individual is capable of making any aims (like actual human and non-human persons), she is harmed if she is prevented from accomplishing her aims by being killed.” The argument is that since the child has no future goals or ‘aims’, by painlessly killing the child, the child experiences no loss. I would argue the opposite. Firstly, a newborn experiences a lot more than just pain and pleasure, they experience hunger, sleepiness and fear to name a few. Furthermore, even if they only experienced pain and pleasure they certainly have aims to seek pleasure and avoid pain. In the same way a person is harmed when someone steals from them their winning lottery ticket, even if they are totally unaware, the newborn is harmed when you kill it. What is the moral difference? If the authors argue that since that child has no knowledge of its future and no ‘aims’ about it, taking that away poses no harm to it, the same should be applied to the person who had the lottery ticket stolen. She had no knowledge of her jackpot and therefore experienced no loss; no harm done right? If you want to say that the person will experience the harm of the loss of money, then the same argument can be applied to the newborn who is deprived of many things after being killed.
Additionally, to prescribe the moral right to life “non-human persons” but not a human newborn seems especially far-fetched. To say that an animal has any more aims than a newborn is ridiculous. A dog, for example, has no knowledge passed its own tail. It’s not thinking or planning about the future. The same way a dog wails at the door when its owner leaves for work and “aims” for the owner to return through the door, a newborn child also “aims” to drink its mother’s milk and wails when it cannot. To say that it applies no value to this is clearly incorrect and the child certainly has future aspiration from birth, namely more food and sleep, to name the earliest that arrive.
I would like to end with a moral question to the authors, what should the cut-off age for after-birth abortion be, many sources say it should be done case by case, but what if a parent discovers that it has become too difficult to care for their child of age 2-4. Should they be able to perform an after-birth abortion; children at this age hardly make plans for the future, how is this morally any different than other after-birth abortions?
P.S. What damages could possibly be received by the mother for giving her newborn up for adoption and if so, how can they compare to the damages brought to the child when killed?
Abstract
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...
Abstract
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 messages especially about Down’s syndrome and those being obviously distressing” [2]. Sometimes it feels like special interest groups have hijacked the debate at the expense of women’s autonomy [4].
The current Covid-19 pandemic has stressed the healthcare systems to breakpoint in most if not all countries affected and in some even beyond. The pandemic has not only meant that large resources has had to be put into Covid-19 but it has caused financial chaos with bankruptcies and reduced incomes. Companies are struggling to survive. We thus have a reduced tax base at the same time as tax money must be redirected to get the economy back on its feet. The reality which we live in is that there is a limit to what percentage of GDP but also absolute money a country can spend on health care. Before the pandemic most European countries spent 10 – 12 % of their GDP on health care with the USA as an outlier at 18 %, while 50 years ago it was only about 6 – 7 %. The absolute sums are probably more important than the percentages because certain costs, such as medicines and instruments, are becoming more and more uniform throughout the world.
Bunnik et al are correct in justifying “public funding of NIPT because it will save the public money” [3]. Three studies – one each from Mexico, South-Korea and the USA [4, 8, 9, 10] – confirm the substantial financial aspects of managing Down’s syndrome. In healthcare systems where the costs directly hit the families, they can be ruinous. In systems where the tax-payers defray this cost we can expect to find an increased resistance to such expenses. This attitude will have been exacerbated in the path of the current Covid-19 pandemic.
In short, in countries with limited resources or where costs of care fall on the individuals and their families, it is pressing to introduce fine rule-out tests.
References:
1. Bunnik EM, Kater-Kuipers A, Galjaard RH, de Beaufort ID. Should pregnant women be charged for non-invasive prenatal testing? Implications for reproductive autonomy and equal access. J Med Ethics. 2020 Mar; 46(3):194-8. doi: 10.1136/medethics-2019-105675.2019.
2. Schmitz D. Why public funding for non-invasive prenatal testing (NIPT) might still be wrong: a response to Bunnik and colleagues. J Med Ethics 2019; doi: 10.1136/medethics-2019-105885
3. Bunnik EM, Kater-Kuipers A, Galjaard RH, de Beaufort ID. Why NIPT should be publicly funded. J Med Ethics 2020; doi: 10.1136/medethics-2020-106218
4. Breimer LH. Non-invasive prenatal testing: Special interest groups vs women’s autonomy. Ind J Med Ethics 2020; Published online on June 20, 2020. DOI:10.20529/IJME.2020.069.
5. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; Public Health Paper 34. 1968. Pp 163.
6. Vanstone M, Cernat A, Nisker J, Schwartz L. Women's perspectives on the ethical implications of non-invasive prenatal testing: a qualitative analysis to inform health policy decisions. BMC Med Ethics. 2018 Apr 16;19(1):27-39.
8. Park GW, Kim NE, Choi EK, Yang HJ, Won S, Lee YJ. Estimating nationwide prevalence of live births with Down syndrome and their medical expenditures in Korea. J Korean Med Sci 2019 aug 12[cited2020 May 12]; 34(31):e207. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689486/
9. Martínez-Valverde S, Salinas-Escudero G, García-Delgado C, Garduño-Espinosa J, Morán-Barroso VF, Granados-García V, et al. Out-of-pocket expenditures and care time for children with Down syndrome: A single-hospital study in Mexico City. PLoS ONE. 2019 Jan 10 [cited 2020 May 12]; 14(1): e0208076. Available from: https://doi.org/10.1371/journal.pone.0208076
10. Kageleiry A, Samuelson D, Duh MS, Lefebvre P, Campbell J, Skotko BG. Out-of-pocket medical costs and third-party healthcare costs for children with Down syndrome. Am J Med Genet A. 2017 Mar; 173(3):627-37.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. This work was written independently; no company or institution supported the author financially or by providing a professional writer.
Lars H Breimer, MA PhD, BM BCh, FRCPath, Dip Pharm Med
Örebro University Institution for Medical Sciences
School of Health and Medical Sciences
Dept of Laboratory Medicine, Clinical Chemistry division
Örebro University Hospital
SE-701 85 Örebro, Sweden
Tel: + 46 19 602 78 17 mobile: + 46 705 827 817
e-mail: lars.breimer@regionorebrolan.se
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.
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...
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 health systems failures due to insufficient funding, corruption and/or poor management. However, even theoretically unexpected, it is also happening in wealthy societies because their health systems became overwhelmed due to the pandemic. Regardless of its cause, misthanasia should not occur in any circumstances. Borasio et al (2020) 3 appropriately mentioned that “It is an ethical imperative to provide high quality palliative care for all patients who are likely to die from COVID-19, especially given their high symptom burden (dyspnea, anxiety etc.).”
To avoid misthanasia it would initially be necessary to acknowledge its existence and scale. In sequence, the palliative care should be organized for all the patients that need it, even in the eventuality of the local health system being unable to provide the appropriate curative treatment approaches. This is a moral imperative. It is a fundamental medical and humanitarian issue that does not require any major investment. Almost seven centuries after the narrative of the Plague in The Decameron it is embarrassing to acknowledge that humankind remains unable to avoid a pandemic or to provide proper curative treatment for all the patients suffering from it. Nevertheless, more empathy and care towards the ones that are left behind could be shown, because at least this is in our hands.
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.
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-organised volunteering roles exist, medical student duties to their study and difficult exams present a challenge in finding a healthy balance between study and volunteering. There is significant pressure to pass and perform well in exams that students may discover volunteering contradicts their academic output. Hence, I believe that the continuing remote education and examination (which pose their ethical considerations) retract students from being able to volunteer their full potential. Given that a large part of medical training is hands, future clinicians and tomorrow’s doctors need as much clinical experience as possible given the prediction of increasing epidemics(5).
Perhaps the best form of education is to adapt to our surroundings and to be able to engage our students in the present moment. Then we will feel fully educated and wholly resourceful.
In response to the article by Savulescu & Cameron [1] “Why lockdown of the elderly is not ageist and why levelling down equality is wrong,” we claim that the article presents an ageist approach that may be as harmful or more than the actual virus. In their work, the authors make reference to philosophical, legal, and practical aspects of locking down older adults, as they make the case for the merits of what they refer to as selective isolation. It is our position, as psychologists and gerontologists, that this approach is ageist, and is a disservice to older adults and society at large.
In the initial response to this article, O'Hanlon, O'Keeffe & O'Neill [2], have done a comprehensive job of refuting these claims based on the science that has been coming in regarding the effects of the lockdown on older adults. We wish to contribute another angle – that of the actual preferences and values of older adults themselves. No discourse about any group in society is complete without including this group. Thus, we attempt to abide by the old adage: "Nothing About Us Without Us".
In a recent qualitative study, we explored the personal experiences and preferences of older adults living in CCRCs (continuing care communities) in Israel during the height of the novel Coronavirus pandemic [3]. We were surprised to discover that CCRC residents in different locations in Israel were subjected to significant restrictions, and in many cases were...
In response to the article by Savulescu & Cameron [1] “Why lockdown of the elderly is not ageist and why levelling down equality is wrong,” we claim that the article presents an ageist approach that may be as harmful or more than the actual virus. In their work, the authors make reference to philosophical, legal, and practical aspects of locking down older adults, as they make the case for the merits of what they refer to as selective isolation. It is our position, as psychologists and gerontologists, that this approach is ageist, and is a disservice to older adults and society at large.
In the initial response to this article, O'Hanlon, O'Keeffe & O'Neill [2], have done a comprehensive job of refuting these claims based on the science that has been coming in regarding the effects of the lockdown on older adults. We wish to contribute another angle – that of the actual preferences and values of older adults themselves. No discourse about any group in society is complete without including this group. Thus, we attempt to abide by the old adage: "Nothing About Us Without Us".
In a recent qualitative study, we explored the personal experiences and preferences of older adults living in CCRCs (continuing care communities) in Israel during the height of the novel Coronavirus pandemic [3]. We were surprised to discover that CCRC residents in different locations in Israel were subjected to significant restrictions, and in many cases were not allowed to leave their personal living areas, both before and after the strict lockdown imposed on all Israeli citizens was lifted. Most CCRCs continued some form of lockdown even after Israel began reopening, a measure similar to the one Savulescu & Cameron argue for in their paper. In our in-depth interviews, residents who lived in CCRCs with such strict lockdowns, expressed anger and ongoing distress in the face of the restriction of their liberties and autonomies. Furthermore, a few of them who had personal backgrounds of earlier traumatic experiences in their lives, such as having survived the Holocaust, reported feeling that the current lockdown was reminiscent of being incarcerated and persecuted. Some went so far as to say that they were prisoners of their age, or that they felt in solitary confinement.
Lastly, many described feeling offended by the ageist and paternalistic discourse that took place at the outset of the pandemic in the Israeli media, that they felt was directed at them (statements such as: “older adults will overburden hospitals and take up precious ventilators”). Thus, the mere discussion about “selective isolation” of a segment of the population based solely on their age, is perceived by that population as offensive and disparaging. CCRC residents who felt that decisions to restrict their autonomy were made without consulting them, or that CCRC managements were not forthcoming about the decision-making process, felt even more offended and frustrated.
In this response we argue that healthcare systems may indeed be overburdened by caring for those who are most susceptible to the novel Coronavirus, yet this is attributable to the vulnerability of those very health care systems – systems that, in many developed countries have been neglected for years. Older adults should not pay the price for these underfunded, overburdened healthcare systems. Dismissing the autonomy and sovereignty of selected groups of people is wrong and may have a detrimental impact, which might even exceed the effects of the pandemic itself.
References
1. Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong [published online ahead of print, 2020 Jun 19]. J Med Ethics. 2020;medethics-2020-106336. doi:10.1136/medethics-2020-106336
2. O’Hanlon SA, O’Keefe ST, O’Neill D. Older people deserve better than paternalistic lockdown [published online ahead of print, 2020 Jun 19]. J Med Ethics. 2020;medethics-2020-106336.responses
3. Ayalon L, Avidor S. “We have become prisoners of our own age”: From a continuing care retirement community to a total institution in the midst of the COVID-19 outbreak. Unpublished manuscript.
The opinion piece by Savulescu and Cameron[1] is a good reminder of why multidisciplinarity is so important for clinical ethics,[2] and even more so where decisions for older people are concerned. There are so many problematic aspects to this paper it is genuinely difficult to know where to start.
Taking language first, the authors write in a reductionist manner about “the aged” and “the elderly”. These terms are repugnant to older people and the United Nations Human Rights Commission,[3] and ignore the diversity of the older population and the need for individual, and individualised, recommendations. The authors’ comment about not defining “an appropriate cut-off to identify ‘the elderly’” also misses this point. While acknowledging that ethnicity is a proxy for other factors that contribute to poorer outcomes, the authors fail to recognise that age is also such a proxy.
The erroneous and nihilistic “inevitable association between age and deterioration of physical health” seems to be a foundation for flawed arguments. Some older people are in poor health and may be well-advised – not coerced - to stay mainly indoors, avoid unnecessary social contact, and to take outdoor exercise at a safe distance. Others will have a different risk profile or will balance the potential benefits and risks of isolation differently. The assertion that “coercion is used in standard quarantine on the basis of risk of harm to others” does not recognise that people without any com...
The opinion piece by Savulescu and Cameron[1] is a good reminder of why multidisciplinarity is so important for clinical ethics,[2] and even more so where decisions for older people are concerned. There are so many problematic aspects to this paper it is genuinely difficult to know where to start.
Taking language first, the authors write in a reductionist manner about “the aged” and “the elderly”. These terms are repugnant to older people and the United Nations Human Rights Commission,[3] and ignore the diversity of the older population and the need for individual, and individualised, recommendations. The authors’ comment about not defining “an appropriate cut-off to identify ‘the elderly’” also misses this point. While acknowledging that ethnicity is a proxy for other factors that contribute to poorer outcomes, the authors fail to recognise that age is also such a proxy.
The erroneous and nihilistic “inevitable association between age and deterioration of physical health” seems to be a foundation for flawed arguments. Some older people are in poor health and may be well-advised – not coerced - to stay mainly indoors, avoid unnecessary social contact, and to take outdoor exercise at a safe distance. Others will have a different risk profile or will balance the potential benefits and risks of isolation differently. The assertion that “coercion is used in standard quarantine on the basis of risk of harm to others” does not recognise that people without any communicable disease are being quarantined at the moment. Quarantining a perfectly healthy individual to reduce the potential for disease transmission in a population comes at a much higher cost and a much lower benefit to that person.
Indeed, the authors are explicit that the main benefits of the selective isolation of older people they advocate are for others: to allow economic recovery (perpetuating the fallacy that older people are not economically active), participation in social life for the ‘non-elderly’ and to prevent the “consumption of limited resources” by older people. However, they suggest that lockdown will also benefit “the elderly by lowering their chances of dying from COVID-19”. In other words, it’s for their own good because that’s what the rest of society believes.
This risk/benefit analysis is skewed and misleading. It does not adequately consider the potential negative health effects of restriction of mobility, of reduced social contact and, as a result, liberty (a patient recently described their lockdown experience as being “worse than prison”). This is to apply until, as the authors breezily suggest, “there is sufficient herd immunity or a vaccine/treatment emerges”. The concept of deconditioning is an extremely important one in geriatric medicine: that even a short-term decrease in mobility affects muscle strength, to a greater extent in older than younger people.[4] Older people also recover less well from the effects of reduced mobility and so the risk of lasting harm is higher for them.[5] The potential effect of mass deconditioning of older people on healthcare resource utilisation has not been considered in the analysis.
No evidence has been adduced for the statements that older people “pose the greatest risk to society” or “are more likely to place significant strain on limited intensive care resources”, both of which are profoundly ageist viewpoints. The fear of the health service breaking down suffers from a highly restricted view of the broader healthcare system and agnosia to distributive justice: the healthcare system did indeed break down in care homes with an extraordinary excess of deaths.[6]
Instead of a Faustian pact to “allow the elderly to choose not to isolate while also restricting [their] access to health resources, such as ... intensive care”, a more appropriate action would have been for society to have had a conversation about the risks and benefits of locking people down based simply on age. We are not aware of any country that took this route, but many imposed their paternalistic views. We could have supported older people to avoid deconditioning, for example by taking exercise outside at set times during the lockdown, or proposed other imaginative solutions.
In conclusion, this paper overstates the benefits to older people of a lockdown, and understates the risks. Taken to its natural conclusion, Savulescu and Cameron’s thesis might suggest that coercing older people into a lockdown is appropriate and proportional because it keeps healthcare resources free for younger people. The bottom line is that superficial analyses that have not been informed by clinical evidence are dangerous and in any future situation similar to the Covid-19 pandemic, we will have to carefully consider why a misguided effort to “protect” our older population could instead permanently affect health outcomes in a negative manner.
References
1. Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong [published online ahead of print, 2020 Jun 19]. J Med Ethics. 2020;medethics-2020-106336. doi:10.1136/medethics-2020-106336
2. Russell C, O'Neill D. Ethicists and clinicans: the case for collaboration in the teaching of medical ethics. Ir Med J. 2006;99(1):25-27.
3. Falconer M, O'Neill D. Out with “the old,” elderly, and aged. Bmj. 2007 Feb 8;334(7588):316
4. Tanner RE, Brunker LB, Agergaard J, et al. Age-related differences in lean mass, protein synthesis and skeletal muscle markers of proteolysis after bed rest and exercise rehabilitation. J Physiol. 2015;593(18):4259-4273. doi:10.1113/JP270699
5. Suetta C, Frandsen U, Mackey AL, et al. Ageing is associated with diminished muscle re-growth and myogenic precursor cell expansion early after immobility-induced atrophy in human skeletal muscle. J Physiol. 2013;591(15):3789-3804. doi:10.1113/jphysiol.2013.257121
6. Graham NSN, Junghans C, Downes R, et al. SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes [published online ahead of print, 2020 Jun 3]. J Infect. 2020;S0163-4453(20)30348-0. doi:10.1016/j.jinf.2020.05.073
It is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intende...
It is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intended and designed to produce action-guiding recommendations to decision makers. That is, unlike other empirical bioethics research, deliberative methods ask members of publics to work together to determine what decision makers ought to do. The normative force of their recommendation, however, is not automatic: it relies on certain conditions being met to ensure the democratic legitimacy of deliberative processes and their outcomes. This is always by degree, and even a process that cannot legitimately prescribe policy action may provide valuable insights into matters of public significance.
What is required to achieve democratic legitimacy is a point of ongoing debate within the deliberative democratic literature. The onus is thus on both researcher and audience to critically evaluate, and continue conversations about, the methodological, epistemological and normative dimensions of deliberative research in empirical bioethics and health policy.
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...
Show MoreO’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...
Show MoreThe 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.
Show MoreThe 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...
Medethics-2020-106709 – see decision 23-July-2020
NIPT is the only ethical test
Abstract
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].
Show MoreThe 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...
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.
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.
Show MoreIn 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...
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...
Show MoreIn response to the article by Savulescu & Cameron [1] “Why lockdown of the elderly is not ageist and why levelling down equality is wrong,” we claim that the article presents an ageist approach that may be as harmful or more than the actual virus. In their work, the authors make reference to philosophical, legal, and practical aspects of locking down older adults, as they make the case for the merits of what they refer to as selective isolation. It is our position, as psychologists and gerontologists, that this approach is ageist, and is a disservice to older adults and society at large.
Show MoreIn the initial response to this article, O'Hanlon, O'Keeffe & O'Neill [2], have done a comprehensive job of refuting these claims based on the science that has been coming in regarding the effects of the lockdown on older adults. We wish to contribute another angle – that of the actual preferences and values of older adults themselves. No discourse about any group in society is complete without including this group. Thus, we attempt to abide by the old adage: "Nothing About Us Without Us".
In a recent qualitative study, we explored the personal experiences and preferences of older adults living in CCRCs (continuing care communities) in Israel during the height of the novel Coronavirus pandemic [3]. We were surprised to discover that CCRC residents in different locations in Israel were subjected to significant restrictions, and in many cases were...
The opinion piece by Savulescu and Cameron[1] is a good reminder of why multidisciplinarity is so important for clinical ethics,[2] and even more so where decisions for older people are concerned. There are so many problematic aspects to this paper it is genuinely difficult to know where to start.
Taking language first, the authors write in a reductionist manner about “the aged” and “the elderly”. These terms are repugnant to older people and the United Nations Human Rights Commission,[3] and ignore the diversity of the older population and the need for individual, and individualised, recommendations. The authors’ comment about not defining “an appropriate cut-off to identify ‘the elderly’” also misses this point. While acknowledging that ethnicity is a proxy for other factors that contribute to poorer outcomes, the authors fail to recognise that age is also such a proxy.
The erroneous and nihilistic “inevitable association between age and deterioration of physical health” seems to be a foundation for flawed arguments. Some older people are in poor health and may be well-advised – not coerced - to stay mainly indoors, avoid unnecessary social contact, and to take outdoor exercise at a safe distance. Others will have a different risk profile or will balance the potential benefits and risks of isolation differently. The assertion that “coercion is used in standard quarantine on the basis of risk of harm to others” does not recognise that people without any com...
Show MoreIt is useful to have a further opportunity to understand Ford and Oswald’s methodological decision making. Methodology, as always, is contestable.
There is one key misconstrual in the authors’ response that I’d like to address. Like all empirical bioethicists, I am committed to conducting respectful and systematic research designed to learn from people by taking their perspectives seriously. Like all deliberative researchers, I regularly provide inclusive groups of members of the public with information and support to deliberate on matters of public importance, with the goal of ensuring that their recommendations have consequences in policy. The final criticism made by the authors in their response is thus somewhat wide of the mark.
What I had proposed in my commentary was not that only the work of philosophers should inform policymakers, but that the basis for drawing normative conclusions in empirical bioethics is different for different kinds of research.
In a qualitative study or survey of people’s ethical judgements about their everyday practices, for example, empirical work is likely to produce evidence of diversity of values and judgements, to different levels of detail. A bioethics researcher then inevitably needs to do the work of developing normative conclusions through their analysis and interpretation.
My central point was that deliberative research has different foundations. It arises from democratic theory, and is thus intende...
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