eLetters

461 e-Letters

  • Financially driven study participants?

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

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

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

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

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

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

    Dear Editor,

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

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

    Even though these well-organise...

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  • Selective isolation of older adults is ageist and unhealthy

    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...

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  • Older people deserve better than paternalistic lockdown

    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...

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  • Response to Ford and Oswald

    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...

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  • Withdrawal and Withholding treatment in terminal illness: Islamic Perspective

    Withdrawal and Withholding treatment in terminal illness:
    Islamic Perspective

    Withholding or withdrawing life support is still an area of controversy. Its applicability is weighed with benefits and risks, and how futile the treatment is for the terminally ill patient.
    Unfortunately, many elder patients with chronic illness spend their last few weeks or months in hospitals. Life support is not required if it prolongs the agony and suffering associated with final stages of a terminal illness. When considering end-of-life decision making, both withholding and withdrawing life support are considered to be ethically equivalent. (1)
    Issues arising from the withdrawal and withholding treatment have not reached total consensus amongst the Muslim jurists. However, article 63 of the Islamic code of medical ethics
    (Code of Conduct1981) stated that, “the treatment of a patient can be terminated if a team of medical experts or a medical committee involved in the management of such patient are satisfied that the continuation of treatment would be futile or useless.” It further stated that “treatment of
    patients whose condition has been confirmed to be futile by the medical committee should not be commenced.” (2,3)
    The Permanent Committee for Research and Fatwa, Fatwa (Decree) No. 12086 (1989) is a landmark in regulating resuscitative measures, stopping of machines in cases thought to be not suitable for resuscitative measures. The decision shou...

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  • Ethical challenges in Scarce Resources Allocation in COVID-19 pandemic: Western and Islamic views

    We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
    The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
    During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
    Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
    Priority for limited resource...

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  • A LESSON TO BE LEARNT? HOW THE COVID-19 PANDEMIC COULD HAVE A POSITIVE IMPACT ON JUNIOR DOCTORS’ ETHICAL DECISION-MAKING.

    We were interested to read Corfield et al’s recent article on Foundation doctors’ confidence in dealing with ethical issues in the workplace(1), which felt particularly relevant to us – a fourth-year medical student and a Foundation doctor. The importance of medical law and ethics (MEL) has been emphasised by the current COVID-19 pandemic. Difficult decisions with complex ethical implications have had to be made at both clinical and managerial levels across the health service.

    Suddenly, junior doctors’ preparedness to deal with ethical dilemmas is framed in a new light. We took particular note of Corfield et al’s concluding remark which highlights the need for a supportive environment which fosters liberal discussion of ethical queries(1). It is well documented that the presence of rigid hierarchies within the clinical environment can deter junior doctors from raising uncertainties(2-4), a phenomenon likely to extend to those of an ethical nature.

    The COVID-19 pandemic represents an unprecedented challenge for medics regardless of their level of seniority, which has engendered a feeling of common endeavour with far-reaching consequences for practice. Interestingly, discussions with colleagues have echoed our perception that these changes have precipitated a less pronounced sense of hierarchy. This in turn has the potential to facilitate more open discussion of ethical issues including those generated by the crisis. In relation to the authors’ findings(1),...

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  • Complicating Condom Use in Casual Sex Encounters

    Dear editor,

    Shahvisi offers cogent arguments for men taking primary responsibility for unwanted pregnancy (1). I do not, in this letter, aim to argue against her conclusion. However, when discussing potential counterarguments to this position, she mentions that it is claimed that perhaps women would not trust men to use long-acting reversible contraceptives (LARCs). Shahvisi does well to point out the relevant data that reveals women in longer term relationships would, in fact, trust their partners to use LARCs (2,3). Yet in discussions of casual sexual encounters, she merely asserts that ‘barrier methods are in any case preferable’(1).

    I argue this is not trivially the case. The use of barrier methods is highly inconsistent, particularly in casual sex (4–8). Despite their role in preventing both sexually transmitted infections (STIs) and unwanted pregnancy, I would argue that this data shows that people’s condom preferences are not so clear cut. Preference for condom use is heterogenous and is tied to desires more abstract than seeking to prevent pregnancy, such as the desire to feel masculine or ‘clean’ (8). Additionally, condoms, the most popular barrier method, are 86% effective at preventing unwanted pregnancy in typical use (9). LARCs are more than 99% effective (10).

    It is my view that defeating the argument that women would not trust men to use LARCs in casual sexual relations thus needs more work. One argument might be that, in a world where...

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