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.
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...
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 should be based on medical criteria and decided by at least three competent physicians. The family should be approached and the facts discussed fully with them. (4,5)
Mohiuddin et al stated that while the notions of futility greatly impact the bioethical discourse regarding withholding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. The justifying conditions appear to rely on physician assessment of the clinical
prognosis. (6)
• Hassan Chamsi-Pasha, Consultant Cardiologist, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
• Other Contributors:
o Majed Chamsi-Pasha, Senior Registrar, Internal Medicine.
o Mohammed.A. Albar, Director of Medical Ethics Center, International Medical Center.
References:
1. Al-Bar MA, Chamsi-Pasha H. Contemporary bioethics: Islamic perspective. New York
(NY): Springer; 2015.http://link.springer.com/book/10.1007/978-3-319-18428-9
2. Kassim, P. N., & Adeniyi, O. B. (2010). Withdrawing and withholding medical treatment: A comparative study between the Malaysian, English and Islamic law. Medicine and Law, 29(3), 443–461.
3. Code of Conduct drawn at the International Conference on Islamic Medicine held in Kuwait, 1981, known as “The Islamic Code of Medical Ethics,” p 67
4. Permanent Committee for Scholarly Research and Ifta. (1989). Ruling on resuscitating the patient if he is dead, his health condition is not fit for resuscitation or his disease is incurable. Fatwa number 12086. http://www.alifta.net/Fatawa/FatawaChapters.aspx?View=Page&PageID=299&Pa....
5. Chamsi-Pasha H, Albar MA. Ethical Dilemmas at the End of Life: Islamic Perspective. J Relig Health. 2017;56(2):400‐410. doi:10.1007/s10943-016-0181-3
6. Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth. 2020;31(1):29‐46. Published 2020 Mar 22. doi:10.1080/11287462.2020.1736243
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...
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 resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. (4) It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. (5)
Withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for physicians and some doctors might refuse to do so. For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. (6)
The National Institute for Health and Care Excellence in the UK published on 20 March 2020 the Guideline with clinical decision-making. The basis of the Guideline is to maximize patient safety and appropriate use of resources. Admission to an intensive care unit is based on some assessment of frailty, comorbidities and likeliness to recover from the intensive treatment.
Solnica et al described the Jewish ethical prospective on medical triage in in the allocation of scarce resources. Utilitarian principles should be the basis for such decision. The difficulty, however, arises when it is impossible to triage patients based solely on utilitarian considerations.
The Jewish tradition also recognizes the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (1)
In response to the COVD-19 pandemic, three Fatwas (decrees) were issued by major Islamic Jurisprudence authorities. The first was issued by the Assembly of Muslim Jurists of America which stated that what is to be considered in prioritizing patients over others is the degree of need; so the one in greater need should be prioritized. If they have the same need, the one with a greater likelihood of recovery, based on clinical tools, should be given precedence. If such likelihood is equal, then those with the longer life expectancy should be given precedence. When applicable, service should be provided on a first come, first served basis. If all previous considerations do not give precedence to some over the others, resorting to lottery is a principle that is endorsed by the Islam. (8)
The second decree was issued on 28.3.2020 by the European Council for Fatwa and Research (ECFR) on managing scarce resources during this pandemic. It states: “Muslim physicians are committed to the regulations of the hospitals they work in. If the matter is assigned to the physicians, they must utilize medical, ethical and humanitarian standards. Withdrawal of life-saving equipment in order to treat a patient arriving later is not permitted. If the physician has no choice but to choose between two patients, then the former is offered the ventillator, unless he is deemed futile; the one in need of urgent treatment over the one whose condition allows delay, and the patient whose successful treatment is more likely.” (9)
The third recommendation was issued by The International Islamic Fiqh Academy which held a symposium on 16th April 2020 discussing the ethical implications of COVID-19 and stated that “Physicians should adhere to the medical and ethical standards. In case of excessive number of patients requiring ventilators with the lack of adequate devices, it is left to the discretion of the physician who prioritizes the one who deserves prioritization, and when they are equal, he resorts to lottery between patients”. (10)
The Islamic law permits withdrawal of futile treatment on the basis a clear medical decision by at least three physicians. (11) In futile cases, many Fatwas (decrees) stated that while life support treatment is permissible to stop, ancillary treatment including nutrition, hydration, pain control, and antibiotics should continue. (12)
References
1. Solnica A, Barski L, Jotkowitz A.Allocation of Scarce Resources During the COVID-19 Pandemic: A Jewish Ethical Perspective. J Med Ethics .2020 Apr 10. doi: 10.1136/medethics-2020-106242.
2. Khoo EJ, Lantos JD. Lessons learned from the COVID-19 pandemic [published online ahead of print, 2020 Apr 14]. Acta Paediatr. 2020;10.1111/apa.15307. doi:10.1111/apa.15307
3. Mannelli C. Whose Life to Save? Scarce Resources Allocation in the COVID-19 Outbreak. J Med Ethics. Epub ahead of print: doi:10.1136/medethics-2020-106227
4. Zucker H, Adler K, Berens D, et al. Ventilator allocation guidelines. Albany: New York State Department of Health Task Force on Life and the Law, November 2015 (https://www .health
.ny .gov/ regulations/ task_force/ reports_publications/ docs/ventilator_guidelines .pdf).
5. Kerstein SJ. Dignity, disability, and lifespan. J Appl Philos 2017; 34: 635-50.
6. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 [published online ahead of print, 2020 Mar 23]. N Engl J Med. 2020;10.1056/NEJMsb2005114. doi:10.1056/NEJMsb2005114
7. National Institute for Health Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE guideline 2020;25.
8. www.amjaonline.org/fatwa/en/87747/
9. www.e-cfr.org
10. http://www.iifa-aifi.org/5254.html
11. Al-Bar MA, Chamsi-Pasha H. Contemporary bioethics: Islamic perspective. New York (NY): Springer; 2015.http://link.springer.com/book/10.1007/978-3-319-18428-9
12. Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth. 2020;31(1):29‐46. Published 2020 Mar 22. doi:10.1080/11287462.2020.1736243
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),...
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), junior doctors who are either underprepared or overconfident when it comes to ethical reasoning, will each be more likely to be exposed to such discussion, leading to better ethical decision-making overall.
This could represent an important learning opportunity to be taken forward over the coming months, one that could promote more confidence and competence amongst Foundation doctors when tackling MEL issues.
References
1. Corfield L, Williams RA, Lavelle C, Latcham N, Talash K, Machin L. Prepared for practice? UK Foundation doctors’ confidence in dealing with ethical issues in the workplace. Journal of Medical Ethics. 2020 Apr 10.
2. Brennan PA, Davidson M. Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up. Bmj. 2019 Jul 2;366:l4461.
3. Care Quality Commission. Opening the door to change: NHS safety culture and the need for transformation. 19 Dec 2018. www.cqc.org.uk/openingthedoor.
4. Srivastava R. Speaking up—when doctors navigate medical hierarchy. New England Journal of Medicine. 2013 Jan 24;368(4):302-5.
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...
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 male LARCs are freely available, the trust that men are indeed using them would stem from a similar place to the trust that one’s sexual partners do not have any STIs. At present, STI status is not routinely verified (e.g., through the exchange of clinic results) before partners embark on casual sex. If at all, statements of trust, such as verbal assertions of STI status, may be proffered prior to casual sex (11,12). I argue it is plausible that, were male LARCs to become readily available, contraceptive status would be navigated in a similar fashion.
2. Campo-Engelstein L. Raging hormones, domestic incompetence, and contraceptive indifference: narratives contributing to the perception that women do not trust men to use contraception. Cult Health Sex [Internet]. 2013 Mar 1;15(3):283–95. Available from: https://doi.org/10.1080/13691058.2012.752106
3. Glasier AF, Anakwe R, Everington D, Martin CW, Spuy Z va. der, Cheng L, et al. Would women trust their partners to use a male pill? Hum Reprod [Internet]. 2000 Mar 1;15(3):646–9. Available from: https://doi.org/10.1093/humrep/15.3.646
4. Reynolds HW, Luseno WK, Speizer IS. Consistent condom use among men with non-marital partners in four sub-Saharan African countries. AIDS Care. 2013;25(5):592–600.
5. Mulumeoderhwa M. “It’s not good to eat a candy in a wrapper”: male students’ perspectives on condom use and concurrent sexual partnerships in the eastern Democratic Republic of Congo. SAHARA J J Soc Asp HIV/AIDS Res Alliance [Internet]. 2018 Aug 27;15(1):89–102. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30149788
6. Bowleg L, Massie JS, Holt SL, Heckert A, Teti M, Tschann JM. How black heterosexual men’s narratives about sexual partner type and condom use disrupt the main and casual partner dichotomy: ‘we still get down, but we not together.’ Cult Health Sex [Internet]. 2020 Feb 10;1–18. Available from: https://doi.org/10.1080/13691058.2019.1683228
7. Fetner T, Dion M, Heath M, Andrejek N, Newell SL, Stick M. Condom use in penile-vaginal intercourse among Canadian adults: Results from the sex in Canada survey. PLoS One. 2020;15(2):e0228981.
8. Sastre F, De La Rosa M, Ibanez GE, Whitt E, Martin SS, O’Connell DJ. Condom use preferences among Latinos in Miami-Dade: emerging themes concerning men’s and women’s culturally-ascribed attitudes and behaviours. Cult Health Sex. 2015;17(6):667–81.
9. Marfatia YS, Pandya I, Mehta K. Condoms: Past, present, and future. Indian J Sex Transm Dis AIDS [Internet]. 2015;36(2):133–9. Available from: https://pubmed.ncbi.nlm.nih.gov/26692603
11. Smith BD, Jewett A, Burt RD, Zibbell JE, Yartel AK, DiNenno E. “To share or not to share?” Serosorting by hepatitis C status in the sharing of drug injection equipment among NHBS-IDU2 participants. J Infect Dis [Internet]. 2013/10/16. 2013 Dec 15;208(12):1934–42. Available from: https://pubmed.ncbi.nlm.nih.gov/24136794
12. Pfeiffer EJ, McGregor KA, Van Der Pol B, Hardy Hansen C, Ott MA. Willingness to Disclose Sexually Transmitted Infection Status to Sex Partners Among College-Aged Men in the United States. Sex Transm Dis [Internet]. 2016 Mar;43(3):204–6. Available from: https://pubmed.ncbi.nlm.nih.gov/26859810
The COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, stayi...
The COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, staying healthily uninfected whilst we strive for containment remains a cause for celebration.
Albert Camus’ The Plague is balm to the fear-riven tear in the fabric of global society. Just as the decimated inhabitants of Shakespeare’s London outlasted the plaque, without modern medicine and public health interventions, the burgeoning coro-demic is but one of Camus' "many plagues in history…yet plagues and wars (still) take people equally by surprise.“ Camus’ contagion will surely go “unaccountably” when it pleases, the sooner if communities adjust and adhere to “bewildering portents” with care and caution to the lives of others. Camus urges the social distancing and lock-downs that today will mitigate the coro-disruption’s festering tenacity, and encourages that the pandemic threat is not fated to last forever.
As we face the rigours of self-isolation, the consumptive poet -doctor John Keats, exiled in the Bay of Naples as typhus raged, reminds the reader of life coming to a premature stop. The threat of cross-infection in my daily patient encounters incites Keat’s “mortality weigh(ing) heavily on me like unwilling sleep,” yet there is consolation in being “half in love with easeful death.” We should all salute the unsung scores of imperilled, some now dead, doctors and nurses that have risen to the occasion.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Adjunct associate professor, School of Public Health and Social Work
O Block, Room O-D610
Victoria Park Road
Kelvin Grove, Brisbane QLD 4059
Queensland University of Technology, Brisbane
Australia
Mob 0404826650
In Ireland, the Health (Regulation of Termination of Pregnancy) Act 2018 provides 'conscientious objection' for doctors and nurses (and their students and trainees). Conscientious objection under this legislation is not provided for pharmacists, pharmacy students or any other healthcare staff. The Irish state does not respect my inalienable human right to freedom of thought, conscience and religion, in this matter. My 'unavoidable personal beliefs' are unrecognised. As a pharmacist my dignity is not respected in the same way that the dignity of doctors and nurses and their students/trainees is respected in the Act.
As an Irish pharmacist I am deeply concerned at the challenge to my right to freedom of conscience and consequently my dignity as a human being. The Irish State must ensure that I as a human being and a pharmacist can enjoy my human and constitutional right to freedom of thought, conscience, religion or belief on the basis of respect for my inherent human dignity. Pharmacists (and others) can have 'unavoidable personal beliefs'.
The right to conscientious objection is not only based on the right to “freedom of conscience”, but also on Article 1 of the Universal Declaration of Human Rights which recognizes that all human beings “are endowed with reason and conscience.” This includes pharmacists.
In his 2013 comprehensive and scholarly review, John Grabenstein (What the World's religions teach, applied to vaccines and immune globulins - https://doi.org/10.1016/j.vaccine.2013.02.026) noted that there are no scriptures associated with any of the World's major religions (Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam) that prohibit vaccines or vaccination. So no grounds for religious exemption can exist, because vaccines and vaccination do not contravene any religious code.
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Cle...
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Clever use of rhetoric of nation, blood and land has made subsequent atrocities viewed as a correct course of action and generated what might be viewed as moral blindness. We are at risk of heading the same way.
Furthermore the paradigm of “informed consent” chosen by the authors is lukewarm, as it assumes a level playing field for a social contract between patient and doctor. This is not the case. Assuming the “consent” is the most suitable concept to use, then “valid” consent presents a better way of thinking about the problem. A valid consent demands absence of duress or fear. This may be possible for economic migrants who cross borders out of choice, but is not the case for refugees. As for access, to use the above examples, the ship has to reach a port, a safe haven for migrants to access healthcare. No doctor will refuse to care for a sick patient and the authors note the existence of that ethical obligation. But to require doctors to climb over the fence built by the legislators, paddle in boats into the sea to reach patients against the policy created by the government or go into communities to explain treacherous legal language is inappropriate and misleading. It gives an impression of apportioning the blame for the human rights crisis in evolution to the medical profession alone. The problem we face as a society is bigger than communication, health promotion or policy interpretation. It concerns our existence as moral, compassionate and responsible beings. It concerns the future of humanity.
References:
1. Glennerster R, Hodson N. Confused out of care: unanticipated consequences of a “Hostile Environment”. J Med Ethics Epub ahead of print: 22.01.2020 doi:10.1136/medethics-2019-105634. [Accessed 22.01.2020].
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...
Show MoreWithdrawal 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.
Show MoreUnfortunately, 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...
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)
Show MoreThe 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...
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),...
Show MoreDear 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...
Show MoreThe COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.
Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).
One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.
How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, stayi...
Show MoreIn Ireland, the Health (Regulation of Termination of Pregnancy) Act 2018 provides 'conscientious objection' for doctors and nurses (and their students and trainees). Conscientious objection under this legislation is not provided for pharmacists, pharmacy students or any other healthcare staff. The Irish state does not respect my inalienable human right to freedom of thought, conscience and religion, in this matter. My 'unavoidable personal beliefs' are unrecognised. As a pharmacist my dignity is not respected in the same way that the dignity of doctors and nurses and their students/trainees is respected in the Act.
As an Irish pharmacist I am deeply concerned at the challenge to my right to freedom of conscience and consequently my dignity as a human being. The Irish State must ensure that I as a human being and a pharmacist can enjoy my human and constitutional right to freedom of thought, conscience, religion or belief on the basis of respect for my inherent human dignity. Pharmacists (and others) can have 'unavoidable personal beliefs'.
The right to conscientious objection is not only based on the right to “freedom of conscience”, but also on Article 1 of the Universal Declaration of Human Rights which recognizes that all human beings “are endowed with reason and conscience.” This includes pharmacists.
In his 2013 comprehensive and scholarly review, John Grabenstein (What the World's religions teach, applied to vaccines and immune globulins - https://doi.org/10.1016/j.vaccine.2013.02.026) noted that there are no scriptures associated with any of the World's major religions (Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam) that prohibit vaccines or vaccination. So no grounds for religious exemption can exist, because vaccines and vaccination do not contravene any religious code.
Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.
The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Cle...
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