This author agrees with the claim that freedom of association is a basic moral right and that the right to have visitors stems from this freedom. This author also agrees that the discussion around visitor policy should be framed as a discussion about rights infringement. However, this author suggests that the discussion around restriction is best described as a potential conflict between two rights: freedom of association and the right to safety. Accordingly, the rights infringement could go either way.
It is reasonable to claim that people have a moral right to safety (or something like it), and it is reasonable to say that this right should be highly protected in a hospital, where the sick and injured seek treatment. If people do have a right to safety, then it follows that this right would be infringed if hospitals did not take reasonable precautions to reduce hospital-acquired infections. Limiting visitors during COVID-19 should be seen as an example of such a precaution.
To be clear, McTernan recognizes that safety is an important consideration, but she does not state that it is a right. This affects the framing of the issue. Appealing to something as a right makes it substantially harder to act against that which is protected by that right. It is for this reason that McTernan correctly argues that restricting visitation is harder when we appeal to freedom of association.
The issue, then, is one in which patients have potentially two conflicting...
This author agrees with the claim that freedom of association is a basic moral right and that the right to have visitors stems from this freedom. This author also agrees that the discussion around visitor policy should be framed as a discussion about rights infringement. However, this author suggests that the discussion around restriction is best described as a potential conflict between two rights: freedom of association and the right to safety. Accordingly, the rights infringement could go either way.
It is reasonable to claim that people have a moral right to safety (or something like it), and it is reasonable to say that this right should be highly protected in a hospital, where the sick and injured seek treatment. If people do have a right to safety, then it follows that this right would be infringed if hospitals did not take reasonable precautions to reduce hospital-acquired infections. Limiting visitors during COVID-19 should be seen as an example of such a precaution.
To be clear, McTernan recognizes that safety is an important consideration, but she does not state that it is a right. This affects the framing of the issue. Appealing to something as a right makes it substantially harder to act against that which is protected by that right. It is for this reason that McTernan correctly argues that restricting visitation is harder when we appeal to freedom of association.
The issue, then, is one in which patients have potentially two conflicting rights that pull in opposite directions. The upshot is that the solution must be a balance between the two rights, which brings us to the next point.
McTernan is against hospitals “weighing the costs and benefits and coming up with some policy on what seems a reasonable amount of access to visitors[.]”(1) And she believes that framing the issue in terms of freedom of association can achieve that goal. However, if the issue is best framed as a potential conflict between two rights, then a cost-benefit analysis (or something like it) cannot be avoided. Unless there is some way to prevent visitors from transmitting the virus, respecting one right will potentially infringe the other. Hence, we will be forced to come up with some policy based on what seems like a reasonable amount of visitation.
We read with interest this risk-benefit and ethical analysis of the utility of SARS-CoV-2 vaccine boosters in university students. We have some major concerns about the choice of hospitalization as the primary measure of benefit. From the onset of the pandemic, healthcare providers, scientists, and public health experts in higher education have been learning from shared experiences, research, and evolving medical knowledge about the best way to safely populate college campuses with students, faculty, and staff. Hospitalizations averted is not the only marker of morbidity that is relevant to the college student population and given the rarity of severe disease requiring hospitalization in young, generally very healthy adults, hospitalization is not a good choice for a marker of COVID-19 related morbidity. We have also strived to minimize the risk of missed classes, severe illness, and need for prolonged medical leaves of absence given the potential adverse academic consequences of illness for students. Colleges and universities have been trying to balance infectious disease mitigation efforts with the need for in-person learning, social interactions, and the increased mental health challenges caused by some of these efforts that furthered the experience of isolation.
Much has changed since early 2020 and most schools have continued to evolve their protocols and policies to reflect new information and relevant data. We are dedicated to learning and contributing to th...
We read with interest this risk-benefit and ethical analysis of the utility of SARS-CoV-2 vaccine boosters in university students. We have some major concerns about the choice of hospitalization as the primary measure of benefit. From the onset of the pandemic, healthcare providers, scientists, and public health experts in higher education have been learning from shared experiences, research, and evolving medical knowledge about the best way to safely populate college campuses with students, faculty, and staff. Hospitalizations averted is not the only marker of morbidity that is relevant to the college student population and given the rarity of severe disease requiring hospitalization in young, generally very healthy adults, hospitalization is not a good choice for a marker of COVID-19 related morbidity. We have also strived to minimize the risk of missed classes, severe illness, and need for prolonged medical leaves of absence given the potential adverse academic consequences of illness for students. Colleges and universities have been trying to balance infectious disease mitigation efforts with the need for in-person learning, social interactions, and the increased mental health challenges caused by some of these efforts that furthered the experience of isolation.
Much has changed since early 2020 and most schools have continued to evolve their protocols and policies to reflect new information and relevant data. We are dedicated to learning and contributing to the continually growing literature related to COVID-19. We pay particular attention to the impact vaccination has on associated issues such as long COVID, worsening mental health, anosmia, postural orthostatic tachycardia syndrome, and other neurological sequela of infection for which data are still being gathered. We are also cautious about changing policy in reaction to a single study, although we are actively reviewing new information. As the authors allude to in their discussion of limitations, it was not possible to comprehensively address the impacts of the COVID-19 on mental health, time lost from academics, and other activities that are uniquely relevant to a college population.
The article does not engage with the objections (published in this journal and also in response to the previous article by the same lead author) to the applicability of the ‘proportionality principle’ to ethical judgment when the considered intervention violates the right to life and discriminates on the basis of healthy, innate biological characteristics of the human race. In particular, the proportionality principle is irrelevant to coercive policies (mandates) if the associated procedure is known to kill a small percentage of people and therefore amounts to a mandated killing of a minority for the benefit of the majority. The right to life cannot be taken away in the interests of others, even if the majority would greatly benefit from the killing, without negating the very concept of human rights: if being born human is not a guarantee of the right to life, then there is no right to life. On this view, vaccination mandates can no longer be considered healthcare but democide.
Any claims by psychiatrists1 to be able to improve people morally should be extremely modest. It is helpful to be reminded that psychiatrists have attempted to do this and still do so, nowadays usually unconsciously or implicitly. In fact where therapeutic approach embodies moral positions, as clarified for the psychoanalytic tradition by Edward Harcourt2, it is important for these to be made explicit so that they can be scrutinised.
People coming to see a psychiatrist are often in a personal crisis, whatever its cause (which may include the effects of mental disorder as well as factors in their lives contributing to that disorder). They may as a result may be driven to re-evaluate their lives, their choices and their relationships (there are parallels with the impact of serious physical illness and confrontation with disability and mortality). In fact any serious illness or intimation of mortality may generate the same kind of self-questioning. Such people are clearly faced with moral questions, whether that be regarding specific decisions, balancing their own needs with those of others, making hard choices or making amends. How they address these things will form part of their recovery and shape it. An important difference between physical and mental illness is that people living through the latter are more likely to be lonely, relatively unbefriended, isolated and short of support from family, friends or other social circles, or indeed alienated from them. They a...
Any claims by psychiatrists1 to be able to improve people morally should be extremely modest. It is helpful to be reminded that psychiatrists have attempted to do this and still do so, nowadays usually unconsciously or implicitly. In fact where therapeutic approach embodies moral positions, as clarified for the psychoanalytic tradition by Edward Harcourt2, it is important for these to be made explicit so that they can be scrutinised.
People coming to see a psychiatrist are often in a personal crisis, whatever its cause (which may include the effects of mental disorder as well as factors in their lives contributing to that disorder). They may as a result may be driven to re-evaluate their lives, their choices and their relationships (there are parallels with the impact of serious physical illness and confrontation with disability and mortality). In fact any serious illness or intimation of mortality may generate the same kind of self-questioning. Such people are clearly faced with moral questions, whether that be regarding specific decisions, balancing their own needs with those of others, making hard choices or making amends. How they address these things will form part of their recovery and shape it. An important difference between physical and mental illness is that people living through the latter are more likely to be lonely, relatively unbefriended, isolated and short of support from family, friends or other social circles, or indeed alienated from them. They are thus at once more vulnerable and more likely to seek guidance from a mental health worker, and mental health workers may be more tempted to give it.
In my view psychiatrists should be wary of seeking directly to improve people morally in such situations, and concentrate on treating their mental disorder. Improvements in someone’s moral condition should be seen as a bonus rather than the goal. Psychiatrists, psychoanalysts and psychotherapists do not have a plausible claim to be more moral than anyone else, and most people are fortunate enough to find people elsewhere in their lives who act as some kind of moral touchstone, be they a parent, another relative, a friend, a teacher, a mentor, a work colleague, a priest, someone else who shows them kindness or indeed a public figure with whom they can strongly identify. Again, these sources of help may be less available to people to people with mental disorders
One way in which a psychiatrist or anyone offering a therapeutic alliance may contribute to someone’s moral understanding is through their own behaviour, for example by being honest, trustworthy and reliable, and concerned. In this way some rudiments of a model for other relationships may be seen. Beyond this, the psychiatrist job is usually to help people to break out of social isolation so that they do break out of their isolation and so find a wider range of non-professional people who can act as their sounding boards.
(It is interesting that some people who are very dismissive of the judgments made of their behaviour by others, have quite high expectations of doctors and therapists, in terms of confidentiality, punctuality and access to certain goods and services).
A further consideration which should encourage humility in any psychiatrist inclined to guide their patients morally is that their patients most often will be in a less favourable socioeconomic position than they are. This does not mean that they have no choices, but the range of choices open to them is likely to be narrower. This will have implications for the morality or otherwise of, for example, benefit fraud, or sex work, or breach of Covid-19 restrictions, or indeed of abortion.
Drug treatments in psychiatry may restore people’s level of concern for and awareness of the needs of others, but this is no different from the effects eg of analgesics in relieving somatic pain, which also makes people withdraw into themselves. In a wider sense, it could be said that morals depend on morale, in that relative freedom from pain, optimism of the will and a sense that change is possible are likely to be associated with a more generous and courageous spirit.
With respect to drugs given specifically to enhance moral behaviour, the studies in this area are limited by the way they measure moral decision-making, and the lack of a demonstrable link between the answers given to questionnaires and any sustained difference in behaviour3. In addition, when people use alcohol or another drug to give themselves the courage to say or do something difficult, or to seek a spiritual experience, there does have to be first the wish to take that challenge or make that decision. This applies to some studies of psychedelic drugs.
There is a more general point here. As Kant noted, changing in a desirable direction this or that quality in a person is no guarantee of moral behaviour:
Moderation in the affections and passions, self-control, and calm deliberation are not only good in many respects, but even seem to constitute part of the intrinsic worth of the person; but they are far from deserving to be called good without qualification, although they have been so unconditionally praised by the ancients. For without the principles of a good will, they may become extremely bad, and the coolness of a villain not only makes him far more dangerous, but also directly makes him more abominable in our eyes than he would have been without it.4
In the forensic arena, improvements in moral awareness and behaviour are again likely to arise as a bonus effect of treatment broadly understood, which includes physical restrictions for periods of time. It is important here to consider how constraints of certain kinds – prison, probation – may themselves play a part in moral improvement, for example by creating a space for enforced reflection, or by giving someone what may be the novel experience of being held to account for their behaviour. Such benefits should probably not be exaggerated.
When attempts have been made specifically to change the mental and moral set and behaviour of people with severe antisocial personality disorder, the results have not been encouraging5. A different approach, used with prisoners identified as having PTSD arising from their violent offending, appeared to be more promising as a way to open up a route to reflection and consideration of the impact on victims6. However this depended on the prisoners being willing to enter the treatment programme in this first place, which recalls the maxim that for someone to be open to arguments for acting in a good way they have first of all to recognise a distinction between acting in a good way and acting in a bad way.
An important influence on moral growth not mentioned in the article is that of the group. Most obviously this can be seen at work in settings such as AA, but also in group therapy more generally, which traditionally is supposed to make people more mature, rather than less neurotic as with individual therapy. Since morality is about interpersonal behaviour, it is not surprising that it is transmitted largely through groups, starting with parents then extended family then school, then social clubs, workplaces, sport and so on. Clearly the kind of lessons learned vary widely depending on the nature of these groups in practice, but they are likely to be much more influential than individual instruction.
For nine years I ran a weekly group for patients on a mixed-gender acute admission ward in a very ethnically and socially diverse town. This had a number of benefits, one important one being a continuing effort to develop at least a minimum morality for co-existence on the ward, through a mixture of discussion and, where it could be tolerated, group feedback to participants about their behaviour. The basic principles modelled were modest but important: the right to have your say, the right to be listened to and basic courtesy. Expressions of care and concern in this setting could be powerful and moving.
A more ambitious and articulated use of group therapy in an inpatient setting was described by Bion and Rickman in a military hospital in World War ll7
The effect of this approach to the problem of neurosis was considerable. There was a readiness, and sometimes an eagerness, to discuss both in public and private the social implications of personality problems. The neurotic is commonly regarded as being self-centred and averse from cooperative endeavour; but perhaps because he is seldom put in an environment in which every member is on the same footing as regards interpersonal relationships.
It is possible that psychiatrists could benefit from training in normative moral theories, but the effect of such training might be to make them less rather than more enthusiastic about direct effects to influence their patients’ moral development.
1. McConnell and colleagues refer to ‘psychiatry’, but these matters are relevant to all mental health professionals
2. Harcourt E 2015 The Place of Psychoanalysis in the History of Ethics Journal of Moral Philosophy
3. Crockett MJ et al 2010 Serotonin selectively influences moral judgment and behavior through effects on harm aversion https://www.pnas.org/doi/10.1073/pnas.1009396107
4. Kant E 1785 Groundwork of the Metaphysics of Morals
5. Tyrer P et al 2015 The lessons and legacy of the programme for dangerous and severe personality disorders Personality and Mental Health 9:96-106
6. Evans C et al 2007 Intrusive Memories and Ruminations Related to Violent Crime Among Young Offenders: Phenomenological Characteristics Journal of Traumatic Stress 20:183-196
7. Bion WR, Rickman J 1943 Intra-group tensions in the therapy: their study as the task of the group Lancet 242: 678-682
McConnell et al. provide a cogent argument that psychiatrists should influence the moral development of their patients in a limited substantive approach.
What interests me, as a practising psychiatrist, is how to achieve this task. The penultimate paragraph of the paper recommends a “pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth”. This recommendation follows a vignette of a woman with autism with “underdeveloped moral conceptions”. It’s worth noting that moral reasoning differs between autistic and neurotypical individuals despite similar moral judgements (Dempsey et al.). I suspect that, for a sustained change in interpersonal function and moral development, the patient would require more than an explanation of social reciprocity by a benevolent and well-meaning psychiatrist.
An earlier vignette describes a man with a possible antisocial personality disorder and unwelcome views about the acceptability of violence. There is an unfortunate paucity of evidence to suggest psychological interventions result in significant change in specific antisocial behaviours (Gibbon et al.). There are experimental therapies that may cultivate moral development in these individuals (Tuck & Glenn), however these are far from accepted in clinical practice.
The article sensibly notes that the needs of people with serious mental disorders should take priority over the flourishing of...
McConnell et al. provide a cogent argument that psychiatrists should influence the moral development of their patients in a limited substantive approach.
What interests me, as a practising psychiatrist, is how to achieve this task. The penultimate paragraph of the paper recommends a “pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth”. This recommendation follows a vignette of a woman with autism with “underdeveloped moral conceptions”. It’s worth noting that moral reasoning differs between autistic and neurotypical individuals despite similar moral judgements (Dempsey et al.). I suspect that, for a sustained change in interpersonal function and moral development, the patient would require more than an explanation of social reciprocity by a benevolent and well-meaning psychiatrist.
An earlier vignette describes a man with a possible antisocial personality disorder and unwelcome views about the acceptability of violence. There is an unfortunate paucity of evidence to suggest psychological interventions result in significant change in specific antisocial behaviours (Gibbon et al.). There are experimental therapies that may cultivate moral development in these individuals (Tuck & Glenn), however these are far from accepted in clinical practice.
The article sensibly notes that the needs of people with serious mental disorders should take priority over the flourishing of the mentally healthy. The President of the Royal College of Psychiatrists last year noted that there is just one consultant psychiatrist per 12,567 population in England. Enhancing the moral development of patients, insofar as it is possible, may be an important future goal for the profession but for now there are many severely unwell patients who need immediate assistance. To quote Carlyle, the main business of psychiatrists remains “not to see what lies dimly at a distance, but to do what lies clearly at hand”.
References:
1. Dempsey, E., Moore, C., Johnson, S., Stewart, S., & Smith, I. (2020). Morality in autism spectrum disorder: A systematic review. Development and Psychopathology, 32(3), 1069-1085.
2. Gibbon S, Duggan C, Stoffers J, Huband N, Völlm BA, Ferriter M, Lieb K. Psychological interventions for antisocial personality disorder. Cochrane Database Syst Rev. 2010 Jun 16;(6).
3. Tuck, N, Glenn, LM. Cultivating conscience: Moral neurohabilitation of adolescents and young adults with conduct and/or antisocial personality disorders. Bioethics. 2021; 35: 337– 347.
I had difficulty with the Goldacre report, when it starts with the apparent contradiction of dismissing trust (in no uncertain terms). yet then proposing these TREs. (Trusted research environments). Where do the authors actually stand?
Eyal is correct that ethicists’ speculations about how the public may respond to human challenge trials are often made without a whisper of evidence.
This is not a new problem. The Institute of Medicine titled a 2001 monograph Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. One might think that a book with this title would demonstrate that the IRB system preserves public trust, but the title is merely an ornamental flourish. The book is devoted entirely to the accreditation of IRBs; public trust is neither analyzed in depth nor is there any attempt to show that accreditation improves trust.
We all agree that trust is important, which is what earns it one cheer. Assertions about its future trajectory merit additional applause only when they are are supported by evidence.
Cite: Institute of Medicine (U.S.). Committee on Assessing the System for Protecting Human Research Subjects. 2001. Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. Washington, D.C.: National Academy Press.
While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in he...
While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in hen's eggs so as to cater to vegan staff and it would be good to have vaccines not developed with HEK293 (or other similar cell lines) for whatever disease will come next to cater for staff who believe the use of such cell lines to be morally dubious.
Utilitarian ‘ethics’, as employed in this article, implicitly rejects all absolute values and associated rights, allowing for limited transgression of rights (including the right to life) for the sake of contemporaneous ‘benefits’ outweighing the ‘costs’. I maintain that this is a self-defeating paradigm; without absolute values there is no objective measure of benefits and costs, therefore no rational basis for the judgement of proportionality. In short, the utilitarian argument is logically circular and vicious. Once the veneer of proportionality is revealed as objectively ungrounded, utilitarian ethics amounts to little more than a public relations strategy for legitimising arbitrary exercises of power.
The argument from proportionality (benefits vs costs) cannot justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social op...
Utilitarian ‘ethics’, as employed in this article, implicitly rejects all absolute values and associated rights, allowing for limited transgression of rights (including the right to life) for the sake of contemporaneous ‘benefits’ outweighing the ‘costs’. I maintain that this is a self-defeating paradigm; without absolute values there is no objective measure of benefits and costs, therefore no rational basis for the judgement of proportionality. In short, the utilitarian argument is logically circular and vicious. Once the veneer of proportionality is revealed as objectively ungrounded, utilitarian ethics amounts to little more than a public relations strategy for legitimising arbitrary exercises of power.
The argument from proportionality (benefits vs costs) cannot justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social opportunity coercion, precluding the possibility of valid medical consent. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not just from ourselves but from our children and from future generations, and we do not have the right to do this. Acquiescence to medical coercion is always unethical, even if the mandated intervention were a placebo.
3. Vaccines are known to occasionally cause deaths of healthy people. When an employee is required to receive vaccination as a condition of employment, that employee is economically coerced to participate in an activity where some percentage of employees are expected to die ‘in the course of employment’ as a direct result of the mandated activity. This goes against the fundamental principles of medical ethics and workplace safety. It may be objected that infectious pathogens also kill people, but these two categories of deaths are not ethically equivalent. Infection with a pathogen for which there exists a vaccine is not mandated, whereas deaths resulting from mandatory vaccination are mandated deaths, a legalised killing of some people for the prospective benefit of the majority. Critically, any discrimination against the unvaccinated (or a privileged treatment of the vaccinated) amounts to a violation of the right to life, because a small percentage of the targeted population are expected to die as a result of this coercive treatment.
As Sanjeev Sabhlok, an Australian economist and politician, recently wrote: “Governments are not authorised by law - by analogy - to burn down additional homes and kill unaffected people in order to save those who might be at risk of being engulfed in a bushfire.”
An earlier version of these arguments were formally submitted to the Inquiry into Public Health Amendment Bill 2021 (No 2) ACT, Australia.
One of the most enlightening statements for me from the report of the WISH patient safety forum 2015 is, "The idea that saving patients’
lives demands heroism is a harmful misconception about health and medicine seen in popular culture. In the real-world, the true heroes are not just rescuing patients, they are voicing their concerns and taking proactive measures to reduce the risks, before a patient is potentially put in harm’s way".
We shouldn't need to rely on heroic rescue or expect it to be a normal part of our every day clinical practice. The idolisation of heroism damages attempts to improve systemic approaches to improving patient care because it neglects and belittles the under-appreciated grind of change to reduce the underlying risk of patient harm. Heroism should be less of an aspiration and more of a flag highlighting the need for organisational improvement.
This author agrees with the claim that freedom of association is a basic moral right and that the right to have visitors stems from this freedom. This author also agrees that the discussion around visitor policy should be framed as a discussion about rights infringement. However, this author suggests that the discussion around restriction is best described as a potential conflict between two rights: freedom of association and the right to safety. Accordingly, the rights infringement could go either way.
It is reasonable to claim that people have a moral right to safety (or something like it), and it is reasonable to say that this right should be highly protected in a hospital, where the sick and injured seek treatment. If people do have a right to safety, then it follows that this right would be infringed if hospitals did not take reasonable precautions to reduce hospital-acquired infections. Limiting visitors during COVID-19 should be seen as an example of such a precaution.
To be clear, McTernan recognizes that safety is an important consideration, but she does not state that it is a right. This affects the framing of the issue. Appealing to something as a right makes it substantially harder to act against that which is protected by that right. It is for this reason that McTernan correctly argues that restricting visitation is harder when we appeal to freedom of association.
The issue, then, is one in which patients have potentially two conflicting...
Show MoreWe read with interest this risk-benefit and ethical analysis of the utility of SARS-CoV-2 vaccine boosters in university students. We have some major concerns about the choice of hospitalization as the primary measure of benefit. From the onset of the pandemic, healthcare providers, scientists, and public health experts in higher education have been learning from shared experiences, research, and evolving medical knowledge about the best way to safely populate college campuses with students, faculty, and staff. Hospitalizations averted is not the only marker of morbidity that is relevant to the college student population and given the rarity of severe disease requiring hospitalization in young, generally very healthy adults, hospitalization is not a good choice for a marker of COVID-19 related morbidity. We have also strived to minimize the risk of missed classes, severe illness, and need for prolonged medical leaves of absence given the potential adverse academic consequences of illness for students. Colleges and universities have been trying to balance infectious disease mitigation efforts with the need for in-person learning, social interactions, and the increased mental health challenges caused by some of these efforts that furthered the experience of isolation.
Much has changed since early 2020 and most schools have continued to evolve their protocols and policies to reflect new information and relevant data. We are dedicated to learning and contributing to th...
Show MoreThe article does not engage with the objections (published in this journal and also in response to the previous article by the same lead author) to the applicability of the ‘proportionality principle’ to ethical judgment when the considered intervention violates the right to life and discriminates on the basis of healthy, innate biological characteristics of the human race. In particular, the proportionality principle is irrelevant to coercive policies (mandates) if the associated procedure is known to kill a small percentage of people and therefore amounts to a mandated killing of a minority for the benefit of the majority. The right to life cannot be taken away in the interests of others, even if the majority would greatly benefit from the killing, without negating the very concept of human rights: if being born human is not a guarantee of the right to life, then there is no right to life. On this view, vaccination mandates can no longer be considered healthcare but democide.
http://dx.doi.org/10.1136/medethics-2020-107026
https://gh.bmj.com/content/7/5/e008684.responses#fundamental-values-cann...
Any claims by psychiatrists1 to be able to improve people morally should be extremely modest. It is helpful to be reminded that psychiatrists have attempted to do this and still do so, nowadays usually unconsciously or implicitly. In fact where therapeutic approach embodies moral positions, as clarified for the psychoanalytic tradition by Edward Harcourt2, it is important for these to be made explicit so that they can be scrutinised.
Show MorePeople coming to see a psychiatrist are often in a personal crisis, whatever its cause (which may include the effects of mental disorder as well as factors in their lives contributing to that disorder). They may as a result may be driven to re-evaluate their lives, their choices and their relationships (there are parallels with the impact of serious physical illness and confrontation with disability and mortality). In fact any serious illness or intimation of mortality may generate the same kind of self-questioning. Such people are clearly faced with moral questions, whether that be regarding specific decisions, balancing their own needs with those of others, making hard choices or making amends. How they address these things will form part of their recovery and shape it. An important difference between physical and mental illness is that people living through the latter are more likely to be lonely, relatively unbefriended, isolated and short of support from family, friends or other social circles, or indeed alienated from them. They a...
McConnell et al. provide a cogent argument that psychiatrists should influence the moral development of their patients in a limited substantive approach.
Show MoreWhat interests me, as a practising psychiatrist, is how to achieve this task. The penultimate paragraph of the paper recommends a “pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth”. This recommendation follows a vignette of a woman with autism with “underdeveloped moral conceptions”. It’s worth noting that moral reasoning differs between autistic and neurotypical individuals despite similar moral judgements (Dempsey et al.). I suspect that, for a sustained change in interpersonal function and moral development, the patient would require more than an explanation of social reciprocity by a benevolent and well-meaning psychiatrist.
An earlier vignette describes a man with a possible antisocial personality disorder and unwelcome views about the acceptability of violence. There is an unfortunate paucity of evidence to suggest psychological interventions result in significant change in specific antisocial behaviours (Gibbon et al.). There are experimental therapies that may cultivate moral development in these individuals (Tuck & Glenn), however these are far from accepted in clinical practice.
The article sensibly notes that the needs of people with serious mental disorders should take priority over the flourishing of...
I had difficulty with the Goldacre report, when it starts with the apparent contradiction of dismissing trust (in no uncertain terms). yet then proposing these TREs. (Trusted research environments). Where do the authors actually stand?
Eyal is correct that ethicists’ speculations about how the public may respond to human challenge trials are often made without a whisper of evidence.
This is not a new problem. The Institute of Medicine titled a 2001 monograph Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. One might think that a book with this title would demonstrate that the IRB system preserves public trust, but the title is merely an ornamental flourish. The book is devoted entirely to the accreditation of IRBs; public trust is neither analyzed in depth nor is there any attempt to show that accreditation improves trust.
We all agree that trust is important, which is what earns it one cheer. Assertions about its future trajectory merit additional applause only when they are are supported by evidence.
Cite: Institute of Medicine (U.S.). Committee on Assessing the System for Protecting Human Research Subjects. 2001. Preserving Public Trust: Accreditation and Human Research Participant Protection Programs. Washington, D.C.: National Academy Press.
While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in he...
Show MoreUtilitarian ‘ethics’, as employed in this article, implicitly rejects all absolute values and associated rights, allowing for limited transgression of rights (including the right to life) for the sake of contemporaneous ‘benefits’ outweighing the ‘costs’. I maintain that this is a self-defeating paradigm; without absolute values there is no objective measure of benefits and costs, therefore no rational basis for the judgement of proportionality. In short, the utilitarian argument is logically circular and vicious. Once the veneer of proportionality is revealed as objectively ungrounded, utilitarian ethics amounts to little more than a public relations strategy for legitimising arbitrary exercises of power.
The argument from proportionality (benefits vs costs) cannot justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social op...
Show MoreOne of the most enlightening statements for me from the report of the WISH patient safety forum 2015 is, "The idea that saving patients’
lives demands heroism is a harmful misconception about health and medicine seen in popular culture. In the real-world, the true heroes are not just rescuing patients, they are voicing their concerns and taking proactive measures to reduce the risks, before a patient is potentially put in harm’s way".
We shouldn't need to rely on heroic rescue or expect it to be a normal part of our every day clinical practice. The idolisation of heroism damages attempts to improve systemic approaches to improving patient care because it neglects and belittles the under-appreciated grind of change to reduce the underlying risk of patient harm. Heroism should be less of an aspiration and more of a flag highlighting the need for organisational improvement.
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