493 e-Letters

  • The Right to Safety and Freedom of Association

    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...

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  • Need to consider other benefits of COVID-19 vaccine boosters in university students

    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...

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  • The proportionality principle is the wrong ethical standard for vaccine mandates

    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...

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  • A laudable but currently unfeasible goal

    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...

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  • Trust is dead, long live trust

    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?

  • One cheer for trust

    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.

  • Re: Vaccine mandates for healthcare workers beyond COVID-19

    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...

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  • Fundamental values are not defeated by utilitarian calculus

    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...

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  • Heroism is a harmful misconception

    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.