Dear Editor

Regarding the Symposium on consent and confidentiality.[1]

We read with interest the recent papers on informed consent published in a recent edition of the JME.[1] Whatever their differences, and however much they questioned some aspects of the duty to respect autonomy through attempting to obtain informed consent for therapeutic interventions, there was a general agreement that competent adult patients are entitled to a core of basic information about their clinical options. There was also a consensus that training in the process of obtaining consent was important. In our experience, there are two different dimensions of such training that are of particular interest. On the one hand, students require good theoretical understanding of the ethical and legal background to the professional emphasis now placed on informed consent. On the other hand, they need practical training in relevant communication skills and how to apply them to obtain consent for specific clinical procedures To do so, doctors must obviously also have a good understanding of these procedures. In a recently conducted study among junior doctors in England (Schildmann J, Cushing A, Doyal L, Vollmann J. The ethics and law of informed consent: knowledge, views and practice of Pre Registration House Officers - manuscript submitted for publication), we encountered serious problems as regards such understanding. No matter how good their philosophical and legal knowledge may be, PRHOs will not be able to deliver the minimal standards of informed consent outlined by O’Neil unless, suffice it to say, they know what – practically speaking - they are talking about![2]

Thus, in contrast to the results of the study of G Bravo et al. published in the same issue of this journal, almost all PRHOs taking part in our survey had a good legal understanding of the differences between competent and incompetent patients.[3] This may be interpreted as a positive result of the curriculum change at their specific medical school which includes sustained sessions about informed consent. These embrace ethics, law and communication skills. Despite this understanding, however, the junior doctors taking part in our study still experienced problems about their role in the consent process. These pertained to time pressure and a lack of support by senior doctors, as well as pressure on them at times to obtain consent in circumstances where they had been taught that they should not . This gap between the standards of informed consent currently taught to medical students and the clinical realities that they face, and into which they are thrusts, is an ongoing problem.[4]

If informed consent is to fulfil the purpose of respecting the autonomy and dignity of patients, sufficient resources are required to train young doctors to do the job properly, especially as regards their understanding of procedures for which they are providing information and their competence as communicators. One thing is clear. If they cannot complete the task in accordance with the guidance issued by both the GMC and the Department of Health, they should not be doing it at all.[5,6]

Trusts and Colleges should ensure that all supervisory staff are aware of their responsibilities in this regard.

References

1. Symposium on consent and confidentiality. J Med Ethics 2003; 29:2- 40.

2. O'Neill O. Some limits of informed consent. J Med Ethics 2003; 29:4 -7.

3. Bravo G, Paquet M, Dubois MF. Knowledge of the legislation governing proxy consent to treatment and research. J Med Ethics 2003; 29:44-50.

4. Doyal L. Closing the gap between professional teaching and practice. British Medical Journal 2001; 322:685-686.

5. Department of Health. Reference Guide to Consent for Examination or Treatment. http://www.doh.gov.uk/consent/refguide.htm (accessed March 27, 2003).

6. General Medical Council. Seeking patients' consent: the ethical considerations. London: General Medical Council, 1998.

Dear Editor:

We would like to thank the authors and editors of the JME’s mini- symposium on the Olivieri case for continuing and extending the dialogue about this important challenge to the North American bioethics community.

This mini-symposium is of special interest to us as members of the Canadian Bioethics Society’s “Working Group on Employment Standards for Bioethics.” We are members of this Working Group precisely because we believe that most of us in the Canadian bioethics community ought to do more to respond to situations such as the Olivieri situation. We welcome the opportunity to continue to learn from that situation and to move forward to strengthen our Canadian community of bioethicists.

Our Working Group, as a formal body, originated at the 1999 Annual Meeting of the Canadian Bioethics Society (CBS). At that meeting, a motion was passed establishing a “Working Group on Employment Standards for Bioethics.” The purpose of the Working Group was, and continues to be, to examine the issues of ethicists’ roles and responsibilities and the environment in which ethicists, particularly those practicing in a non- tenured environment, work. We have been endeavouring to grapple with a number of the kinds of issues raised in the mini-symposium, including accountability on the part of both bioethicists and the organizations employing them, standards of practice in bioethics, protection for whistleblowers, and how to respond to problems inherent in the moral climate of the organizations in which we work.

Among our undertakings to date: • A Draft Discussion Paper, "Working Conditions for Bioethics in Canada;" • A “Model Code of Ethics for Bioethics;” • Workshops, panels, or discussions at the CBS’s Annual Meetings in 1999, 2000, 2001, and 2002; and • An essay prize “to encourage junior scholars to engage in scholarly work related to working conditions in bioethics; professionalism in or the professionalization of bioethics; or the social role of bioethics.”

The Working Group’s current works-in-progress include: • A Qualitative Study of Conflicts of Interest Among Bioethicists; • A working paper on various models of workplace dispute resolution; • A “model contract” for clinical ethics consultants; • A framework for a peer support network. A record of our work on these issues can be found on the CBS’s website, at http://www.bioethics.ca/

We know that no one aspect of our work to date constitutes a panacea. It’s likely that no draft document or peer support network could have averted the Olivieri debacle. But we remain committed to the ideal that this work is of value, and that ongoing discussion and open and frank self -examination is crucial.

The JME’s mini-symposium reminds us that we have a great deal still to do, and that this kind of work is urgently needed. We can ignore all of these matters (since crises happen but rarely in any individual’s work- life) but we do so at our peril. The publication of the JME mini-symposium is a milestone – a wake up call for all of us working in bioethics. We applaud the JME’s attention to this crucial issue, and invite the bioethics community and its many stakeholders to join us in our continuing attempts to grapple with this difficult issue in a constructive way.

Finally, we recognize the need for healing in the bioethics community, and suggest that this healing will require collegiality and constructive moves in the direction of reconciliation. Only in this way will bioethics be strengthened as a community, and left more capable of responding to cases like the Olivieri case in the future.

Dear Editor

I am surprised by glaring omissions in your article, Ethical problems arising in evidence-based complementary and alternative medicine by Ernst, Cohen and Stone. Their paper undoubtedly presents an outdated picture of the development of complementary and alternative Medicine (CAM) in the UK at this time

The authors state “that providers of CAM are often not medically trained” and that “their understanding of anatomy, physiology, pathology and other disciplines of Western Science may be limited…” It goes on to say, “ Unlike the situation of widespread licensure in the US for chiropractors, acupuncturists, massage therapists and to some extent naturopathic physicians, most CAM professions in the UK are not statutorily regulated (the only two exceptions in the UK are chiropractors and osteopaths.)”

The authors fail to report that statutory regulation of the UK herbal and acupuncture sectors is now imminent. There is no mention that in 2,000 the House of Lords Select Committee on Science and Technology published a report on CAM [1] and that this report specifically called for the statutory regulation of the acupuncture and herbal medicine sectors. Nor do the authors refer to evidence given to the Select Committee (Sections 5.51 and 5.52) by the Under Secretary for State for Public Health, Yvette Cooper, who told the Committee that on safety grounds, the Government had specifically identified acupuncture and herbal medicine as therapies that it would like to see achieve statutory self-regulation. She also pointed out (Section 5.44) that the 1999 Health Act now provided a fast-track route for the statutory regulation of a health profession previously only achievable by cumbersome primary legislation.

The article also omits to mention that in 2001, the Government responded to the Select Committee Report recommending that herbal medicine and acupuncture should as soon as possible seek statutory regulation under the Health Act 1999 [2] and that the following year the Department of Health set up two independent committees, the Herbal Medicine Regulatory Working Group (HMRWG) and the Acupuncture Regulatory Working Group (ARWG) to give detailed consideration of how statutory regulation of acupuncture and herbal medicine could best be achieved. Both Committees met regularly throughout 2002/3 and published their recommendations in September 2003.[3,4] Having considered these two reports, the Government is set to publish, any day now, a public consultation document seeking views on aspects of the statutory regulation of herbal and acupuncture practitioners in the UK. Following a thirteen-week consultation period, the Government will once again take stock before finally consulting on draft legislation that will eventually lead to legislation laid before Parliament. Although there is no firm timetable, we anticipate the statutory regulation of UK herbalists and acupuncturists to pass into law in 2006. I submit that all this presents a very different picture to the one painted by Ernst, Cohen and Stone.

As for training, it is accepted by the herbal profession that herbalists of all traditions require a good standard of western medicine including pharmacology. The Core Curriculum published in the HMRWG report is a detailed account of this training, which is overseen by the Accreditation Board of European Herbal Practitioners Association. Traditional acupuncturists too must be trained in conventional western medicine so that they can recognise the limits of their competence and know when to refer. Several British Universities currently offer degree training in these disciplines and such training has now been available for the past decade. The UK leads the world in the development of CAM and its level of acceptance surely does not so much represent a “challenge to healthcare professionals of all disciplines” as Ernst et al assert, but rather a golden opportunity to integrate the best of orthodox and CAM for the benefit of millions of patients who clearly wish to access both modalities.

References

(1) House of Lords’ Select Committee on Science and Technology, Session 1999-2000. 6th Report. Complementary and Alternative Medicine. The Stationary Office, 2000.

(2) Department of Health. Government Response to the House of Lords Select Committee on Science and Technology’s Report on Complementary and Alternative Medicine. The Stationary Office, March 2001.

(3) Recommendations on the Regulation of Herbal Practitioners in the UK A Report from the Herbal Medicines Regulatory Working Group, published on behalf of the HMRWG by the Prince of Wales’s Foundation for Integrated Health, 2003.

(4) The Statutory Regulation of the Acupuncture Profession, the Report of the Acupuncture Regulatory Working Group, published on behalf of the ARWG by the Prince of Wales’s Foundation for Integrated Health, 2003.

Dear Editor

Bennett Foddy interprets the view I express in 'Deafness, culture, and choice' (JME 2002: 28) correctly: deaf children are contingently, and not necessarily, worse off as a result of their disability. Indeed, this claims seems almost tautological: to be better or worse off is inherently relational, so it is easy to imagine worlds in which the deaf would not be worse off. A world in which everyone was deaf is one obvious case.

But Foddy's claim that this fact shows the deaf have a right to ensure that their children are also deaf is false. His argument seems to have two premises. First, he argues that if the deaf are only contingently worse off than the hearing, then this must be because they are discriminated against. "[T]heir deafness is a constraint only because our society discriminates against those who cannot hear", he writes. Second, he implies that since their lives are constrained only as a result of discrimination, we have no right to object to their parents' choices to ensure that they are deaf. Both claims are false.

First, it is false to think that in all cases in which X is worse off as a result of Y's actions, X has had her rights violated by Y. Y might have been justified in acting as she did, even in cases in which X is an innocent bystander. Every person has different abilities and limitations, but our social world is necessarily designed so that certain abilities are rewarded more than others and certain limitations are more constraining. This is simply a result of the fact that choices must be made: buildings must be designed, systems of communication chosen, modes of transport developed, and so on. Some people are worse off as a consequence of these choices, through no fault of their own. This is simply inevitable.

This kind of situation prevails with regard to the deaf. Moreover, our choices here are not arbitrary, but instead reflect the advantages of using using all the modes of communication available to us. Foddy thinks that the only good argument which might be advanced for the universal abandonment of sound as a means of communication and entertainment would turn on the transition costs of moving to a soundless society, but this is false. Sound has qualities which vision does not. It is not limited by the direction of the gaze of individuals, it is able to wake sleeping people (think of the difficulty of replacing fire alarms with lights which would be as effective), and so on. In choosing a world in which sound is important, we make a justified choice. As a result, the deaf are worse off. But they are not discriminated against, because their rights are not infringed (which isn't to say that the deaf are not discriminated against in many other ways, of course).

So Foddy's first premise is straightforwardly false. His second premise is also disputable, if not as obviously wrong as the first. Suppose the disadvantages of the deaf were entirely a product of discrimination. Would it not still be the case that the choice of deaf parents to ensure that their children would be worse off than they would otherwise be is, at least, questionable? Of course, all of us, who (in this scenario) are responsible for the discrimination against the deaf would bear a significant portion of the blame for the disadvantages of such deaf children. But this would not exonerate the deaf parent entirely. Suppose you knew that a crazed gunman would shoot indiscriminately at every person he saw in the park today. If you nevertheless took your child to the park, we would think much less of you, despite the fact that the risks faced by your child were produced by the evil actions of the gunman. The fact that a harm is a product of wrongful actions does not give a parent the right to place their child in its way.

The desire of deaf parents to have children who resemble them and who identify with their culture is understandable. Nevertheless, there are powerful reasons to think that, all things considered, this is a desire upon which they ought not to act.