I would first like to congratulate Dr. Seale for producing a thought-
provoking piece of research that has captured the imagination of the
nation's media. I would also like to point out an interesting discordance
that I have noted with regard to the findings of this important research,
which ought to stimulate further discussion.
Although religious doctors were significantly less likely tha...
I would first like to congratulate Dr. Seale for producing a thought-
provoking piece of research that has captured the imagination of the
nation's media. I would also like to point out an interesting discordance
that I have noted with regard to the findings of this important research,
which ought to stimulate further discussion.
Although religious doctors were significantly less likely than their
non-religious colleagues to provide continuous or deep sedation until
death or to provide treatment with at least some intent to shorten life,
when religious doctors did provide such treatment they were significantly
less likely to have discussed this with their patient.
This is the opposite of what would be expected if the religion-driven
values of the doctors were the key influence on the decision to provide or
withhold treatment with the potential to shorten life. If the religious
beliefs of some doctors may make them reluctant to choose such a treatment
option, in those instances in which they do choose that course of action,
we would perhaps expect them to have been more likely to have involved the
patient in the decision. Why, when these doctors do provide such
treatment, should they be less inclined to discuss this with their
patient? These findings warrant further exploration.
Given these findings, I strongly suspect the presence of an
undetected confounder. For example, perhaps in the cases where religious
doctors provided (or withheld) treatment with some intent to shorten life,
the distribution of reasons for doing so was different to that in non-
religious doctors who took the same decisions. Perhaps the religious
doctors only felt compelled to do so in cases when they felt the patient's
suffering was particularly intolerable, whereas the threshold may have
been slightly lower for non-religious doctors who have a more favourable
opinion of treatment options that may shorten life. Thus, in the context
of such extreme and apparently intolerable suffering, the doctors
providing potentially life-shortening treatment may have felt that it was
inappropriate (and even unethical) to delay treatment in order to engage
in a discussion about this treatment option with their patients.
Of course, this is speculation. However, this hypothesis, together
with other viable hypotheses, certainly warrant further investigation in
order to explore important confounding factors and resolve this apparent
discordance in the findings of this research.
RK Mohindra's recent paper criticises NICE's decision-making
regarding the use of antibiotic prophylaxis to prevent infective
endocarditis. He is also critical of our defence of NICE, but does not
actually engage with our argument, stating simply that he was "surprised"
to see a philosophical defence of something that should be decided by
evidence. We find it surprising that Mohindra believes that...
RK Mohindra's recent paper criticises NICE's decision-making
regarding the use of antibiotic prophylaxis to prevent infective
endocarditis. He is also critical of our defence of NICE, but does not
actually engage with our argument, stating simply that he was "surprised"
to see a philosophical defence of something that should be decided by
evidence. We find it surprising that Mohindra believes that logic should
play no part in assessments of evidence; this brief reply analyses this
and four other fundamental problems with his paper. In addition to this
first error, Mohindra is mistaken about the evidence being in equipoise in
his example case; his conclusion about cost-effectiveness does not follow;
he is wrong to suggest that NICE is engaged in a de facto clinical trial;
and is in error to suggest that anyone could ever win compensation because
they were not given prophylaxis.
Philosophy and logic
We argued in our paper that NICE's decision was logical and sensible,
given the lack of evidence for any effectiveness of antibiotic prophylaxis
(AP) in preventing infective endocarditis (IE), and that those who
disagreed were putting faith before logic and evidence.[1] In explaining
his reaction to our paper, Mohindra states that "The source of my surprise
was the fact that both philosophical and theological argument had been
brought to bear in order to persuade clinicians of the merits of this
particular piece of NICE guidance. Guidance that should have been driven
by the empirical data."[2] Here Mohindra suggests by implication that the
NICE guidance itself was based on "philosophical and theological argument"
rather than evidence, which does not follow from the fact that our paper
dealt in part with such arguments. More importantly, our paper did not use
theological argument: it pointed out that the attitudes towards evidence
displayed by many cardiologists are similar to those of some religious
people. If anything, our argument is more evidence-based than his own: we
criticised some cardiologists for faith in the face of evidence, and his
paper seems to be a further example of this. In addition, despite
criticising our paper, he offers no rebuttal of any of its key arguments.
It is also somewhat ironic that Mohindra criticises our use of philosophy
rather than evidence in a clinical journal when he claims to regard logic
and evidence as the crux of the matter. It shouldn't need saying, but
logic is philosophy, and the scientific method is a type of applied
philosophy. Criticising someone for using philosophical argument is the
same as criticising him for using logical argument.
Evidence and equipoise
Mohindra is certainly right to point out that there is not much
evidence regarding the benefits and harms of AP. He quotes the NICE
statement that "There is insufficient evidence to determine whether or not
antibiotic prophylaxis in those at risk of developing infective
endocarditis reduces the incidence of IE when given before a defined
interventional procedure (both dental and non-dental)."[3] From this
Mohindra concludes that "a fact neither formally proved nor formally
disproved lies at the heart of the NICE guidance." He goes on to argue
that this is different from a normal case of equipoise, where there is
approximately equal evidence both for and against an intervention; in the
case of AP for IE, there is virtually no evidence for or against, so this
is a case of what he calls "insufficient evidence clinical equipoise"
rather than the usual "competing evidence equipoise":
"There is evidence that carries adequate probative force both for and
against the proposition (competing evidence equipoise); or there is
insufficient evidence to support the determination of either the truth or
falsehood of the proposition (insufficient evidence equipoise)."
Unfortunately, this appears to be an attempt to create a false
distinction. What does "adequate" mean here? If the evidence both proves
and disproves the proposition, then there is insufficient evidence to
support the determination of either the truth or falsehood of the
proposition; the two supposedly different types of equipoise are actually
identical. Equipoise is simply the state of being in equilibrium, and
clinical equipoise is the term we use for the evidence base being in
equilibrium. This is true whether there is no evidence on either side or a
great deal, but the same amount, on each side. In fact, "insufficient" in
this context means that there is not enough evidence to decide one way or
the other, so cases of "competing evidence equipoise" are the same
because there is insufficient evidence on either side to make a decision.
Cost-effectiveness and resistance
Mohindra argues that we can make a decision based on a value
judgement in cases of "competing evidence equipoise" but that to do so in
cases of "insufficient evidence equipoise" is to make a value judgement
that by necessity cannot be based on any evidence of cost-effectiveness,
as there is no evidence concerning effectiveness. He does not explain why
the same is not true in cases of competing evidence equipoise, which again
suggests that this is a false distinction. Nonetheless, he states that:
"Two points emerge from this position. First in the absence of
adequate empirical evidence the use of other expert opinion as a
foundation for new expert opinion based guidance does not move the
evidential ball at all. Second, and critically, NICE cannot logically
reach a conclusion upon cost-effectiveness in the absence of adequate
evidence of effectiveness or ineffectiveness."
Regarding the first point, NICE never claimed to have produced new
evidence. They simply put an end to the practice of using an intervention
for which there is no evidence base. It is somewhat ironic that Mohindra
should criticise NICE for basing their guidance on expert opinion and
producing no new evidence when he seems to favour continuing to give
patients a treatment for which there is no evidence because of the faith-
based expert opinion of some cardiologists.
With regard to the second point, it is indeed true that a typical decision
about cost-effectiveness cannot be made in the absence of evidence of
effectiveness. But in the absence of evidence of effectiveness, there is
no reason whatsoever to even consider cost-effectiveness; it would be
irresponsible to spend money on treatment that is not supported by
evidence. Furthermore, as we pointed out in our original article, there is
also the cost of increased resistance to antibiotics and consequent harm
to patients, which Mohindra fails to consider.[4] If the evidence
regarding benefit to the patient is in equipoise, but the treatment costs
money and will contribute towards the development of antibiotic
resistance, the overall picture is that this is not a case of equipoise at
all.
Trials and tribulations
Mohindra argues that NICE should have concluded that more research is
needed into the use of AP to prevent IE. He also claims that NICE is
essentially running an unofficial trial: "the effect of the NICE guidance
is to institute a de facto population wide prospective cohort study to
test the null hypothesis that antibiotic prophylaxis does not reduce the
population wide incidence of IE". Is this true?
It is clearly not true. If anyone is guilty of conducting an
unethical trial, it is cardiologists who gave AP in the past or continue
to do so. As stated above and in our original article, NICE concluded that
AP should not be prescribed because there is no evidence for its efficacy.
Mohindra himself suggests that more research is needed because the
evidence is in equipoise. This means that a trial is necessary in order to
justify the use of AP for IE. Clinical trials test new interventions for
which there is no evidence base. But if the evidence is in equipoise, it
is giving prophylaxis that is the trial, not withholding it. If NICE had
allowed the widespread use of AP to continue, that would have been a
clinical trial by stealth, and that was what was happening before the new
guidance was issued: patients were being used as trial subjects because
the collective wisdom of cardiologists was that AP prevented IE. Such
faith-based experimentation in the face of the evidence is exactly what
our original paper targeted, and NICE actually put an end to "a de facto
clinical trial protocol outside the pre-existing legal regulatory
framework", as Mohindra calls it.
Compensation and consolation
Finally, Mohindra's point about compensation is deeply flawed. He
references Connaughton, who has suggested that "the NHS might adequately
compensate anyone whose health suffered as a consequence of the new
guidelines."[5] This whimsical wish could never be fulfilled. It would be
impossible to prove that an incidence of IE was caused by a failure to
administer AP in terms of causality, but also because there is no evidence
that AP prevents IE anyway. This argument would only work if there was
evidence of IE's efficacy, and Mohindra's use of the argument suggests he
has faith that AP does work despite the lack of evidence; in other words,
he is committing the very error that we highlighted in our original paper.
It is also irresponsible to suggest that patients could claim compensation
when they have no chance of doing so. Contrary to Mohindra's claim, this
view has no legal or ethical force.
Conclusion
We argued in our original paper that some cardiologists resemble the
people who accepted Pascal's Wager [6]. Just as someone might choose to
believe in God because of the prospective benefits and despite the lack of
evidence of His existence, so some cardiologists choose to believe in the
efficacy of AP, despite the lack of evidence that it works, in a modern
example of the so-called "no-lose" philosophy in medicine.[7] In his
attempt to discredit NICE's guidance on IE, Mohindra commits several
logical errors, and shows that his beliefs are based on faith rather than
evidence. Ironically, he argues that "absence of evidence does not imply
evidence of absence" to make the point that the lack of evidence does not
mean that AP is not effective against IE, seemingly unaware that this very
statement is frequently used as a theological argument for the existence
of God, just like Pascal's Wager. We seem to have come full circle. Both
logic and evidence indicate that NICE's guidance is quite correct.
Mohindra's suggestion that NICE is engaged in an illegal trial is
irresponsible, as is his suggestion that compensation could be claimed for
harm caused by omitting AP. Despite Mohindra's attempt to introduce a
false distinction, equipoise is equipoise, and there is not equilibrium in
this case.
References
1. Shaw D, Conway DI. Pascal's Wager, infective endocarditis and the "no-lose" philosophy in medicine. Heart 2010;96:15-18.
2. Mohindra RK. A case of insufficient evidence equipoise: the NICE guidance on antibiotic prophylaxis for the prevention of infective endocarditis. J Med Ethics doi:10.1136/jme.2010.036848 (online early).
3. National Institute for Health and Clinical Excellence. Clinical Guideline 64: prophylaxis against infective endocarditis. http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf (accessed 9 Aug 2010)
4. Lewis MA. Why we must reduce dental prescription of antibiotics: European Union Antibiotic Awareness Day. Br Dent J 2008;205:537-8.
5. Connaughton M. Commentary: Controversies in NICE guidance on infective endocarditis. BMJ 2008;336:771.
6. Pascal B. Pensees (no 233). http://www.gutenberg.org/files/18269/18269-h/18269-h.htm (accessed 9 Aug 2010)
7. Galbraith S. The "no lose" philosophy in medicine. J Med Ethics 1978;4:61-3.
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human rese...
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human research where some sensitive research projects are not reviewed by research ethics committees at all."
I agree that these are important problems. However, I would like to share some ideas emerging from my own view of these issues as applied to less developed countries. The thing to be seriously concerned about is the lack of standards. In many poor institutions in those countries, a gang based system is used to judge on research proposals. If it is a research proposed by the same group or by a friend, it is approved. If the project is proposed by an external group or by groups with which there is a conflict of interest, the project is managed differently managed. This problem of lack of standards can also be seen in other academic judgements such as nominations for local awards or professorship appointments. The standardization of international criteria for the acceptability and reliability of ethical regulation of research and for other form of academic judgements might be an answer.
References
1. E Gefenas, V Dranseika, A Cekanauskaite, K Hug, S Mezinska, E Peicius,
V Silis, A Soosaar, and M Strosberg. Non-equivalent stringency of ethical
review in the Baltic States: a sign of a systematic problem in Europe? J.
Med. Ethics 2010 36:435-439; doi
In developing countries, most cases of malaria occur in rural areas
far from hospitals, where health care providers cannot adequately manage
severe malaria cases. Hospital referral causes treatment delays. Most
deaths occur during the first 24 hours, highlighting the need for earlier
actions to reduce mortality. Gomes and colleagues reported recently the
benefits of pre-referral rectal artesunate.(1) A single pre-referra...
In developing countries, most cases of malaria occur in rural areas
far from hospitals, where health care providers cannot adequately manage
severe malaria cases. Hospital referral causes treatment delays. Most
deaths occur during the first 24 hours, highlighting the need for earlier
actions to reduce mortality. Gomes and colleagues reported recently the
benefits of pre-referral rectal artesunate.(1) A single pre-referral
artesunate suppository reduced the risk of death or permanent disability
in patients reaching a clinic with facilities for injection, if the travel
time was more than 6 to 15 hours. Gomes et al. argued that the only way to
give effective antimalarial treatment to patients in the community who
cannot be treated orally is to take them to a health-care facility for
injectable treatment. More recently, Kitua et al. claimed that artesunate
suppository is the sole treatment that can be given by minimally trained
persons in remote setting.(2) For many years, others and we demonstrated
that rectal quinine would allow early treatment initiation with a potent,
widely available antimalarial drug. In 2005, a Cochrane review raised
three questions.(3) The first question was the limited sample size. Since
then, efficacy was confirmed in 4348 children at the community level in
Senegal, Mali, Niger, Burkina Faso and Uganda.(4-8) Second, safety was
questioned. A large control trial in Burkina Faso including 898 children
demonstrated that rectal quinine administration was safe and well accepted
by patients, parents and care-takers.(9-10) The third question regards the
use of rectal quinine in severe malaria: Two clinical trials in Uganda and
Niger demonstrated that rectal quinine was as effective as intravenous in
severe malaria.(4-5) The demonstration of rectal artesunate efficacy is an
important advance in the strategy for severe malaria treatment. Awaiting
the widespread distribution of artesunate rectocaps at rural health
facilities, rectal quinine remains a precious public health tool in the
pre-referral arsenal that should be an alternative when artesunate is not
available,(11) especially for African children treatment.
Hubert Barennes & Eric Pussard
Acknowledgement: We thank Leila S. Srour for revising the document.
We declare that we have no conflict of interest.
1 Gomes MF, Faiz MA, Gyapong JO, et al, for the Study 13 Research
Group. Pre-referral rectal artesunate to prevent death and disability in
severe malaria : a placebo-controlled trial. Lancet 2008; 373:557-66
2 Kitua A, Folb P, Warsame M, Binka F, Faiz A, Ribeiro I, Peto T,
Gyapong J, Yunus EB, Rahman R, Baiden F, Clerk C, Mrango Z, Makasi C,
Kimbute O, Hossain A, Samad R, Gomes M. The use of placebo in a trial of
rectal artesunate as initial treatment for severe malaria patients en
route to referral clinics: ethical issues. J Med Ethics 2010; 36:116-120.
3 Eisenhut M, Omari AA. Intrarectal quinine for treating Plasmodium
falciparum malaria. Cochrane Database Syst Rev 2005;1:CD004009.
4 Achan J, Byarugaba J, Barennes H, Tumwine JK. Rectal versus
intravenous quinine for the treatment of childhood cerebral malaria in
Kampala, Uganda: a randomized, double-blind clinical trial. Clin Infect
Dis 2007; 45:1446-1452
5 Barennes H, Munjakazi J, Verdier F, Clavier F, Pussard E. An open
randomized clinical study of intrarectal versus infused Quinimax for the
treatment of childhood cerebral malaria in Niger. Trans R Soc Trop Med Hyg
1998; 92:437-440.
6 Barennes H, Balima-Koussoube T, Nagot N, Charpentier JC, Pussard E.
Safety and efficacy of rectal compared with intramuscular quinine for the
early treatment of moderately severe malaria in children: randomised
clinical trial. BMJ 2006; 332:1055-1059.
7 Eisenhut M, Omari A, MacLehose HG. Intrarectal quinine for
treating Plasmodium falciparum malaria: a systematic review. Malar J 2005;
4(1):24.
8 Landais E, Poisson C, Condamine JL. [Analysis of 1697 cases of
childhood malaria treated using intra-rectal Quinimax (QIR) in the
Tilaberi health district in Niger]. Med Trop (Mars ) 2007; 67:471-476.
9 Ndiaye JL, Tine RC, Faye B, Dieye eH, Diack PA, Lameyre V et al.
Pilot feasibility study of an emergency paediatric kit for intra-rectal
quinine administration used by the personnel of community-based health
care units in Senegal. Malar J 2007; 6:152.
10 Thera MA, Keita F, Sissoko MS, Traore OB, Coulibaly D, Sacko M et
al. Acceptability and efficacy of intra-rectal quinine alkaloids as a pre-
transfer treatment of non-per os malaria in peripheral health care
facilities in Mopti, Mali. Malar J 2007; 6:68.
11 Newton PN, McGready R, Fernandez F, Green MD, Sunjio M, Bruneton C
et al. Manslaughter by fake artesunate in Asia--will Africa be next? PLoS
Med 2006; 3:e197.
Aksoy applied Islam principles for ethically justifying and endorsing
obligatory cadaveric organ donation for transplantation. "That maxim means
that when there is no other way to save a life, forbidden means become
permitted; this includes the removal of organs from a cadaver [1]".
The most fundamental questions that Aksoy has not asked or answered:
(1) Are transplantable organs removed from the truly...
Aksoy applied Islam principles for ethically justifying and endorsing
obligatory cadaveric organ donation for transplantation. "That maxim means
that when there is no other way to save a life, forbidden means become
permitted; this includes the removal of organs from a cadaver [1]".
The most fundamental questions that Aksoy has not asked or answered:
(1) Are transplantable organs removed from the truly dead or from
living human beings arbitrarily defined as dead?
(2) Are the medical criteria of neurological determination of death
(heart-beating donation) or cardio-respiratory determination of death (non
-heart-beating donation) scientifically consistent with human death? [2,
3]
If organs are procured before true death, the act of procuring organs
is the proximate cause of death of the person.
Scientific evidence has undermined the biological concept of brain
death for declaring human death [4]. In the 2008 report, the US President
's Council on Bioethics replaced the term "brain death" with "total brain
failure" [5]. The report cited series of scientific and clinical studies
undermining the biological rationale equating the concept of brain death
with human death (see page 56 Table 2: Physiological Evidence of Somatic
Integration). In stead, the Council postulated a novel philosophical
rationale equating this irreversible neurological condition as human death
and justifying continuation of cadaveric organ donation. Similarly, the
validity of the newly developed criteria for circulatory-respiratory
determination of death in the context of organ donation has also been
challenged [6].
Current worldwide practice of cadaveric organ procurement is
inconsistent with the legal standard of death set forth in the Uniform
Determination of Death Act of 1981[7]. In the 1986 Resolution of the Pan-
Islamic Council Jurisprudence on Resuscitation Apparatus in Amman, Jordan,
Muslim scholars adopted a Western definition of death. However, this
Council failed to address the scientific flaws and the arbitrary nature of
this definition designed solely for the purpose of permitting cadaveric
organ donation. This omission potentially has sociocultural consequences
[8]. The Council was also aware that the Quran include many verses from
which signs of life can be inferred. "Then He fashioned him in due
proportion, and breathed into him the Ruh [soul] (created by God for that
person), and He gave you hearing (ears), sight (eyes) and heart. Little is
the thanks you give! (Sura As-Sajda 32: 9) ". The dual interconnectedness
of functions and capacity to function of both the heart and the brain in a
human being are consistently emphasized throughout the Quran verses.
Advocates of cadaveric organ donation commonly cite the following
verse from the Quran: "if anyone killed a person -not in retaliation of
murder, or (and) to spread mischief in the land - it would be as if he
killed all mankind, and if anyone saved a life, it would be as if he saved
the life of all mankind (Sura Al-Maeda 5:32) ".
Advocates of organ donation emphasize that the act of saving a single
human life is of paramount value to saving the whole of mankind. What the
scholars should be emphasizing about this verse, however, is that its
warning about, and condemnation of, the active termination of life or the
killing of another human being has priority over the commendation for
saving one. Killing a human being for organs to save another life is not
an exception.
When Aksoy and others affirmed that cadaveric organ donation should
be a social obligation and that "the community is under a collective
obligation to find the right organs for transplantation in order to
preserve the lives and health of its sick members", it is imperative to
ask these two fundamental questions:
First, is society willing to embrace "utilitarian homicide" in
medical practice by sanctioning procuring organs for transplantation, even
when the determination of death is uncertain, to save the lives of others?
Defining death arbitrarily to allow procuring transplantable organs from a
dying person is not different from other forms of active medical
termination of a human life (eg, euthanasia), except that the former
appears to be successfully veiled by a utilitarian ideology [9].
Second, does the claim of collective responsibility and obligation in
the context of organ procurement apply when current scientific evidence
proves that organ donors are not dead but "close enough to death" [10] to
justify proceeding with surgical removal of transplantable organs, which
is turn, becomes the proximate cause of death?
Mohamed Y. Rady, MD, PhD
Professor of Medicine, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine
Mayo Clinic Hospital, Mayo Clinic, Phoenix, Arizona, 85254, United States
of America
Joseph L. Verheijde, PhD, MBA
Associate Professor of Biomedical Ethics, College of Medicine, Mayo Clinic
Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix,
Arizona, 85254, United States of America
References
1. Aksoy S: Some principles of Islamic ethics as found in Harrisian
philosophy. J Med Ethics 2010, 36(4):226-229.
2. Rady MY, Verheijde JL: Islam and end-of-life organ donation.
Asking the right questions. Saudi Med J 2009, 30(7):882-886.
http://www.smj.org.sa/DetailArticle.asp?ArticleId=4669
3. Cattermole GN, Rady MY, Verheijde JL: Islam and end-of-life organ
donation. Letter and Authors reply. Saudi Med J 2009, 30(11):1491-1493.
http://www.smj.org.sa/DetailArticle.asp?ArticleId=4845
4. Verheijde J, Rady M, McGregor J: Brain death, states of impaired
consciousness, and physician-assisted death for end-of-life organ donation
and transplantation. Med Health Care Philos 2009, 12:409-421.
http://www.springerlink.com/content/xu6n305k7q7475t3/
5. Controversies in the determination of death. A White Paper of The
Presdient 's Council on Bioethics [http://www.bioethics.gov/]
http://bioethics.georgetown.edu/pcbe/reports/death/
6. Halpern SD, Truog RD: Organ donors after circulatory determination
of death: Not necessarily dead, and it does not necessarily matter Crit
Care Med 2010, 38(3):1011-1012
8. Rady MY, Verheijde J, Ali M: Islam and End-of-Life Practices in
Organ Donation for Transplantation: New Questions and Serious
Sociocultural Consequences. HEC Forum 2009, 21 (2):175-205.
http://www.springerlink.com/content/xt08n3557878p98x/
9. Verheijde JL, Rady MY, McGregor JL, Friederich-Murray C:
Enforcement of presumed-consent policy and willingness to donate organs as
identified in the European Union Survey: The role of legislation in
reinforcing ideology in pluralistic societies. Health Policy 2009,
90(1):26-31.
10. Bernat JL: Dead, or as good as dead? Lahey Clinic Medical Ethics
Journal 2009, 16(2):3.
Sir, I read carefully the paper about popular television medical
dramas (1), and I think that these stories cannot be analyzed only from
the point of view of professionalism or of an ethical behavior. House is
not a story, it is a tale: it does not deal with real medicine (it is full
of factotum doctors, absent nurses, violence unto patients); nevertheless,
it gives moral teachings. A tale is something unrealistic but inspiring...
Sir, I read carefully the paper about popular television medical
dramas (1), and I think that these stories cannot be analyzed only from
the point of view of professionalism or of an ethical behavior. House is
not a story, it is a tale: it does not deal with real medicine (it is full
of factotum doctors, absent nurses, violence unto patients); nevertheless,
it gives moral teachings. A tale is something unrealistic but inspiring at
the same time. House MD is a fairy tale, and this tale has three main
features: a) Gregory House is a truth seeker, because he is sure that a
truth exists (be it a treatment for the patient or a name for the
disease), and he goes till the threshold of the ultimate mystery to find
it (he arrives to arrest his own heart to discover what happens after
death); b) his quest for truth is favored by his suffering (and it
decreases when suffering is blunted) that tunes him with the patient and
shows him the patients secret; c) House's quest of truth is lame without an
alliance between himself and the patient (which is the opposite of medical
paternalism).
These three points make all the ethical flaws in the TV
series, secondary; because in a tale, we cannot avoid violence (the bad
queen will always try to kill Snow White), incongruence (if a wolf eats a
baby, she cannot be extracted alive from its tummy) and bad ethical
examples (children abandoned in the forest); but violence, incongruence
and badness serve in a fairy tale to promote the moral happy ending. And in
House MD a happy ending is always present, but it is not always the happy ending
we are looking for (e.g. an ethical behavior); the happy ending is the
discover of the humanity of the drug-addicted patient, of the homeless, of
the dying trumpet player that House, through this discover, will be able
to cure.
REFERENCES:
1) Czarny MJ, Faden RR, Sugarman J. Bioethics and professionalism in
popular television medical dramas J Med Ethics 2010;36:203-206
Dear Editor, I read the recent publication by Rwabihama et al with a great
interest. I was impressed by the conclusion that "The process of
establishing ethics committees could affect their functioning and
compromise their independence in some African countries and in North
America [1]." The problem of the reliability of ethical committees for
biomedical research in developing countries is important and should be raised. Some...
Dear Editor, I read the recent publication by Rwabihama et al with a great
interest. I was impressed by the conclusion that "The process of
establishing ethics committees could affect their functioning and
compromise their independence in some African countries and in North
America [1]." The problem of the reliability of ethical committees for
biomedical research in developing countries is important and should be raised. Sometimes,
biases in judging the project (due to peer group, seniority of the
researcher in that institution, financial support from external
medical companies, etc.) can be expected. To set a standard international
cross-country system to control such committes is required.
References
Jean-Paul Rwabihama, Catherine Girre, and Anne-Marie Duguet. Ethics
committees for biomedical research in some African emerging countries:
which establishment for which independence? A comparison with the USA and
Canada. J. Med. Ethics 2010 36:243-249
Editor, I read the report by Czarny et al with a great interest [1].
I agree that there might be some issues to reflect upon with respect to bioethics and
professionalism in television medical dramas. In my country, there are
also many non-medical dramas in which the roles of physicians and other medical
personnel are shown. Relevant ethical concerns extend to wider issues than professionalism,
such as the promotio...
Editor, I read the report by Czarny et al with a great interest [1].
I agree that there might be some issues to reflect upon with respect to bioethics and
professionalism in television medical dramas. In my country, there are
also many non-medical dramas in which the roles of physicians and other medical
personnel are shown. Relevant ethical concerns extend to wider issues than professionalism,
such as the promotion of private hospitals (which is a theme in one of these dramas).
References
1. Matthew J Czarny, Ruth R Faden, and Jeremy Sugarman
J. Bioethics and professionalism in popular television medical dramas Med.
Ethics 2010 36:203-206
The practice of living organ donation requires living persons to be
willing to donate and medical practitioners to perform the surgical
interventions. In the case of the vast majority of kidney donors, there is
no doubt of their altruistic motives; indeed one could argue that donating
their kidneys constitutes a supererogatory act on their part. The moral
difficulty, however, lies with the medical practitioner performing a...
The practice of living organ donation requires living persons to be
willing to donate and medical practitioners to perform the surgical
interventions. In the case of the vast majority of kidney donors, there is
no doubt of their altruistic motives; indeed one could argue that donating
their kidneys constitutes a supererogatory act on their part. The moral
difficulty, however, lies with the medical practitioner performing an
invasive surgical procedure to remove a healthy organ from a healthy
patient. Najma Maple and colleagues [1] assume that just because the
majority of persons are willing to undergo medical procedure x with risk
y, their willingness implies that it is morally acceptable for medical
practitioners to perform x. This implication is problematic. Living kidney
donation not only results in the obvious effects of any surgery (post-
surgical pain, lost work time, etc.), but also carries both short- and
long-term health risks. Short-term risks for donors range from infection
to bleeding up to death [for a summary, see 2]. Long-term risks include a
rise of an average of 5-mm Hg of systolic blood pressure ten years after
kidney donation surgery [3] (in one study, 37.5% of donors became
hypertensive [4]), and kidney problems up to end-stage renal failure
[4,5]. From a population health perspective, living kidney donors are at
high risk of progressing to end-stage chronic kidney disease and
ultimately requiring either dialysis or a kidney transplant over their
lifetime. Effectively, living kidney donation practice can no longer be
considered as solving but exacerbating a future epidemic of end-stage
kidney disease in a population, and for society to deal with in 20-30
years later. This population health problem will amplify future crisis of
kidney shortage for transplantation and burden an already strained health
care system.
The principle of nonmaleficence (do no harm) forbids a medical
practitioner from performing actions that harm the health of a patient. In
the case of renal transplantation (and a fortiori, in cases of
transplantation of other solid organs), the risks to the donor are
significant. Even if nonmaleficence were considered to be a prima facie
duty, the risks to kidney donors are too great for the good gained for the
recipient to override this fundamental principle of medicine.
References
1 Maple NH, Hadjianastassiou V, Jones R, Mamode N. Understanding the
risk in living donor nephrectomy. J Med Ethics 2010;36:142-7, doi:
10.1136/jme.2009.031740.
2 Potts M, Evans DW. Is solid organ donation by living donors
ethical? The case of kidney donation. In: Weimar W, Bos MA, Busschbach JJ
(Eds.), Organ Transplantation: Ethical, Legal, and Psychosocial Aspects,
pp. 377-81. Lengerich: Papst Science Publishers, 2008.
3 Boudville N, Ramesh Prasad GV, Knoll G et al. Meta-analysis: risk
for hypertension in living kidney donors. Ann Intern Med 2003;145:185-96.
4 Azar SA. Nakhjavani MK, Faragi A et al. Is living kidney donation
really safe? Transplant Proc 2007;39:822-3.
5 Kido R, Shibagaki Y, Iwadoh K et al. How do living kidney donors
develop end-stage renal disease? Am J Transplant 2009;9:2514-19.
However else they might be described, the obviously living,
functioning, bodies of 'brain stem dead' organ donors are certainly not
cadavers - which are dead bodies, corpses (OED). The perpetuation of
their misrepresentation, unfortunately propagated by the Department of
Health[1] in 1983, prejudices all attempts to assess the true level of
public acceptance of organ transplantation practice.
However else they might be described, the obviously living,
functioning, bodies of 'brain stem dead' organ donors are certainly not
cadavers - which are dead bodies, corpses (OED). The perpetuation of
their misrepresentation, unfortunately propagated by the Department of
Health[1] in 1983, prejudices all attempts to assess the true level of
public acceptance of organ transplantation practice.
1. Cadaveric organs for transplantation. A Code of Practice including
the diagnosis of brain death. Health Departments of Great Britain and
Northern Ireland, February 1983.
Dear Editor,
I would first like to congratulate Dr. Seale for producing a thought- provoking piece of research that has captured the imagination of the nation's media. I would also like to point out an interesting discordance that I have noted with regard to the findings of this important research, which ought to stimulate further discussion.
Although religious doctors were significantly less likely tha...
Introduction
RK Mohindra's recent paper criticises NICE's decision-making regarding the use of antibiotic prophylaxis to prevent infective endocarditis. He is also critical of our defence of NICE, but does not actually engage with our argument, stating simply that he was "surprised" to see a philosophical defence of something that should be decided by evidence. We find it surprising that Mohindra believes that...
Dear Editor
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human rese...
In developing countries, most cases of malaria occur in rural areas far from hospitals, where health care providers cannot adequately manage severe malaria cases. Hospital referral causes treatment delays. Most deaths occur during the first 24 hours, highlighting the need for earlier actions to reduce mortality. Gomes and colleagues reported recently the benefits of pre-referral rectal artesunate.(1) A single pre-referra...
Aksoy applied Islam principles for ethically justifying and endorsing obligatory cadaveric organ donation for transplantation. "That maxim means that when there is no other way to save a life, forbidden means become permitted; this includes the removal of organs from a cadaver [1]".
The most fundamental questions that Aksoy has not asked or answered:
(1) Are transplantable organs removed from the truly...
Sir, I read carefully the paper about popular television medical dramas (1), and I think that these stories cannot be analyzed only from the point of view of professionalism or of an ethical behavior. House is not a story, it is a tale: it does not deal with real medicine (it is full of factotum doctors, absent nurses, violence unto patients); nevertheless, it gives moral teachings. A tale is something unrealistic but inspiring...
Dear Editor, I read the recent publication by Rwabihama et al with a great interest. I was impressed by the conclusion that "The process of establishing ethics committees could affect their functioning and compromise their independence in some African countries and in North America [1]." The problem of the reliability of ethical committees for biomedical research in developing countries is important and should be raised. Some...
Editor, I read the report by Czarny et al with a great interest [1].
I agree that there might be some issues to reflect upon with respect to bioethics and professionalism in television medical dramas. In my country, there are also many non-medical dramas in which the roles of physicians and other medical personnel are shown. Relevant ethical concerns extend to wider issues than professionalism, such as the promotio...
The practice of living organ donation requires living persons to be willing to donate and medical practitioners to perform the surgical interventions. In the case of the vast majority of kidney donors, there is no doubt of their altruistic motives; indeed one could argue that donating their kidneys constitutes a supererogatory act on their part. The moral difficulty, however, lies with the medical practitioner performing a...
However else they might be described, the obviously living, functioning, bodies of 'brain stem dead' organ donors are certainly not cadavers - which are dead bodies, corpses (OED). The perpetuation of their misrepresentation, unfortunately propagated by the Department of Health[1] in 1983, prejudices all attempts to assess the true level of public acceptance of organ transplantation practice.
1. Cadaveric organs for...
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