Regarding this controversial topic you may be interested in my, Australian, views on the matter:-
While I appreciate that the Hippocratic Oath in effect stipulates physicians should “do no harm”, this is not the end of the matter.
To only allow (or disallow) a “terminally” ill person to decide when they wish to end their life is looking at this problem from the wrong end. It is not if they are ill, terminally or otherwise, but a person’s quality of life – their perception of that quality, which should be the main issue.
Recall and understand that all life, repeat ALL life, is terminal – we cannot escape the end. It is terminal! Sooner or later we all die – ill or not. Palliative care, however well administered, will not halt this process. Furthermore it is impossible to accurately determine the exact time or date in the future as to when a person may die. So to stipulate a time or date (in Australia six months is suggested), sometime in the future which may determine whether or not a person is “allowed to die” is regrettable, to say the least.
Why should anyone have to “live” according to another person’s expectations? We have no “right” to interfere. It is not our life; it is not our choice.
We, and by “we” I include all humans, were presumably born to live in the world. Now if a human being decides, for whatever reason, that the life he or she is currently experiencing...
Regarding this controversial topic you may be interested in my, Australian, views on the matter:-
While I appreciate that the Hippocratic Oath in effect stipulates physicians should “do no harm”, this is not the end of the matter.
To only allow (or disallow) a “terminally” ill person to decide when they wish to end their life is looking at this problem from the wrong end. It is not if they are ill, terminally or otherwise, but a person’s quality of life – their perception of that quality, which should be the main issue.
Recall and understand that all life, repeat ALL life, is terminal – we cannot escape the end. It is terminal! Sooner or later we all die – ill or not. Palliative care, however well administered, will not halt this process. Furthermore it is impossible to accurately determine the exact time or date in the future as to when a person may die. So to stipulate a time or date (in Australia six months is suggested), sometime in the future which may determine whether or not a person is “allowed to die” is regrettable, to say the least.
Why should anyone have to “live” according to another person’s expectations? We have no “right” to interfere. It is not our life; it is not our choice.
We, and by “we” I include all humans, were presumably born to live in the world. Now if a human being decides, for whatever reason, that the life he or she is currently experiencing in the world is not a “quality life”, who is to say they are wrong? We, you or I, cannot experience that person’s view with all the emotional, stressful or painful events they may have suffered or endured during their life to date. How can anyone, other than the person concerned, determine what level of “quality” is acceptable or unacceptable?
We can have no idea how this expression of life plays out; or how life events affect a person’s outlook, towards themselves or others – no one can “know” this except the person concerned. They make a choice based on such experience – good, bad or indifferent - it their decision. You or I are in no position to say they are wrong.
What evidence, what insight do we have such that anyone can proclaim that a particular person’s view or expression of life is wrong and that we (or at least the “experts”) alone know better? We may not like or approve of their view but - so what!
Furthermore, what evidence is there for the “experts” to state that those who wish to end their life may be suffering from a “mental disorder” (hence the requirement – in those Australian States that have passed or are considering passing legislation allowing Euthanasia - for a psychiatric assessment on any person wishing to end their life). Disordered from what? From “normal”? As far as I can discover there is no accepted definition of “normal”. Possibly those considered “mentally disordered” react to life’s trials and tribulations differently from those around them – God knows there are enough “odd-ball” people in the community! Are they “wrong”? Or are those who condemn euthanasia just being intolerant and lacking in understanding or compassion?
Consider what (in Australia) may have a bearing on a person’s perception of a “quality” life; a lack of adequate employment; the current gross inequality in income; inadequate provision of low cost accommodation leading to homelessness; inequality in access to adequate medical intervention; inequality in access to adequate levels of education; widespread condemnation of various religious beliefs and practices (in Australia, principally those that are non-Christian); widespread racism; abuse (abuse in any form – emotional, financial, physical or sexual) and bullying, particularly the use of social media to attack the vulnerable.
Then there is widespread over prescribing of antidepressant and antipsychotic medications (remember that, allegedly, one in five -1 in 5 – will, allegedly, suffer from a “mental illness” in their lifetime). There are many reasons why all concerned should be critical about psycho-pharmaceutical drug treatment, such as uncertain causes, the problematic accuracy of the few diagnostic tests available, commercial conflict of interest, poor understanding regarding the mechanism of drug action and their many side-effects together with the related problem of publication bias [Note: The reanalysis of the – originally ghost written - GlaxoSmithKline Study 329 relating to their antidepressant drug formulation paroxetine, Paxil, (also known as Serotax or Aropax) provides an illuminating, if unfortunate, example of these issues].
And then there is extreme pain. Anything that results in an actual or perceived loss of personal control will (possibly) bring about a loss of dignity and of “hope” - those most subjective attitudes of mind.
Furthermore for some to say that only God can decide when or where any person dies is surely a gross over assumption – how do they know? What special insight do they possess? Is it not possible, because (I assume) God gave us free will that God may have already decided to allow a person who wants to die, to die?
Then what about those who say that the legalization of euthanasia would see the end of compassion? Surely it would be more compassionate to allow someone who wishes to end their life to do so in a private setting of their choice, with (possibly) family and friends in attendance?
Far rather this than, to get their way, forcing a person to take extreme actions – drinking or drugging themselves to death; jumping off a high rise building or cliff; driving at high speed into the support column of a freeway overpass or into a tree on a country road; consume rat poison or drink some corrosive liquid (such as ammonia) and take four days, in agony, to die.
Recall also that the British philosopher David Hume (1711 –1776) said, “I believe that no man ever threw away Life while it was worth keeping.”
Finally I will repeat a quote, from the Indian sage Jiddu Krishnamurti (1895-1986), who said, “It is no measure of health to be well adjusted to a profoundly sick society”.
There we have it – in a nutshell!
What follows below is a “Black Box” warning, relating to anti-depressant medications:-
US Federal Drug Administration Product Information Warning:
Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Although there has been a long-standing concern that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients, a causal role for antidepressants in inducing such behaviors has not been established. Nevertheless, patients being treated with antidepressants should be observed closely for clinical worsening and suicidality, especially at the beginning of a course of drug therapy, or at the time of dose changes, either increases or decreases.
Read into this what you will (particularly with reference to the re-analysis of Paxil – above).
I will be very interested in any response you may offer.
Yours sincerely
Andrew Campbell-Watt
87/2462 Albany Hwy
Gosnells
Western Australia 6110
Phone: +61 413582949
Email: acampbellwatt@gmail.com
PS. I am a 78 year old retiree who has never had any contact with any euthanasia group. Also for your information, I am twice a widower – my first wife committed suicide and died in agony and the second, after 36 years of a loving relationship, suffered a severe illness and whilst in palliative care was given, at my suggestion – and without any questions being asked – higher and higher doses of morphine (via a syringe driver) until she died.
The family was in attendance at her death, which was quiet, dignified and peaceful.
Recently we conducted a study that identified an “ethics ecosystem” that, as a form of research governance, ensures that common ethical principles are operationalised by a number of actors within this ecosystem. This ethics ecosystem includes researchers, research ethics committee members, research institutions, publishing houses and Editors, and external Associations [1, 2].
In their paper ‘In defence of governance: ethics review and social research’, Sheehan et al [3] attempt to find a strong ethical answer for the need for such levels of ethical governance at the ethical review level for the social sciences. In doing this, the authors respond to a number of hypothetical claims against the need for such a review governance system. They then create their case that society has a stake in social research because of its link to enquiry, and in turn, human flourishing. They explain that because individual members of society will reasonably disagree about this ‘stake’, i.e., what specific research enquiry should proceed through ethical review to further human flourishing, this needs to be settled via a ‘fair process’ governance (i.e., a committee style) model.
While this paper is certainly a comprehensive and interesting analysis highlighting many of the discussions in this area, the authors fail to sufficiently link their final argument to ‘enquiry’.
We believe we can provide a better defense for an ethical review framework. This can be achieved by...
Recently we conducted a study that identified an “ethics ecosystem” that, as a form of research governance, ensures that common ethical principles are operationalised by a number of actors within this ecosystem. This ethics ecosystem includes researchers, research ethics committee members, research institutions, publishing houses and Editors, and external Associations [1, 2].
In their paper ‘In defence of governance: ethics review and social research’, Sheehan et al [3] attempt to find a strong ethical answer for the need for such levels of ethical governance at the ethical review level for the social sciences. In doing this, the authors respond to a number of hypothetical claims against the need for such a review governance system. They then create their case that society has a stake in social research because of its link to enquiry, and in turn, human flourishing. They explain that because individual members of society will reasonably disagree about this ‘stake’, i.e., what specific research enquiry should proceed through ethical review to further human flourishing, this needs to be settled via a ‘fair process’ governance (i.e., a committee style) model.
While this paper is certainly a comprehensive and interesting analysis highlighting many of the discussions in this area, the authors fail to sufficiently link their final argument to ‘enquiry’.
We believe we can provide a better defense for an ethical review framework. This can be achieved by asking first and foremost “How can we conduct ethical social science research?” rather than, as Sheehan et al ask, How can we defend ethics review? By re-framing this initial question, the justification for a level of research ethics governance becomes clearer.
At present, our “ethics ecosystem” ensures that conducting ethical research and behaving ethically is reinforced through a governance network of interconnected actors from the academic system. The Ethics Ecosystem comprises individuals (researchers), organisations (research institutions) and external bodies (publishing houses, funding bodies, professional associations) all working together and playing a role in the promotion, evaluation and enforcement of a shared understanding of ethically responsible research behavior [1]. This ensures that research is conducted responsibly in a way that is valued by the academy, minimises risk to participants, and guards against academic misconduct.
When working well, it is hard to see the importance that each actor and each level of the ecosystem has in the maintenance of shared understandings of ethical behaviour. Only when this ecosystem is compromised can we see the need for a higher form of research ethics governance.
Such is the case for social media research.
Social media sites are increasingly being seen as rich sources of health data for scholars- as avenues for research project recruitment; as intervention platforms for specific health conditions; to explore social support and health; and as a source of publicly available data. Data-mining techniques used to access public health data have, for example, been drawn upon to improve infectious disease surveillance; to understand disease patterns; and to explore health behaviours[4]. A number of ethical concerns have emerged in relation to the use of such data, and the ongoing and complex nature of social media research has been suggested to be potentially challenging for researchers and ethics committees. Concerns relate to whether to classify social media research as human subjects’ research or text-based analysis; what constitutes public and private spaces; and vulnerability, potential harm, intrusiveness, and confidentiality [5-12].
We explored how the ethics ecosystem was functioning with relation to this new mode of ethically complex research. We spoke to actors at many levels of the ecosystem including researchers, research ethics committee members, universities, publishing houses, and journal Editors. We identified a lack of community consistency, which fosters a culture in which decisions about the ethical use of SM data is primarily made by a reliance on individual researchers implementing a form of “personal ethics”; rather than by a shared norm around the use of SM data by actors within an overarching ethics ecosystem. Such a ‘personal ethics’ if left unchecked, can be dangerous in terms of unethical research falling between the cracks in terms of research governance.
At the researcher level of the ethics ecosystem, researchers placed emphasis on the subjective, individual nature of ethics when justifying their research practices:
Interviewer: Are there any guidelines in particular that you follow in your own research?
Researcher : It’s my guidelines. Everybody has their own definition of ethics….
They spoke about working around the non-obligatory ‘vague’ guidelines to justify their research;
They are [guidelines] slightly contradictory in places and you can argue around them...so there is some issues around integrity that don’t necessarily hold true and you can argue either way for some of the issues around that
With such a personal approach to ethics, researchers’ ability to justify their ethical choices to both other researchers, as well as, where necessary, to ethical review boards became a key priority;
There is a sense of you got to develop the sense of what's right here, be the expert in that and then put that across and you know, make your case
At the researcher ethics committee level of the ethics ecosystem, because little social media research was submitted for ethical review (researchers used ‘personal ethics’ to often justify this decision), committee members had little experience or shared understanding of how to review this research. Within this framework of ethical decision-making, focus was placed on researchers’ justifications of their research approach
sometimes make different decisions even for projects that look pretty similar. It’s how they build up their case doing that particular project
Similar ethical decision-making, focused on a researcher’s justification of their personal ethics, was also evident at the Editor level of the ecosystem.
This personal ethics is not necessarily problematic per se but if we remove the stability of shared understanding within the ethics ecosystem, researchers are left to justify which research is ethical or not by themselves and not within themselves. This leads to the disintegration of the multi-member ethics ecosystem, its governance role and ethic pluralism applied at all levels. The risk of this, we argue, provides a stronger justification for research ethics governance than the ones considered by Sheehan et al.
Ethics Approval: Ethics approval for this research was granted by Lancaster University
References
1. Samuel G, Derrick G. Social media research, ‘personal ethics’, and the Ethics Ecosystem. New Social Media, New Social Science Blog 2017.
2. Social media approaches to health research: an empirical analysis of decision-making within the UK ethical landscape. Social Media and Health: Meeting the Ethical Challenges; 2017 4th October; Wellcome Trust.
3. Sheehan M, Dunn M, Sahan K In defence of governance: ethics review and social research Journal of Medical Ethics Published Online First: 10 October 2017. doi: 10.1136/medethics-2017-104443
4. Vayena E, Mastroianni A, Kahn J. Ethical Issues in Health Research With Novel Online Sources. American Journal of Public Health 2012;102(12):2225-30.
5. McKee HA, Porter JE. The ethics of internet research: a rhetorical, case-based process. New York: Peter Lang Publishing, 2009.
6. Zimmer M. ‘‘But the data is already public’’: on the ethics of research in Facebook. Ethics Inf Technol 2010;12:313-25.
7. Snee H. Making Ethical Decisions in an Online context: Reflections on using blogs to explore narratives of experience. Methodological innovations online 2013;8(2):52-67.
8. Lomborg S. Personal internet archives and ethics. Research Ethics 2013;9(1):20-31.
9. Swirsky E, Hoop J, Labott S. Using Social Media in Research: New Ethics for a New
Meme? American Journal of Bioethics 2014;14(10):60-61.
10. Convery I, Cox D. A review of research ethics in internet-based research. Practitioner Research in Higher Education 2012;6(1):50-57.
11. Markham A, Buchanan E. Ethical Decision-Making and Internet Research: Recommendations from the AoIR Ethics Working Committee, 2012.
12. Henderson M, Johnson NF, Auld G. Silences of ethical practice: dilemmas for researchers using social media. Educational Research and Evaluation: An International Journal on Theory and Practice 2013;19(6):546-60.
Authors Montero and Villarroel discuss problems that might arise from “conscientious objection” (CO) to the new law in Chile that legalized abortion in cases of life endangerment of the woman, fatal fetal abnormality, and rape. (“A critical review of conscientious objection and decriminalisation of abortion in Chile”, Jan 6). The law provides the “right” to exercise CO, with the only caveat that health institutions are required to immediately refer patients to non-objecting practitioners. We share the authors’ concerns that conscientious objection may prove be quite widespread in Chile with the new law. In fact, we argue it will create serious, widespread problems for access to safe and legal abortion, despite the referral requirement.
Of course, in a Catholic-dominated country like Chile with a total abortion ban, the new law represents a major advance, and it will undoubtedly help many women. We appreciate the challenges and hard work to get the law passed and acknowledge it may have been difficult to do so without CO as a political compromise. Unfortunately, last-minute lobbying by Catholic hospitals resulted in a court’s expansion of the CO clause in the law, giving the “right” of CO to not just doctors, but also support workers and even institutions (when only individuals can have a conscience). This law will be very difficult to reverse and women will suffer the consequences.[1]
Authors Montero and Villarroel discuss problems that might arise from “conscientious objection” (CO) to the new law in Chile that legalized abortion in cases of life endangerment of the woman, fatal fetal abnormality, and rape. (“A critical review of conscientious objection and decriminalisation of abortion in Chile”, Jan 6). The law provides the “right” to exercise CO, with the only caveat that health institutions are required to immediately refer patients to non-objecting practitioners. We share the authors’ concerns that conscientious objection may prove be quite widespread in Chile with the new law. In fact, we argue it will create serious, widespread problems for access to safe and legal abortion, despite the referral requirement.
Of course, in a Catholic-dominated country like Chile with a total abortion ban, the new law represents a major advance, and it will undoubtedly help many women. We appreciate the challenges and hard work to get the law passed and acknowledge it may have been difficult to do so without CO as a political compromise. Unfortunately, last-minute lobbying by Catholic hospitals resulted in a court’s expansion of the CO clause in the law, giving the “right” of CO to not just doctors, but also support workers and even institutions (when only individuals can have a conscience). This law will be very difficult to reverse and women will suffer the consequences.[1]
The authors rightly recognize the difference between conscientious objection in health care, and civil disobedience. Yes, Chilean health care professionals who object to abortion and the new abortion law have been using the conscientious objection debate as a political weapon to undermine and repeal the new democratically-decided law. They are being disobedient, not conscientious, because they are prioritizing their personal religious beliefs over women’s right to heath and life. CO is “dishonourable disobedience.”[2] In contrast, other doctors exercise a conscientious commitment to their patients’ well-being and safety by providing abortion when necessary, especially in a stigmatized or legally restricted environment such as Chile.
However, the authors assert without any justification that if CO involves acting according to conscience, then both CO and conscientious commitment “merit identical regard” and one does not prevail over the other. We strongly disagree. CO in reproductive health care is a misnomer because it is not “conscientious” – it is the unethical abuse and abandonment of medical ethics and the duty of care, while conscientious commitment fully respects medical ethics and patients’ right to health care. CO exploits an imbalance of power between doctor and patient, with doctors enjoying a chosen and privileged position of trust and a state monopoly over health care, while vulnerable patients bear the full burden of CO. This is the opposite of CO in the military, where ordinary citizens are drafted into service against their will and must accept punishment or alternate service if they object.
The authors assume that CO in health care is a right, albeit one that must be limited. However, evidence-based arguments indicate that CO in health care is inappropriate and should be prohibited, in the same way as for refusals based on discriminatory racist or sexist beliefs.[2] Currently, Sweden, Finland, and Iceland do not allow a refusal to treat in reproductive health care,[3] and all countries should follow their example if they take evidence-based medicine and women’s human rights seriously.
It may be difficult to overcome the entrenched tradition of accepting CO, especially in Catholic-dominated countries like Chile, but the answer is not to accommodate CO as a right and regulate it – instead, it should be denounced as a violation of patient rights, with steps taken to reduce it as far as possible until it can be effectively abolished.
Some writers distinguish between what might be called ‘genuine CO’ and ‘obstructionist CO’[4] – but this distinction is impossible to make in an objective way. In fact, the very nature of CO is to be obstructionist because most of those who invoke it want to stop women from having abortions. As we have concluded elsewhere:
“Personal conscientious objection to a treatment that a patient requests has no valid place in health care. Treatment decisions by HCPs [health care professionals] must be patient-directed, not self-directed, and must be based on evidence, medical ethics, and professional obligations. If the treatment is legal, within the HCP’s qualifications, requested by a mentally healthy patient, and primarily beneficial (which abortion is), there is simply no excuse to refuse.”
Montero and Villarroel recommend that the Chilean government regulate CO to prevent “misuse.” But they offer no recommendations for how to do this. As they acknowledge, a significant number of hospitals and doctors will never obey any law allowing abortion, so we can safely assume that these objectors will never obey any regulations on CO either. It is naïve to call for CO regulation when existing CO regulations around the world are widely ignored and enforcement is almost non-existent.[2] In particular, it is well known that many anti-abortion doctors will refuse to make referrals because they feel this makes them “complicit”.[5] They are rarely if ever held to account for such refusals.
If CO regulations sometimes appear to “work”, it is only in a handful of countries that impose strict limits on it, including Norway, England, and Portugal. But Norway and England both have very low levels of objectors anyway, plus England side-steps the CO problem by shifting most abortion care to private clinics.[6] As for Portugal, no rigorous data exist on the prevalence of objection, few objectors are aware of their legal reporting duties under the law, and it is unknown if hospitals and objectors are obeying the law or what actually happens to women.[7]
The authors point out that the Chilean health care system is beset by major shortcomings, with the public sector experiencing “runaway demand, inadequate outpatient services, and a shortage of facilities and hospital beds.” In such an environment, converting the 100,000 estimated illegal abortions a year into safe, legal procedures will undoubtedly strain resources and run up against significant abortion stigma and widespread denial of services.
Historical experience and evidence from other countries, especially Catholic countries like Italy,[8] shows that allowing CO will seriously undermine Chile’s new abortion law and prevent Chilean women from accessing the service. Because that is the political intent of CO. It is a religiously-motivated boycott of a democratically-decided law. It is a refusal to treat based on personal beliefs, something that should not be allowed in any area of medicine – the fundamental purpose of which is to provide care, not refuse it. Chile will not succeed in regulating CO for the simple reason that you cannot “regulate” the exercise of religious beliefs with rational arguments. Similarly, it is impossible to avoid the “misuse” of CO, as CO is a misuse in itself.
Instead, governments should implement strong educational, enforcement, and disciplinary measures against the exercise of CO. Otherwise, not much will change. If the regulation of CO is to work, it must have as its goal the eventual elimination of CO. Some examples of measures that would reduce and eliminate the exercise of CO include:
• Require all public hospitals to provide abortions (as in Portugal, Norway, and France).
• Inform medical students applying to the Obstetrics/Gynecology specialty that abortion is a mandatory part of the curriculum and an expected part of their practice.
• Provide compulsory training in medical schools in abortion techniques for all Ob/Gyn students, and in contraception provision for all family medicine students.
• Include the requirement to participate in abortion in job descriptions at the point of hiring.
• Require existing objectors to take continuing education courses or values clarification workshops on the need for reproductive health care services, why women request abortions, the negative effects of CO on patients, and their fiduciary duty to patients. Also, expose them to patients needing abortion.
• Assist remaining objectors to move to other disciplines or areas where their objection won’t be a problem.
• Impose disincentives against any remaining objectors, such as: require them to register and file reports for each refusal, monitor and discipline them, hold objectors financially liable for harms done to patients, prohibit existing objectors from working alone, allow employers to prioritize hiring of non-objecting physicians, and pay objecting physicians less.
The point is that CO regulations should be designed to actively discourage and eliminate CO, with the understanding that CO is unethical and inappropriate in health care. Any law or policy that implies or recognizes a right to CO, while assuming that objectors will follow any prescribed limits without oversight, is bound to fail and will hurt women. We hope that steps can be taken in Chile to minimize these inevitable harms to women’s health and violations of their rights – such as encouraging pro-choice doctors to make a conscientious commitment to provide life-saving abortion care to women.
[3] Fiala C, Gemzell Danielsson K, Heikinheimo O, Guðmundsson JA, and Arthur J. Yes We Can! Successful Examples of Disallowing ‘Conscientious Objection’ in Reproductive Healthcare. European Journal of Contraception and Reproductive Healthcare. 2016 pp 201-206. http://www.conscientious-objection.info/wp-content/uploads/2016/10/Yes-w...
[7] Chavkin W, Swerdlow L, Fifield J. Regulation of Conscientious Objection to Abortion: An International Comparative Multiple-Case Study. Health and Human Rights Journal. 2017 Jun;19(1):55-68. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473038/
On p.5 the authors comment on the use of mindfulness exercises as "a tool to relieve suffering
and increase functioning". They claim that "This goes against common epistemic values" where these epistemic values are described as "the sort of values that lead one to accept uncomfortable truths, and to be honest, even brutally honest, with oneself."
As far as I can see there is no argument given for that claim, and what is more, it seems to go precisely contrary to the purpose of mindfulness exercises in that these are intended to enable one to be honest with oneself and face uncomfortable truths (e.g.: "... we cultivate acceptance by taking each moment as it comes and being with it fully, as it is [...] receptive and open to whatever we are feeling, thinking, or seeing". [Kabat-Zinn, Full catastrophe living, p.28f: https://books.google.at/books?id=fIuNDtnb2ZkC]). Mindfulness is to a large extent a tool to enable one be "honest, even brutally honest, with oneself".
There is a number of other strange claims in this article, I will mention only one: "Suppose an atheist was having trouble coping emotionally with a natural disaster in which there were many casualties. They might object to imagining the people who died in the disaster frolicking in heaven, even if doing so would help them cope. They do not believe in heaven, thus the imaginati...
On p.5 the authors comment on the use of mindfulness exercises as "a tool to relieve suffering
and increase functioning". They claim that "This goes against common epistemic values" where these epistemic values are described as "the sort of values that lead one to accept uncomfortable truths, and to be honest, even brutally honest, with oneself."
As far as I can see there is no argument given for that claim, and what is more, it seems to go precisely contrary to the purpose of mindfulness exercises in that these are intended to enable one to be honest with oneself and face uncomfortable truths (e.g.: "... we cultivate acceptance by taking each moment as it comes and being with it fully, as it is [...] receptive and open to whatever we are feeling, thinking, or seeing". [Kabat-Zinn, Full catastrophe living, p.28f: https://books.google.at/books?id=fIuNDtnb2ZkC]). Mindfulness is to a large extent a tool to enable one be "honest, even brutally honest, with oneself".
There is a number of other strange claims in this article, I will mention only one: "Suppose an atheist was having trouble coping emotionally with a natural disaster in which there were many casualties. They might object to imagining the people who died in the disaster frolicking in heaven, even if doing so would help them cope. They do not believe in heaven, thus the imaginative exercise is in tension with their core beliefs. Mindfulness exercises involve a similar tension with the core beliefs." Well, I am an atheist, and I would have no qualms whatsoever about such an imaginative exercise - after all, it is just imagination (of course, I would find it a bit surreal, but so what if it helps).
Discussing the alleged "metaphysical loadedness" of mindfulness exercises would need more space and time than I have here, but that claim seems no more convincing to me than the ones above, despite the constant repetition of this claim in the article.
I was intrigued to read this article about US practice relating to consent and minors.
Intrigued; and very pleased that I practice in the UK, where this was agreed, very sensibly, years ago.
The UK law permits a minor to consent to treatment, as long as they are capable of understanding the issues involved. And for vaccination, the issues (when you leave out the non-science-based scary stuff) are usually straightforward.
This means that vaccinating adolescents against HPV is straightforward - a few simple questions to establish that they understand what the vaccines for, and have an acceptable understanding of the almost-negligible risks involved, and you can vaccinate them, without requiring parental consent and with the full support of healthcare systems and the courts.
The ludicrous situation in the USA where some parents can prevent their children from accessing vaccines at the right time (before sexual debut), when the children themselves have a clearer understanding of the issues than their parents and want to be vaccinated is now, thankfully, a largely historical issue here.
Before any question about the existence, during the existence, one must ask what is the use of existing, because if it is useless, the debate on the existence itself is only a moral judgment invented by us humans. But I do not see how life will have served me when I was in the grave or reduced to ashes. If I am told that I have served someone else, I say what is the value of existing for the person I served? Have I been made as a therapy for this person? As for society that has a life span just a little longer than mine, I do not see the value of its existence either, since society is not a conscious entity and will end just as my existence will end without interest for me. So if I serve society, have I been made to be a social slave? Once this paradox of existence is solved, what are all the philosophies about existence itself? This is for me only a useless debate, an absurd gloss. And now a question: why do not men prevent women from taking the mortal risk of having a child, since this is indeed a deadly risk? For the sake of this woman, should not a man do everything to prevent him from committing suicide, because the conception is the equivalent of a Russian roulette suicide?
The depth of ethical analysis in this article is stupefyingly superficial, ill informed and immature. The author's "critical reflection"comprises some half guesses and frankly irrelevant conjecture about what the deceased's intentions were before his untimely death. The author apparently can't see any good reasons for a child to have a two parents, despite this being a foundation of western civilisation, recognised as beneficial in the literature, and given effect in our laws. The author sees nothing odd in a woman wanting to have a baby with a dead man. Where do the universities find these people.
Innovation is derived from the Latin innovatus which means “to renew or change”. In the broadest sense of the term, it can be viewed as the stimulus that modifies existing processes. Further, innovation has been one of the driving forces in the evolution of society through various revolutionary periods. This concept incorporates connotations of invention and creativity as impulses in themselves, however has recently been applied to commercialised settings. Hence, despite scientific interests, civic duties and altruism providing motivation for innovation, the strongest motive in recent times seems to be with a view to increasing profit. From a bottom-up level, inexperienced and junior innovators with the former inclinations could be met with resistance from the complexity of deriving economic viability. Furthermore, a central component to successful innovation involves promoting a culture to challenge outdated norms and the status quo. Change cannot occur if it is believed that present methods are infallible, as this removes the impetus for a goal-driven action. Consequently, many ideas may not reach fruition. However, within the medical field, it is wise that innovation occurs with incremental and calculated adjustments by enlarge, rather than with abrupt renovations. Wherever innovation leads to novel technology, the ultimate outcome of such is unforeseeable. The collingridge dilemma highlights an important notion that in early stages a new technology is still open to soc...
Innovation is derived from the Latin innovatus which means “to renew or change”. In the broadest sense of the term, it can be viewed as the stimulus that modifies existing processes. Further, innovation has been one of the driving forces in the evolution of society through various revolutionary periods. This concept incorporates connotations of invention and creativity as impulses in themselves, however has recently been applied to commercialised settings. Hence, despite scientific interests, civic duties and altruism providing motivation for innovation, the strongest motive in recent times seems to be with a view to increasing profit. From a bottom-up level, inexperienced and junior innovators with the former inclinations could be met with resistance from the complexity of deriving economic viability. Furthermore, a central component to successful innovation involves promoting a culture to challenge outdated norms and the status quo. Change cannot occur if it is believed that present methods are infallible, as this removes the impetus for a goal-driven action. Consequently, many ideas may not reach fruition. However, within the medical field, it is wise that innovation occurs with incremental and calculated adjustments by enlarge, rather than with abrupt renovations. Wherever innovation leads to novel technology, the ultimate outcome of such is unforeseeable. The collingridge dilemma highlights an important notion that in early stages a new technology is still open to social manipulation and as this malleability is lessened over time the potential for change is reduced.
The NHS system delivers care based on bioethical principles with emphasis on justice- that is, healthcare is widely accessible and free to all members of society, without discrimination on the grounds of socio-economic status, age and ethnicity. An evidence-based approach to treatment was exemplified with the inception of NICE in 2005. The use of scientific, robust research undoubtedly aids in the service of healthcare and ensures harm is reduced to a minimum. NICE publish updates and review their recommendations to reach this end, and in this way it is a protagonist in medical innovation. However, as the subject of healthcare is the human body, the complexities of such make it difficult to be certain of therapeutic successes being attributed to medical care alone. Other factors such as spontaneous remission, placebo and fundamental attribution error may skew our judgements of efficacy. In this way it is pertinent that we challenge customary management protocols wherever treatment failure occurs. Medical innovation, then, is essential to improve patient care.
However, speculation that financial motivations appear to provide the incentive for developing new therapies has naturally arisen. Authors have suggested this may manifest as delaying research results while researchers ascertain patents; leading to a culture of data distortion and neglect of the primary bioethical principles [1]. As the financial market provides the driving force for medical innovation to reach a profit goal, it follows that limiting product development through sanctioning of financial resources necessarily can limit innovation potential. Is it not then possible to foresee how this can be detrimental to patient care? Provided that political and social commitments i.e. moral, may impact the significance of medical research and its goals, innovation is an ideal. The competitive stimulus to acquire financial gains may drive innovation in other settings as well as medicine. This provides enough force for most individuals irrespective of personal concern for duty.
For medical professionals including medical students, the aim is for the improvement and promotion of care. Beginning with fundamentals; the adage “Primum non nocere”, is known to most students from the onset of medical studies. Medical students devote considerable time to through studying the principles of medical science, that it is often easy to forget the reason and aim of their work. With respect to bioethical principles, medical students ought to be encouraged to further medical progress but with an awareness that their actions are primarily for the benefit of patients. To improve the status quo, it is necessary to promote and implement a change in attitudes predominating medical schools. Naturally, when one devotes time, resources and efforts to achieve an aim, one would like compensation for these efforts. Despite the instrumental improvements that financial incentives influence with positive change, it is necessary that one remains conscious of the holistic approach to the patient.
References:
[1] Blumenthal D, Causino N, Campbell E, Louis K. Relationships between Academic Institutions and Industry in the Life Sciences — An Industry Survey. New England Journal of Medicine. 1996;334(6):368-374.
Paul et al. (2018) “Implementing post-trial access plans for HIV prevention research” present a much-needed discussion on the implementation of post-trial access plans. Here, I just want to signal a mistake on the conceptual definition of access, to an otherwise flawless paper.
If I am correct, the mistake would be related to the formulation of the following question:
"it the responsibility of researchers and sponsors only to ensure that all participants have access to effective preventive therapies, or does that responsibility extend further, to ensuring that participants actually receive them?" (Paul et al 2018:4)
I believe that "to ensure that participants have access to an intervention" is logically equivalent to "ensuring that participants actually receive an intervention". The MRCT Center's framework on post-trial responsibility defines access as “[…] the ability, right or permission of an individual to use an object or asset, and implies the removal of barriers to allow such use” (MRCT Center 2017:76). If a person does not actually receive an effective preventive therapy, she does not have the ability to use it. Therefor she has no access. Hence, distinguishing between the above expressions is conceptual mistake.
Instead, what I believe that the authors wanted to discuss is how much sponsors and researchers need to do to ensure access to an investigational intervention. In fact, irrespective of the abo...
Paul et al. (2018) “Implementing post-trial access plans for HIV prevention research” present a much-needed discussion on the implementation of post-trial access plans. Here, I just want to signal a mistake on the conceptual definition of access, to an otherwise flawless paper.
If I am correct, the mistake would be related to the formulation of the following question:
"it the responsibility of researchers and sponsors only to ensure that all participants have access to effective preventive therapies, or does that responsibility extend further, to ensuring that participants actually receive them?" (Paul et al 2018:4)
I believe that "to ensure that participants have access to an intervention" is logically equivalent to "ensuring that participants actually receive an intervention". The MRCT Center's framework on post-trial responsibility defines access as “[…] the ability, right or permission of an individual to use an object or asset, and implies the removal of barriers to allow such use” (MRCT Center 2017:76). If a person does not actually receive an effective preventive therapy, she does not have the ability to use it. Therefor she has no access. Hence, distinguishing between the above expressions is conceptual mistake.
Instead, what I believe that the authors wanted to discuss is how much sponsors and researchers need to do to ensure access to an investigational intervention. In fact, irrespective of the above formulation of the question, the author’s discussion of this question is about whether "referring participants" to local healthcare is enough to fulfil sponsors and post-trial access obligations or not, especially when "referral alone" is shown not be sufficient in some circumstances described in the paper to guarantee responsible transition to appropriate healthcare. However, “referral alone” is not equivalent to access but just a “post-trial access mechanism” (MRCT Center 2017:78).
Hence, I believe that the authors should reformulate the above question that may induce some conceptual confusion. Inspired by a question at the end of the paper, I suggest the following reformulation:
Is referral [alone] sufficient to fulfil [sponsors and] researchers’ [part of post-trial access] obligations [in all cases], or ought they to go further [sometimes?] [...] (Paul et al 2018:5, edited by Mastroleo)
Finally, what I believe that can be of help clarifying this conceptual mistake is to clearly distinguish between different questions, that is, (1) what would be the obligations entailed by post-trial access responsibility in a particular trial, including post-trial access, if any (Cho et al 2018); (2) what is the appropriate distribution of that responsibility between different responsible agents in a particular situation, and finally (3) what are the appropriate post-trial mechanisms that each agent has to fulfil to comply collectively with their part of the responsibility to (referral alone, improved referral, etc.).
References
Cho, H. L., Danis, M., & Grady, C. (2018). Post-trial responsibilities beyond post-trial access. The Lancet, 391(10129), 1478-1479. https://doi.org/10.1016/S0140-6736(18)30761-X
Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard (MRCT Center). (2017). MRCT Center Post-Trial Responsibilities Framework Continued Access to Investigational Medicines I. Guidance Document [Version 1.2, November 2017]. MRCT Center. Retrieved from http://mrctcenter.org/wp-content/uploads/2017/12/2017-12-07-Post-Trial-R...
Paul, A., Merritt, M. W., & Sugarman, J. (2018). Implementing post-trial access plans for HIV prevention research. Journal of Medical Ethics, medethics-2017-104637. https://doi.org/10.1136/medethics-2017-104637
We would like to congratulate Dr Derick T Wade on the article advocating a formalised approach to best interest meetings for people suffering from prolonged disorders of consciousness (1). It is a bold and pragmatic approach, borne out of his extensive experience, which will undoubtedly be of use to the practicing clinicians in the concerned jurisdiction. We are writing to supplement it with a few points which we consider worthy of additional noting.
Firstly, we are glad of the title using the term “prolonged disorder of consciousness” given that persistent vegetative state (PVS) and minimally conscious state (MCS) are problematic from phenomenological and practical points of view. As Dr Wade notes, the two are difficult to differentiate and in practice permanence takes significant and possibly indeterminate time to establish. Unfortunately, the Law maintains a distinction between the two founded in the leading case of Anthony Bland. Abolishing the distinction would in practice prevent splitting hairs over what is likely to be an equally tragic outcome for the individual concerned, and the surviving relatives. From a legal and philosophical point of view, it can be argued, as it was in the Bland case, that patients in PVS lack any “best interests”. To quote Lord Mustill – “The distressing truth which must not be shirked, is that the proposed conduct is not in the best interests of Anthony Bland, for he has no best interests of any kind” – ackno...
We would like to congratulate Dr Derick T Wade on the article advocating a formalised approach to best interest meetings for people suffering from prolonged disorders of consciousness (1). It is a bold and pragmatic approach, borne out of his extensive experience, which will undoubtedly be of use to the practicing clinicians in the concerned jurisdiction. We are writing to supplement it with a few points which we consider worthy of additional noting.
Firstly, we are glad of the title using the term “prolonged disorder of consciousness” given that persistent vegetative state (PVS) and minimally conscious state (MCS) are problematic from phenomenological and practical points of view. As Dr Wade notes, the two are difficult to differentiate and in practice permanence takes significant and possibly indeterminate time to establish. Unfortunately, the Law maintains a distinction between the two founded in the leading case of Anthony Bland. Abolishing the distinction would in practice prevent splitting hairs over what is likely to be an equally tragic outcome for the individual concerned, and the surviving relatives. From a legal and philosophical point of view, it can be argued, as it was in the Bland case, that patients in PVS lack any “best interests”. To quote Lord Mustill – “The distressing truth which must not be shirked, is that the proposed conduct is not in the best interests of Anthony Bland, for he has no best interests of any kind” – acknowledging the profound nature of the damage he suffered leading to absence of any cognitive process (2). In contrast, those in MCS, require a balancing approach to establish their best interests which may lead to a different decision concerning withdrawal of CANH (3). A patient’s ascertainable wishes are determinative in the decision-making as recognised by Charles J in Briggs v The Walton Centre NHS Trust & Another, who, notably, framed his decision in terms of consent / refusal and stated– “I have concluded that as I am sure that if Mr Briggs had been sitting in my chair and heard all the evidence and argument he would, in exercise of his right of self-determination, not have consented to further CANH treatment that his best interests are best promoted by the court not giving that consent on his behalf.” (4)
Secondly, Dr Wade also hints at the dual obligation faced by the clinicians looking after patients with disorders of consciousness, where an obligation towards the family and society at large is also apparent. These obligations are however suppressed by the perceived professional obligation to protect life as laid out by the General Medical Council. The conflict of duties is a fundamental critique of deontological approach to ethics and thus a perennial problem of bioethics and healthcare ethics where utilitarian considerations emerge. However the law not only makes it clear that prolongation of life may not be the best option for the patient but also that healthcare has to be rationed at many levels.
Finally, while second opinion is invaluable in life or death decisions, and strongly supported by the recent case law (5), consideration may also be given to review and adjudication by ethics committees, something we feel is underused in the UK in spite of growing complexity of ethical and legal problems associated with healthcare.
References:
1. Wade D T. Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management. J Med Ethics. Published online 14 September 2017; doi10.1136/medethics-2017-104244.
2. Airedale NHS Trust v Bland [1993] UKHL 17 (04 February 1993)
3. Re M; W v M [2011] EWHC 2443 (COP)
4. Briggs v Briggs and Walton Centre NHS FT and another [2016] EWCOP 53
5. Tracey, R (On the Application Of) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822 (17 June 2014)
Dear Sir or Madam,
Euthanasia? All life is terminal!
Regarding this controversial topic you may be interested in my, Australian, views on the matter:-
While I appreciate that the Hippocratic Oath in effect stipulates physicians should “do no harm”, this is not the end of the matter.
To only allow (or disallow) a “terminally” ill person to decide when they wish to end their life is looking at this problem from the wrong end. It is not if they are ill, terminally or otherwise, but a person’s quality of life – their perception of that quality, which should be the main issue.
Recall and understand that all life, repeat ALL life, is terminal – we cannot escape the end. It is terminal! Sooner or later we all die – ill or not. Palliative care, however well administered, will not halt this process. Furthermore it is impossible to accurately determine the exact time or date in the future as to when a person may die. So to stipulate a time or date (in Australia six months is suggested), sometime in the future which may determine whether or not a person is “allowed to die” is regrettable, to say the least.
Why should anyone have to “live” according to another person’s expectations? We have no “right” to interfere. It is not our life; it is not our choice.
We, and by “we” I include all humans, were presumably born to live in the world. Now if a human being decides, for whatever reason, that the life he or she is currently experiencing...
Show MoreRecently we conducted a study that identified an “ethics ecosystem” that, as a form of research governance, ensures that common ethical principles are operationalised by a number of actors within this ecosystem. This ethics ecosystem includes researchers, research ethics committee members, research institutions, publishing houses and Editors, and external Associations [1, 2].
In their paper ‘In defence of governance: ethics review and social research’, Sheehan et al [3] attempt to find a strong ethical answer for the need for such levels of ethical governance at the ethical review level for the social sciences. In doing this, the authors respond to a number of hypothetical claims against the need for such a review governance system. They then create their case that society has a stake in social research because of its link to enquiry, and in turn, human flourishing. They explain that because individual members of society will reasonably disagree about this ‘stake’, i.e., what specific research enquiry should proceed through ethical review to further human flourishing, this needs to be settled via a ‘fair process’ governance (i.e., a committee style) model.
While this paper is certainly a comprehensive and interesting analysis highlighting many of the discussions in this area, the authors fail to sufficiently link their final argument to ‘enquiry’.
We believe we can provide a better defense for an ethical review framework. This can be achieved by...
Show MoreBy Christian Fiala and Joyce H Arthur
Authors Montero and Villarroel discuss problems that might arise from “conscientious objection” (CO) to the new law in Chile that legalized abortion in cases of life endangerment of the woman, fatal fetal abnormality, and rape. (“A critical review of conscientious objection and decriminalisation of abortion in Chile”, Jan 6). The law provides the “right” to exercise CO, with the only caveat that health institutions are required to immediately refer patients to non-objecting practitioners. We share the authors’ concerns that conscientious objection may prove be quite widespread in Chile with the new law. In fact, we argue it will create serious, widespread problems for access to safe and legal abortion, despite the referral requirement.
Of course, in a Catholic-dominated country like Chile with a total abortion ban, the new law represents a major advance, and it will undoubtedly help many women. We appreciate the challenges and hard work to get the law passed and acknowledge it may have been difficult to do so without CO as a political compromise. Unfortunately, last-minute lobbying by Catholic hospitals resulted in a court’s expansion of the CO clause in the law, giving the “right” of CO to not just doctors, but also support workers and even institutions (when only individuals can have a conscience). This law will be very difficult to reverse and women will suffer the consequences.[1]
The authors rightly recogniz...
Show MoreOn p.5 the authors comment on the use of mindfulness exercises as "a tool to relieve suffering
and increase functioning". They claim that "This goes against common epistemic values" where these epistemic values are described as "the sort of values that lead one to accept uncomfortable truths, and to be honest, even brutally honest, with oneself."
As far as I can see there is no argument given for that claim, and what is more, it seems to go precisely contrary to the purpose of mindfulness exercises in that these are intended to enable one to be honest with oneself and face uncomfortable truths (e.g.: "... we cultivate acceptance by taking each moment as it comes and being with it fully, as it is [...] receptive and open to whatever we are feeling, thinking, or seeing". [Kabat-Zinn, Full catastrophe living, p.28f: https://books.google.at/books?id=fIuNDtnb2ZkC]). Mindfulness is to a large extent a tool to enable one be "honest, even brutally honest, with oneself".
There is a number of other strange claims in this article, I will mention only one: "Suppose an atheist was having trouble coping emotionally with a natural disaster in which there were many casualties. They might object to imagining the people who died in the disaster frolicking in heaven, even if doing so would help them cope. They do not believe in heaven, thus the imaginati...
Show MoreI was intrigued to read this article about US practice relating to consent and minors.
Intrigued; and very pleased that I practice in the UK, where this was agreed, very sensibly, years ago.
The UK law permits a minor to consent to treatment, as long as they are capable of understanding the issues involved. And for vaccination, the issues (when you leave out the non-science-based scary stuff) are usually straightforward.
This means that vaccinating adolescents against HPV is straightforward - a few simple questions to establish that they understand what the vaccines for, and have an acceptable understanding of the almost-negligible risks involved, and you can vaccinate them, without requiring parental consent and with the full support of healthcare systems and the courts.
The ludicrous situation in the USA where some parents can prevent their children from accessing vaccines at the right time (before sexual debut), when the children themselves have a clearer understanding of the issues than their parents and want to be vaccinated is now, thankfully, a largely historical issue here.
Before any question about the existence, during the existence, one must ask what is the use of existing, because if it is useless, the debate on the existence itself is only a moral judgment invented by us humans. But I do not see how life will have served me when I was in the grave or reduced to ashes. If I am told that I have served someone else, I say what is the value of existing for the person I served? Have I been made as a therapy for this person? As for society that has a life span just a little longer than mine, I do not see the value of its existence either, since society is not a conscious entity and will end just as my existence will end without interest for me. So if I serve society, have I been made to be a social slave? Once this paradox of existence is solved, what are all the philosophies about existence itself? This is for me only a useless debate, an absurd gloss. And now a question: why do not men prevent women from taking the mortal risk of having a child, since this is indeed a deadly risk? For the sake of this woman, should not a man do everything to prevent him from committing suicide, because the conception is the equivalent of a Russian roulette suicide?
The depth of ethical analysis in this article is stupefyingly superficial, ill informed and immature. The author's "critical reflection"comprises some half guesses and frankly irrelevant conjecture about what the deceased's intentions were before his untimely death. The author apparently can't see any good reasons for a child to have a two parents, despite this being a foundation of western civilisation, recognised as beneficial in the literature, and given effect in our laws. The author sees nothing odd in a woman wanting to have a baby with a dead man. Where do the universities find these people.
Innovation is derived from the Latin innovatus which means “to renew or change”. In the broadest sense of the term, it can be viewed as the stimulus that modifies existing processes. Further, innovation has been one of the driving forces in the evolution of society through various revolutionary periods. This concept incorporates connotations of invention and creativity as impulses in themselves, however has recently been applied to commercialised settings. Hence, despite scientific interests, civic duties and altruism providing motivation for innovation, the strongest motive in recent times seems to be with a view to increasing profit. From a bottom-up level, inexperienced and junior innovators with the former inclinations could be met with resistance from the complexity of deriving economic viability. Furthermore, a central component to successful innovation involves promoting a culture to challenge outdated norms and the status quo. Change cannot occur if it is believed that present methods are infallible, as this removes the impetus for a goal-driven action. Consequently, many ideas may not reach fruition. However, within the medical field, it is wise that innovation occurs with incremental and calculated adjustments by enlarge, rather than with abrupt renovations. Wherever innovation leads to novel technology, the ultimate outcome of such is unforeseeable. The collingridge dilemma highlights an important notion that in early stages a new technology is still open to soc...
Show MorePaul et al. (2018) “Implementing post-trial access plans for HIV prevention research” present a much-needed discussion on the implementation of post-trial access plans. Here, I just want to signal a mistake on the conceptual definition of access, to an otherwise flawless paper.
If I am correct, the mistake would be related to the formulation of the following question:
"it the responsibility of researchers and sponsors only to ensure that all participants have access to effective preventive therapies, or does that responsibility extend further, to ensuring that participants actually receive them?" (Paul et al 2018:4)
I believe that "to ensure that participants have access to an intervention" is logically equivalent to "ensuring that participants actually receive an intervention". The MRCT Center's framework on post-trial responsibility defines access as “[…] the ability, right or permission of an individual to use an object or asset, and implies the removal of barriers to allow such use” (MRCT Center 2017:76). If a person does not actually receive an effective preventive therapy, she does not have the ability to use it. Therefor she has no access. Hence, distinguishing between the above expressions is conceptual mistake.
Instead, what I believe that the authors wanted to discuss is how much sponsors and researchers need to do to ensure access to an investigational intervention. In fact, irrespective of the abo...
Show MoreDear Editor,
We would like to congratulate Dr Derick T Wade on the article advocating a formalised approach to best interest meetings for people suffering from prolonged disorders of consciousness (1). It is a bold and pragmatic approach, borne out of his extensive experience, which will undoubtedly be of use to the practicing clinicians in the concerned jurisdiction. We are writing to supplement it with a few points which we consider worthy of additional noting.
Firstly, we are glad of the title using the term “prolonged disorder of consciousness” given that persistent vegetative state (PVS) and minimally conscious state (MCS) are problematic from phenomenological and practical points of view. As Dr Wade notes, the two are difficult to differentiate and in practice permanence takes significant and possibly indeterminate time to establish. Unfortunately, the Law maintains a distinction between the two founded in the leading case of Anthony Bland. Abolishing the distinction would in practice prevent splitting hairs over what is likely to be an equally tragic outcome for the individual concerned, and the surviving relatives. From a legal and philosophical point of view, it can be argued, as it was in the Bland case, that patients in PVS lack any “best interests”. To quote Lord Mustill – “The distressing truth which must not be shirked, is that the proposed conduct is not in the best interests of Anthony Bland, for he has no best interests of any kind” – ackno...
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