To the Editor: Harassment and bullying are unacceptable in any
workplace, let alone the health professions whose calling purportedly
subscribe to healing, compassion and humanity. The highly publicised
examples of sexism and exploitation serves notice to perpetrators fuelled
by the perverse incentive of hierachical authority gradients. It goes
without saying that we need a paradigm shift in standing up to the
inertial s...
To the Editor: Harassment and bullying are unacceptable in any
workplace, let alone the health professions whose calling purportedly
subscribe to healing, compassion and humanity. The highly publicised
examples of sexism and exploitation serves notice to perpetrators fuelled
by the perverse incentive of hierachical authority gradients. It goes
without saying that we need a paradigm shift in standing up to the
inertial stance of "it has always been thus, and ever will be." However,
supervisors and senior staff still need a remit to act as fair and
assertive counsellors to help underperforming and impaired junior doctors
when poor attitudes and errors of diagnosis and treatment lead to harm in
patient care. One wonders whether the recent media frenzy swirling around
sexism, bullying and exploitation within the surgical specialities in
training hospitals and through the two decades I have practiced as a
doctor holds a negative sting in its tail. An unintended consequence that
erodes our ability to train and graduate the competent specialist is that
supervisors of training are now much more likely to walk on eggshells when
it comes to fair-mindedly assessing junior staff not truly suited to
advanced training in their chosen specialty, possess negative attitudes
and are debilitated in their home and work lives. All of us must act
against the inertia of institutionalised abuse and the intergenerational
transference of the "we all go through it" ethos, but I fear training
standards will be allowed to lapse and that supervisors will try avoid any
necessary but difficult conversations and interventions with a trainee
that is not genuinely performing to a minimum standard.
More than the bi- and tri- of parenthood, the equity and justice of
paid parental leave, same sex parents and gay marriage are ethical and
pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face
in sustaining a career and raising their children. However, we neglect to
mention that the childless in society already subsidize and assist with
the...
More than the bi- and tri- of parenthood, the equity and justice of
paid parental leave, same sex parents and gay marriage are ethical and
pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face
in sustaining a career and raising their children. However, we neglect to
mention that the childless in society already subsidize and assist with
the home and work lives respectively of women who choose to become
mothers. Having children is routinely portrayed as a long financial
sacrifice for, and discrimination against, women who choose to take time
off from the workforce to have families. In most advanced economies, the
whole of dependent childhood is already heavily subsidised by advantageous
tax concessions, free schooling, affordable childcare and long stretches
of generously paid parental (including fatherhood) leave.
The childless worker is expected to assume the additional
responsibilities left behind by new mothers departed for the home front.
Parents use sick leave entitlements to look after children when they
cannot get babysitters. Every election cycle in Australia, baby bonuses
and family incentives are trotted out to this voter demographic.
Yet what protects those of us who choose to not reproduce? Unlike
food, water, shelter and warmth, having a child is not necessary for our
physical wellbeing. Most parents in later life see it as a positive life-
enhancing journey rather than a costly punishment. Adult children
represent a return on a parents' investment in having a carer in frailty
and old age. Children are the embodiment of a parent's genetic legacy and
a darwinian imperative.
The deliberately childless being burdened with the additional work
that new mothers displace to them also represents discrimination of those
expected to share indirectly the upkeep of other's children. The argument
that society and the workplace has deterred women from having families
should also take into account that until babies become independent tax
funding adults, they are represent a largely subsidized lifestyle choice
exercised by aspiring parents-to-be.
Ireland, by becoming the first nation to approve same-sex marriage by
referendum, powerfully bolsters the quest for gay equality, a movement
that has achieved a string of victories around the world over the past
decade but remains a distant goal in Australia, where leaders of both
political strips have either embraced vibrant opposition to it (Abbott and
company) or asked for a parliamentary conscience vote (some of the
Opposition). Until we let Australia speak by popular vote, these
approaches enable the entrenchment of less than tolerant attitudes of
those in power in Canberra. It smacks of "Aussie, Aussie, Aussie, No! No!
No!"
May 2015 marks Ireland 's emergence into the fraternity of 19 nations
that have legalised same-sex marriage, eroding the entrenchment of
discrimination based on outdated arguments. There is no evidence that it
undermines the union between man and woman and that gay marriage erodes
the sanctity of "traditional" procreation. The importance of biological
ties and of motherhood and fatherhood is now more absurd as an argument to
deny a fundamental human right to two men or two women who want to
formalise their lives together in a recognised union.
The outcome in Ireland sends an unmistakable signal to politicians
and religious leaders in Australia and around the world who continue to
harbour negative views against gays and lesbians. It also should offer
hope to sexual minorities in Russia, the Arab world and many African
nations where intolerance and discriminatory laws remain widespread. The
tide is shifting quickly. Even in unlikely places, love and justice will
continue to prevail.
I encourage Cutas to assess, in future, the influence of paid
parental leave (and its societal equity), the gender composition of
parents, and the formalisation of marriage (and legalisation of same sex
marriage) in children's development and welfare.
Respect for citizens' rights to confidentiality have come a long way
over the past decade or so in the UK but not without resistance in some
parts of the medical establishment. Along with and allied to
confidentiality, respect for a person's right to know what is being said
about them (access to files) has been something of a struggle and still is
for those who are incarcerated in prisons or hospitals. 'Secrecy' rather...
Respect for citizens' rights to confidentiality have come a long way
over the past decade or so in the UK but not without resistance in some
parts of the medical establishment. Along with and allied to
confidentiality, respect for a person's right to know what is being said
about them (access to files) has been something of a struggle and still is
for those who are incarcerated in prisons or hospitals. 'Secrecy' rather
than 'confidentiality' is historically one way of maintaining a very
unequal balance of power. In institutions it encourages abuse of
vulnerable people. Secrecy is a different concept to confidentiality and
should not be part of a professional relationship. The limits to
confidentiality when spelt out honestly and not fudged in order to extract
information should not be a huge issue when people are in prison or
psychiatric institutions. It would be useful to hear from people who have
spent time in them when they feel safe enough to speak publicly, even if
anonymously. The few one sided documentaries viewed by the public are
highly controlled versions of for example life in Broadmoor high security
hospital or in prisons. It is rare to read any first hand accounts
alongside those of professionals. Their perspective would be interesting.
Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options....
Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options.
Most of these patients have conditions such as motor neurone disease or
early dementia in which death within six months would not be expected.
Recently, I was asked to see a patient with purely psychiatric diagnoses
and have thus been thinking very hard about the issues discussed in their
paper.
It seems difficult to argue that intractable mental distress is
intrinsically less worthy of our concern than intractable somatic
distress. Most people who kill themselves do so as a result of
psychological rather than physical distress. Much of that distress proves
to be transient and/or tractable (and frequently aggravated by various
intoxications) but some of it is neither. The largest and most
comprehensive survey of suicides in a single 'western' country during the
entire 20th century [1] concluded that many suicides were due to eminently
'understandable' combinations of circumstance and personality or world-
view. Obvious mental illness was a less important factor.
The present era of DSM-5 imperialism is associated with sometimes
ludicrous claims for the effectiveness of antidepressants, despite
consistent evidence that placebo and non-specific mechanisms are much more
prominent than pharmacological ones. Personality disorders are, almost by
definition, resistant to both drugs and psychotherapy. When someone has
reached their mid-thirties without relief and despite such appropriate
interventions as exist, psychiatry should perhaps show a little
therapeutic humility.
Much of the organised opposition to MARS is religious and I think it
goes back to the Augustinian view that suicide is a worse sin than
homicide because it implied criticism of the world that God had created
[2] - a position that led to the ritual desecration of the corpse until
1825 in Britain. Even today, both the main churches officially deny
Christian burial in consecrated ground to suicides, though the Church of
England voted this year to revoke the relevant Canon Law. They get round
the prohibition in practice by claiming that all suicides must have been
suffering from insanity. The official position of psychiatry seems rather
similar.
REFERENCES.
1.Weaver J. Sorrows of a Century: interpreting suicide in New Zealand 1900
-2000.Montreal. McGill-Queen's university press. 2014.
2. Brewer C. Christian attitudes to suicide. In: C Brewer and M Irwin
Eds. I'll See Myself Out, Thank You. Thirty personal views in support of
assisted suicide. Newbould on Stour. Skyscraper. 2015
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases...
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases does PPI (Patient and Public Involvement) in the
research applications we see "adequately reflect the perspectives and
input of ... citizens." The predominant reason for this is a n
unwillingness to go outside the institution and its familiar sources to
the public 'out there'. This is despite the regular requirement to do so
of funding bodies and the law.
If institutions were to comply on a regular and consistent basis, the
need for PLR would be confined to what, in my perception, is the very
limited number of occasions when it would be practicable.
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprise...
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprised by it.
I've been making some effort to understand Islamic medical ethics and its
intersection with Western medical ethics for a couple of years now, as
part of the establishing the policy for King's College Hospital's clinic
in Abu Dhabi, where it has been important to recognise, and apply, both
the ethics of both countries and traditions. Throughout many discussions
of particular practical matters, and ethical decisions, the teachings of
Adab have not been mentioned.
The original sources are the right place to go for an understanding,
but I, and I think others, would find a guide to the field would be
extremely useful. Books that I can find in English on the subject appear
to be either historical, or literary, or to be concerned with non-medical
aspects of adab.
Conflict of Interest:
I am co-chair of the ethics committee of KCH Clinics Abu Dhabi - I'd hope more of a supporting, than a competing, interest, but I should mention it.
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagree...
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagreement and respect can and must co-exist.
Problems arise when conscience impedes the implementation of laws. In
her article, Minerva identifies an example of this in Italy, where a
women's access to abortion services is limited due to the high proportion
of doctors who, for conscientious reasons, forgo involvement in abortion
procedures. Minerva surveys the problem and suggests how it could be
mitigated, after a brief critique of the concepts of conscience absolutism
and what she terms the compromise position.
Minerva defines conscience absolutism as the healthcare
practitioners' right to decline a service, to the extent that it may
"compromise the right of the patient to be cured"[1]. It is possible that
some healthcare practitioners take this view with abortion, even if the
mother's life is immediately threatened. Many, however, as Minerva
acknowledges, hold the compromise position, whereby the healthcare
practitioner's right of refusal is respected, but he agrees to refer the
patient to a willing colleague. To most, this is preferable to conscience
absolutism. It is worth noting that UK law makes a concession for this in
Section 4 of the 1967 Abortion Act, which says, "no person shall be under
any duty... to participate in any treatment authorised by this Act to
which he has a conscientious objection", unless the mother's life is at
risk[3].
However, Minerva argues that such a set-up is inadequate in Italy;
intervention is needed to facilitate access to abortion because, "the
public health system has the responsibility and duty to guarantee to
citizens all safe and beneficial treatments they are entitled to
request"1. In response, I would argue that a woman's legal right to
abortion does not negate a physician's right to conscience. If the state
has a duty to protect both these rights, it cannot use one right to
supplant the other.
Finally, Minerva's second of three recommendations to redress the
issue of abortion access merits comment. She proposes that physicians
should be discouraged from conscientiously objecting by providing an
incentive - she suggests pay rises and holidays - to those who will
perform abortions. The right to conscience is ostensibly respected in
this case, though the moral agency behind it is insulted. At best, it is
profoundly patronising to incentivise doctors to compromise on personal
conscience for the sake of expediency.
In conclusion, regardless of one's view of abortion, the right to
conscientious objection must be maintained in a free society, even at the
expense of unmet requests. The physician is not a slave to the public's
demands. Minerva rejects conscience absolutism; we must reject demand
absolutism.
References:
1. Minerva F. J Med Ethics 2015;41:170-173
2. Trigg R. J Med Ethics 2015;41:174
3. Abortion Act 1697, Section 4
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without...
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without that.
Science is all about "profession" and social well being via technology and
services but yes all these technologies just can't change the fate.
Religion teaches us to how we can spend a good life but science teaches us
best way to use the neccesities around us in the form of technologies.
All religions teach us to be ethical, faithful towards our duties
under legal rules. Who so ever is a patient (birth control based to gays
or lesbians), a doctor must treat him/her as a "subject". The point is a
medical or paramedical staff at "duty" must follow their duty even what
ever religion they follow. But yes, I feel a good religious practicing
medical or paramedical staff will be ethically and morally will be better
than a religious non practicing staff. Religion can make us a better human
if we practice a religion and this will be reflected in our jobs and
strength of our moral ethics in dealing with the patients.
Its not the matter which religion we belong, but it does matter how
the world see us and how we treat the humans ethically and morally and
yes, if a non religious person with no ethics and no morals follow the
regulations and rules concerning with patient and communication skills, he
may be even better doctor than a religious doctor.
Way of passing life (religion) Vs profession must be treated
separately.
Greater transparency and regulatory oversight in disclosing gifts and
payments to physicians from drug and medical device companies could well
reduce their influence on a doctor's prescribing habits and medical
management recommendations. The threat of a very public loss of
professional reputation among peers and patients is likely to discourage a
physician accepting drug and medical device company generosity. However, a
m...
Greater transparency and regulatory oversight in disclosing gifts and
payments to physicians from drug and medical device companies could well
reduce their influence on a doctor's prescribing habits and medical
management recommendations. The threat of a very public loss of
professional reputation among peers and patients is likely to discourage a
physician accepting drug and medical device company generosity. However, a
more positive, potentially more effective and formative approach would be
include in medical school ethics curricula the psychology of gifting and
the adverse influence on clinical practice exerted by pharmaceutical
company incentives and honoraria. Instead of policing behavior to stop
physicians raiding Big Pharma's cookie jar, we should intensively caution
our medical students about inappropriate ties with pharmaceutical
industry. The latter could form the basis of a career-long ethical
approach towards refusing undue gifts and payments.
Careful scrutiny of drug-company sponsored clinical trials could lead
doctors to the conclusion that exciting but expensive new treatments are
not superior to reliable old work horses. Sponsored studies may ignore
comparisons with long-established effective drugs (there's little income
in established patent-expired drugs. By aggressively marketing their
newest products, drug companies would have physicians believe otherwise.
If only doctors had the time at work (preferably paid and without
clinical obligation) and the necessary skills to assess the methodological
robustness of a study, decipher its findings and apply its conclusions to
patients. Such favourable conditions are rarely available outside the
journal club, postgraduate training, teaching hospital and medical school.
If health executives really care about research bearing relevance to
patient care in ambulatory and community practice, they need to fund
doctors to train in appraising the quality of what they read and pay them
for the time spent keeping up to date. Better informed doctors are likely
to deliver better care and dividends in improved care will likely outgrow
remuneration to doctors.
Burgeoning health-care evidence needs to be efficiently delivered to
doctors caring for patients in digestible allotments that will not prove
overwhelming. This involves communicating information relevant to their
clinical practice or specialty, in a format and schedule compatible with
achieving balance in a doctor's work and personal life.
Paying doctors for non-clinical time to learn about the latest
evidence is a good start. Even if one has not assessed the original
studies, investigation and treatment summaries updated with newly emerging
clinical research provides a short-hand way for ensuring patients receive
the best of care, but requires commensurate time to absorb.
The argument for substantial benefit conferred by the placebo effect
in treatment trials has been around for a while. Clinical triallists do
not deny that inactive sugar pills and IV medications or sham surgery have
some quantifiable benefit when compared with doing nothing at all.
Patients who consent to participate in treatment studies tend to be more
motivated and confident that they will get better than those who ref...
The argument for substantial benefit conferred by the placebo effect
in treatment trials has been around for a while. Clinical triallists do
not deny that inactive sugar pills and IV medications or sham surgery have
some quantifiable benefit when compared with doing nothing at all.
Patients who consent to participate in treatment studies tend to be more
motivated and confident that they will get better than those who refuse to
be enrolled, despite only having a one in two chance of receiving a
potentially beneficial therapy. Randomised controlled trials attempt to
discern whether new therapies result in a clinically relevant benefit
(improved survival, reduced symptoms) in addition to that conferred by the
human mind's empowerment to enhance immunological and psychological
defences from participation in studies. Furthermore the awareness of being
closely observed and monitored for clinical progress or deterioration is
an incentive for patients to do better (the Hawthorne effect, aiming to
gain approval from investigators and other participants), regardless of
whether a study subject receive the tested or inactive treatment.
Ebola haemorrhagic fever, with its high case fatality risk, has no
reliably proven effective single drug or immune treatment. Although
several repatriated adults in advanced health systems have survived with
novel immune therapy, it could well have been the excellent critical care
and fluid resuscitation that were responsible for their recovery. The
latter would almost certainly not be available on a day to day basis in
the impoverished West African countries where EHF trials would be
conducted. In addition to placebo comparisons, the study of advanced fluid
resuscitation, immunomodulators and vaccines in vulnerable people who
cannot afford such treatments even if they were found to work remains
ethically challenging.
To the Editor: Harassment and bullying are unacceptable in any workplace, let alone the health professions whose calling purportedly subscribe to healing, compassion and humanity. The highly publicised examples of sexism and exploitation serves notice to perpetrators fuelled by the perverse incentive of hierachical authority gradients. It goes without saying that we need a paradigm shift in standing up to the inertial s...
More than the bi- and tri- of parenthood, the equity and justice of paid parental leave, same sex parents and gay marriage are ethical and pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face in sustaining a career and raising their children. However, we neglect to mention that the childless in society already subsidize and assist with the...
Respect for citizens' rights to confidentiality have come a long way over the past decade or so in the UK but not without resistance in some parts of the medical establishment. Along with and allied to confidentiality, respect for a person's right to know what is being said about them (access to files) has been something of a struggle and still is for those who are incarcerated in prisons or hospitals. 'Secrecy' rather...
Dear Editor. I do occasional psychiatric assessments for people contemplating medically-assisted rational suicide (MARS) in Switzerland and broadly agree with Schuklenk and van der Vathorst's arguments. Usually, my role is limited to assessing mental capacity and excluding the existence of a treatable psychiatric condition that might be influencing the patient's decision to include MARS in the list of acceptable options....
The Article states "In health research, funding bodies and academic institutions actively undertake patient and public involvement programmes to ensure that studies adequately reflect the perspectives and input of patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for seven years. I do not recognise this statement, nor would my colleagues. In very few cases...
I think this is a very important article. Well written, well researched and timely.
It seems that there is a large body of ancient wisdom locked away in the Adab writings. I suspect that there will be material of great value to Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing ethic, to Sharia. I'm ashamed of my ignorance, and also surprise...
In his commentary on Francesca Minerva's paper 'Conscientious Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for people who agree", and, "it is against the spirit of democracy to ride roughshod over other's [sic] beliefs"[2]. His point is apposite: in a democratic society an individual's conscience in matters of ethical controversy ought not to be compromised by popular sensitivities. Sharp disagree...
With respect to all authors, I have read the article and the comments made in the e-letter. I agreed with Biggar to little extent. But one of the important point here is the reason of following religion Vs following the science. Religion is not only about the beliefs but also about the practices. It teaches us 24 hours way of passing life by giving us the heavenly or moral knowledge either with a concept of God or without...
Greater transparency and regulatory oversight in disclosing gifts and payments to physicians from drug and medical device companies could well reduce their influence on a doctor's prescribing habits and medical management recommendations. The threat of a very public loss of professional reputation among peers and patients is likely to discourage a physician accepting drug and medical device company generosity. However, a m...
The argument for substantial benefit conferred by the placebo effect in treatment trials has been around for a while. Clinical triallists do not deny that inactive sugar pills and IV medications or sham surgery have some quantifiable benefit when compared with doing nothing at all. Patients who consent to participate in treatment studies tend to be more motivated and confident that they will get better than those who ref...
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