494 e-Letters

  • Heroism is a harmful misconception

    One of the most enlightening statements for me from the report of the WISH patient safety forum 2015 is, "The idea that saving patients’
    lives demands heroism is a harmful misconception about health and medicine seen in popular culture. In the real-world, the true heroes are not just rescuing patients, they are voicing their concerns and taking proactive measures to reduce the risks, before a patient is potentially put in harm’s way".
    We shouldn't need to rely on heroic rescue or expect it to be a normal part of our every day clinical practice. The idolisation of heroism damages attempts to improve systemic approaches to improving patient care because it neglects and belittles the under-appreciated grind of change to reduce the underlying risk of patient harm. Heroism should be less of an aspiration and more of a flag highlighting the need for organisational improvement.

  • In New Zealand Zero-Covid resulted in the best outcome

    The argument Jecker and Au mount against an elimination strategy for Covid-19 fails to account for the New Zealand experience. They discuss the question of excess mortality and suggest that tactics to reduce Covid-19 related deaths inadvertently increase deaths from other causes. Whilst this is intuitively true actual country wide data undermines their argument: https://blogs.otago.ac.nz/pubhealthexpert/mortality-declines-in-aotearoa... New Zealand experienced negative excess deaths for the years 2020-21 as did Australia and Taiwan. Had New Zealand experienced the same rate of excess deaths as the USA we could have expected 19,900 deaths which would have disproportionately affected ethnic minorities and the vulnerable. The elimination strategy in New Zealand was by far the best strategy to address health disparities, without it many more of those suffering disparities would have died.

  • Reconsenting paediatric research

    Murdoch et al. give an excellent account of the law in Canada relating to consent to research in children when they mature. Laws must be based on moral principles, which always have a beneficial intention and are everywhere similar for both treatment and research, for both adults and children and for the publication of identifying data.

    A competent adult can accept,reject or discontinue treatment. But a doctor must only provide treatment, which is beneficial physically or emotionally. In a publicly funded service she may need to balance the benefit to the individual against the needs of the community. The .patient is always free to consult a different doctor. A patient's personal details must not be revealed without express permission.

    An adult can also accept, reject or stop participation in research intended to benefit others. Again he must not be identified without permission. He cannot require the eradication of data obtained because that would harm others.

    A guardian, on behalf of a child, consents to treatment or research with the same rights and restrictions. As far as possible the informed consent of the child should be obtained.. When the child reaches maturity he must be fully informed and assumes responsibility for his own care. He can discontinue beneficial treatment but cannot demand that the doctor reverses it, because that would require her to cause harm. He can change doctors. He can stop participation in research but he cannot hav...

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  • Fifty years later: the significance of the Nuremberg Code

    Fifty years later: the significance of the Nuremberg Code
    E Shuster 1 Affiliations expand, PMID: 9358142 DOI: 10.1056/NEJM199711133372006
    Veterans Affairs Medical Center, Philadelphia, PA 19104, USA.

    The prosecution of doctors guilty of appalling human rights abuses at Nuremberg was achieved on the mistaken premise that the research community already had a code of conduct which, if applied, would have made such abuses impossible. In fact, not only was there no such code but when the 'Nuremberg Code' was published after the trial it continued to be ignored by many doctors for some thirty years afterwards. Indeed its central principle of informed consent has itself been eroded by subsequent international agreements on the ethics of medical research. This review shows that the mechanisms for approval of medical research which have now been promulgated in England and Wales, in practice, are applied on a very variable basis. Research in vulnerable groups unable to give fully informed consent such as children, prisoners and the incompetent elderly require the application of more rigorous standards of ethical control than those currently in operation. The use of vulnerable populations in the developing world and the application of international standards to them is also considered. A number of suggestions for improvements in current proce...

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  • Pharmacists are vulnerable too!!

    The vulnerabilities of pharmacists would appear to be invisible in the euthanasia/assisted suicide debates.

    As healthcare systems and societies are changing, the social positions of doctors, pharmacists, nurses and patients within them were changing too. In the past, clinical experts’ authority and patients’ autonomy have been in conflict. The current patient-centered / person-centered model of medical care, aims to establish egalitarian relationships between patients and healthcare clinicians and providers .

    Vulnerability can be defined as a lack of autonomy and independence, bodily and psychological insecurity, marginalized or deviant status, lack of acknowledgement within the society (1).Vulnerable groups are exposed to discrimination, intolerant attitude, subordination. Vulnerability is usually seen as an inherent quality of certain social groups (but not others). However it has many dimensions and might be attributed to relatively “powerful” groups (2). Doctors, pharmacists and nurses i.e. so called powerful groups, are rarely characterized as vulnerable groups, but within certain circumstances, they can be recognized as “vulnerable”.

    Doctors, pharmacists and nurses are in a situation where they are becoming more controlled by the patients. There is an emphasis on the myth that citizens (patients) should be autonomous and the inevitability and normality of dependency is not recognised (3). Dependency is an unavoidable feature of...

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  • The response to COVID-19 of many countries has been dictated so far by the media, or better by those who control the media, rather than the scientists. To find a solution, scientists should be free of this conditioning

    Dahlquist and Kugelberg (2021) correctly notice as the many non-pharmaceutical interventions (NPIs) which have been introduced to stop or slow down the COVID-19 pandemic through coercion are not publicly justified through a scientific consensus on the factual propositions that are used to support the policies, and as such, they would be illegitimate. It has been an unfortunate circumstance of this pandemic, that not only the NPIs but also the therapeutic approaches have been the subject of media misinterpretation, at the expense of a correct debate in between the scientific community, with scientists expressing opinions not welcomed by the media routinely abused for doing their work. Examples of policies lacking every scientific support, but still approved by the media, are everywhere. To find a working solution to the pandemic, definitively we do need free science “on the top”, rather than “on the tap” or even “on a leash”, limiting the interference by governments and corporations directly and through the media serving their interests. Misinformation by media is what has made the response to COVID-19 less effective than what could have been listening to the majority of the scientists. The response to COVID-19 of many countries has been dictated so far by the media, or better by those who control the media, rather than the scientists. To find a solution, scientists should be free of this conditioning.

    1. Dahlquist M, Kugelberg HD. (2021). Public j...

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  • Words/Nga Kupu

    Words/Nga Kupu*
    The suggestion of a “Words” column focussing particularly on words from a non-western ethical tradition is great. We are journeying through perilous waters and will need to adapt our ethical framework to the new reality. A value of diversity is that we can draw on concepts from other traditions. Of course, a “Word” in a language you do not speak is of no use. The word is part of a language, which is the embodiment of a culture, and ethics is inevitably culture bound. Even words shared between cultures do not necessarily share exact meanings. A consideration of Justice within the bioethical community culture would be incomplete without reference to Rawls. A consideration of Justice within a Māori community would be centred around Te Tiriti o Waitangi/ The Treaty of Waitangi(1). A simple translation is not enough. The definition of Whakawhanaungatanga is a good starting place, but more depth is needed. It is embedded in a Māori concept of health(2), and the richness of the concepts cannot be appreciated without appreciating the context in which it is used. Whilst it is a Māori word it is now also a New Zealand word. A whole generation of medical students have been taught Māori concepts of health, including Whakawhanaungatanga, significantly spearheaded by the work of Pitama and Lacey(3). Parry as a 5th year student wrote a heart-warming case study that illustrated the value of using these concepts(4). The New Zealand ethical landscape is an example of t...

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  • Conversations and Intentional Killing

    We should be careful of the way we talk. Human society can be described as a long conversation about what matters. In this conversation, the language we use to describe our healthcare and social care practices not only reveals our attitudes and virtues, it shapes them. In order to promote self-worth and respect for individuals who use professional services there must be an understanding of how the language used in a profession influences professionals and the individuals with whom professionals work. The term ‘ service user’ or ‘client’ may be one reluctantly used by many healthcare professionals. The language of ‘service user’ or ‘client’ is acceptable at the political level. However it may be potentially detrimental to those it labels in healthcare and may also be damaging to the underlying ethical practices of many healthcare professions.

    Language is a means of communication in healthcare, it can indicate attitudes and it is an integral part of social and professional life and behaviour. The particular meaning we attach to words reveal the underlying values and attitudes we hold about the people or things to which we are referring. Language exerts hidden power as our words may be simple descriptions or they may change lives. This power may not be detected by the vulnerable/underserved in society and by those with less power . Power and status in healthcare and social care interactions determine how each party behaves e.g. The term ‘service user’ or ‘cl...

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  • MAID, social determinants, and the slippery slope.

    In their recent article, Jocelyn Downie and Udo Schuklenk conclude, first, that the Canadian experience denies the existence of a 'slippery slope' expanding medical termination from a limited to a broader medical constituency. Second, they argue a faiure to provide social constituents of health and support is a significant factor in the increased requests for 'medical aide in dying.' (1) It is hard to credit their conclusions on either point.
    As they note, 2016 legislation legalized 'medical assistance in dying" in cases of serious and incurable illness, disease or disability in an advanced state of decline with death an inevitable and foreseeable conclusion. But as they note (pg. 3-4) new legislation has broadened those criteria to include those with 'disabilities' whose death is not reasonably foreseeable as well as others with chronic, non-progressive disorders including mental illness. Indeed, enui seems to now be an acceptable rational for termination among even those without serious chronic illnesses or disorders. (2)
    That is precisely the definition of the slippery slope, a narrow framework of action is broadened to include ever larger classes of peoples.
    Similarly, they give short-shirt to the issues of the social constituents of health, ignoring the complex of predicate failures that may lead one to seek a rapid death. These include the limited availability of expert palliative care, the shortage...

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  • In Defense of Instrumental Value

    The authors argue that when we prioritize healthcare workers for ventilators because of their instrumental value as healthcare workers, we fail to value human lives equally. While they suggest that “it may be ethically justifiable for healthcare workers to receive priority for some scarce healthcare resources” and argue that healthcare workers should have sufficient personal protective equipment (PPE), they do little to explain why granting priority for these resources isn’t also, as they argue with ventilators, a case of failing to attribute equal value to human lives. Indeed, it is not clear that they think prioritizing healthcare workers for vaccines was the right thing to do: “. . . our social fabric has shown signs of unravelling as vaccine roll-outs have pulled on loose threads” and prioritizing vaccines has resulted “in unanticipated frustration, mistrust and strife.” The authors are right in their conclusion about ventilators, but we should reject the concerns their article raises about vaccines and PPE. If saving the most lives is the goal, it is consistent with valuing each person’s life equally to prioritize healthcare workers for preventive measures, particularly at the outset of a pandemic.
    The authors mention three reasons ventilators are different from preventive measures like PPE and vaccines: 1) Efficacy: Those who require a ventilator will not return to work quickly. 2) Lifesaving: While ventilators rescue endangered lives, preventive measures only...

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