498 e-Letters

  • Expanded terminal sedation in end-of-life care (Gilbertson et al. doi:10.1136/jme-2022-108511)

    As a retired palliative care physician, I am puzzled by several aspects of this article. First, authors’ choice of terminology: ‘terminal sedation’ and ‘expanded terminal sedation’. It is more than 20 years since the use of the former began to be discouraged because of perceived ambiguity, and replaced by ‘palliative sedation’ (PS)[1] – as reflected in current professional guidelines.[2] And despite dissenting voices,[3] most clinicians would probably consider ‘expanded terminal sedation’ to be ‘slow euthanasia’.
    PS was used to describe a deliberate switch from escalation of symptom management to a deliberate reduction in a patient’s level of consciousness in order to ease otherwise intolerable refractory suffering in ‘imminently dying’ patients. The sedation varied from light to deep depending on individual need. Some guidelines refer to ‘intermittent’ as well as ‘continuous’ sedation. Recently, because of the lack of clarity in many reports, there’s been a trend towards limiting discussion to ‘deep continuous sedation until death’ (CDSUD) – the most contentious aspect of sedation near the end of life.
    Second, it may be correct that ‘the Doctrine of Double Effect (DDE) continues to shape much of the ethical and legal literature concerning end-of-life care’ (EOLC), but what about the medical literature? Would it surprise the authors if I say that, when a practicing clinician, I never agonized about ‘double effect’? As they noted, DDE was originally formulate...

    Show More
  • Fundamental values are not defeated by utilitarian calculus

    Utilitarian ‘ethics’, as employed in this article, implicitly rejects all absolute values and associated rights, allowing for limited transgression of rights (including the right to life) for the sake of contemporaneous ‘benefits’ outweighing the ‘costs’. I maintain that this is a self-defeating paradigm; without absolute values there is no objective measure of benefits and costs, therefore no rational basis for the judgement of proportionality. In short, the utilitarian argument is logically circular and vicious. Once the veneer of proportionality is revealed as objectively ungrounded, utilitarian ethics amounts to little more than a public relations strategy for legitimising arbitrary exercises of power.

    The argument from proportionality (benefits vs costs) cannot justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.

    1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).

    2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social op...

    Show More
  • Re: Vaccine mandates for healthcare workers beyond COVID-19

    While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in he...

    Show More
  • Some negatives of generative AI

    The article on the ethics of generative AI should be read in tandem with the recommendations on “Chatbots, ChatGPT, and Scholarly Manuscripts” issued by the World Association of Medical Editors (https://wame.org/page3.php?id=106).

    While acknowledging the positive contribution chatbots can make to the development of texts on ethics and other academic fields, I would cite a few key negatives:

    1) Chatbots like ChatGPT appear to be biased in favour of what they are proposing. This bias is evidenced in the references they provide, which uniformly support the point of view expressed by the chatbot. References opposing the point of view are not provided. This is probably inherent in the instructions in the algorithms applied by a chatbot, which must be along the lines of “provide an argument and supporting evidence”. No doubt this tendency to bias can be cured in future editions of the chatbot.
    2) Chatbots have been found to invent references where there are none. This is puzzling. Why did the programmers allow that? This should be an easy fix.
    3) Chatbots are only as up to date in their references as their programming (their “training”). For ChatGPT, the cut-off date is sometime in mid-2021 – anything that appeared later than their training material that is simply not in their universe. In fast-moving fields, thus, there is a strong risk that what is asserted in the chatbot’s output has been superseded by...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • Pharmacists and Assisted Suicide : Thoughts after reading "The Judgment of the German Federal Constitutional Court regarding assisted suicide: a template for pluralistic states? "

    Pharmacists are essential healthcare professionals and are critical members of the whole healthcare team. Pharmacists work in varied settings such as community and hospital, hospice/palliative care industry and regulatory affairs. Regardless of where pharmacists work, and whether their roles provide direct or indirect patient care, all pharmacists contribute to safe and quality health care. Pharmacists may hold roles in many specialty areas of a healthcare system including the emergency department, infectious disease, oncology, pain management and anticoagulation management (1).

    Although effective, medicines are often challenging to manage and use appropriately. This is due to a number of factors, such as increasingly complex pharmacotherapies, polypharmacy, ageing populations with multiple diseases, and limited, or inadequately coordinated resources in healthcare systems. While performing a medication review, many pharmacists work together with GPs/consultants to optimise the patient's pharmacotherapy and reduce the potential risks of polypharmacy. An example of an expected health related goal suggested by a patient during a medication review could be a desire to reduce pain. During the medication review, the patient’s pain medication could be optimised by a pharmacist to achieve this goal (1).

    Pharmacists are pivotal in the lethal drug medication use process. Assisted suicide(i.e. physician assisted) will not take place without the use of medicat...

    Show More
  • Not a (global) controversy

    This article addresses a critically important topic, but I would not classify it as a 'current controversy'. The UK Animal Welfare and Ethical Review Body (AWERB) task of 'helping to promote a culture of care within the establishment and, as appropriate, the wider community' includes supporting the wellbeing of animal technologists and care staff. There is a good level of understanding that the culture of care includes caring for staff, in the belief that people who are cared for will behave more compassionately towards animals, and that science, animal welfare and staff morale will all benefit [see references in 1]. The AWERB task of 'supporting named persons, and other staff dealing with animals, on animal welfare, ethical issues and provision of appropriate training' can also be interpreted as providing emotional support and ensuring staff feel competent, capable and confident with respect to humane killing.

    Outside the UK, the European Union working document on Animal Welfare Bodies and National Committees also discusses the importance of supporting staff and ensuring mutual respect as part of a good culture of care, including encouraging scientists to work with (and value the contribution of) animal technologists and care staff [2].

    In my experience of working with AWERBs, many of these were (and are) very mindful of the emotional loading exterted on staff who had to humanely kill animals because of the pandemic [3]. The i...

    Show More
  • 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.