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...
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 medications dispensed by pharmacists.
Prescribing > Dispensing > Administration
The two quotes below ( (a.) and (b.)) taken from Professor Urban Wiesin’s very stimulating article (2) will be of interest to pharmacists worldwide.
a. “Nobody can be forced to assist with suicide, this is also the case for physicians”.
b. “Doctors ought to have a role in assisted suicide, simply on considering the facts. No other profession can ………. recognise inadequate pain therapy better. No other profession can provide more adequate information about the options for medical treatment of an illness”.
The pharmacy profession worldwide is regularly excluded from conscientious objection provisions in legislation. This exclusion denies the dignity of pharmacists as human beings and their central role in medication use.
The following questions must be asked
• Are pharmacists less dignified/ less free than doctors?
• Are pharmacists lacking in a conscience/ are they robots?
• Is the complex role of pharmacists in assisted suicide not understood / purposely ignored / not visible?
• Are conscientious pharmacists valued by society / health systems/ other professions?
Pharmacists will be at the vortex of some of society’s most controversial moral dilemmas. Pharmacist are highly trained professionals with moral, ethical and legal accountability. The human rights and dignity of pharmacists must be recognised and protected.
(1) www.fip.org/file/4757 Patient safety .Pharmacists’ role in “Medication without harm” 2020. FIP. International Pharmaceutical Federation.
(2) Wiesing U The Judgment of the German Federal Constitutional Court regarding assisted suicide: a template for pluralistic states?Journal of Medical Ethics Published Online First: 11 June 2021. doi: 10.1136/medethics-2021-107233
Even when there is no reason to doubt the truth of what patients say, it does not necessarily follow that clinicians must do exactly what patients want despite the risks. Is Priest’s line of thought here, in part at least, analogous to that of Minerva (1) and therefore open to a similar critique as that of Saad (2) who coined the term Patient Preference Absolutism to describe such a position?
1. Minerva F. Cosmetic surgery and conscientious objection. Journal of Medical Ethics 2017;44:230- 233.
2. Saad T C Mistakes and missed opportunities regarding cosmetic surgery and conscientious objection Journal of Medical Ethics 2018;44:649-650
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...
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 issue of potential staff distress around using particular killing techniques, especially physical methods, is also frequently discussed by AWERBs. Further support for staff is forthcoming from the UK Institute of Animal Technology, which frequently produces materials and holds meetings and workshops to help its members develop resilience and deal with AUB.
However, I can believe that not all AECs, IACUCs etc worldwide are concerned with staff mental health (practice can also vary regarding achieving all the tasks between different AWERBs and AWBs), and it is a shame to think that mitigating AUB might be viewed as controversial by some.
I read with great attention and not a little emotion the short article of Clinical Ethics by SDTR [1]. The narrative and flat form fails to hide the author's strong ethical commitment. Few points, in my view, deserve a greater focus in the challenging and highly contributing considerations.
The core of this contribution is the question: “when as a hospitalised medically qualified patient, one sees fellow patients in difficulty, or deteriorating clinically, unnoticed by medical staff, the question of whether it is ethical to intervene arises”.[1]
The issue is complex and is very much about the mutual assistance that patients (may) give each other, as have often given each other, when confined to a hospital ward, on a desert island, in a prison, in a concentration camp, in a college. This aspect of natural solidarity, observable also in ethology in many animal species, even in captivity, can come into brutal contrast not so much with "education", which concerns cultural and social aspects of shared ethics, but more with "instruction", also intended as training and usual professional activity. Actually, impact of curricular studies of medicine on youngsters is complex, but seems to modify only some and limited aspects of previously acquired thoughts and feelings on health and disease. [2] Are there deontological appropriate rules of conduct for doctors that can be immediately contrary to elementary ethics? Regretfully yes, and without dist...
I read with great attention and not a little emotion the short article of Clinical Ethics by SDTR [1]. The narrative and flat form fails to hide the author's strong ethical commitment. Few points, in my view, deserve a greater focus in the challenging and highly contributing considerations.
The core of this contribution is the question: “when as a hospitalised medically qualified patient, one sees fellow patients in difficulty, or deteriorating clinically, unnoticed by medical staff, the question of whether it is ethical to intervene arises”.[1]
The issue is complex and is very much about the mutual assistance that patients (may) give each other, as have often given each other, when confined to a hospital ward, on a desert island, in a prison, in a concentration camp, in a college. This aspect of natural solidarity, observable also in ethology in many animal species, even in captivity, can come into brutal contrast not so much with "education", which concerns cultural and social aspects of shared ethics, but more with "instruction", also intended as training and usual professional activity. Actually, impact of curricular studies of medicine on youngsters is complex, but seems to modify only some and limited aspects of previously acquired thoughts and feelings on health and disease. [2] Are there deontological appropriate rules of conduct for doctors that can be immediately contrary to elementary ethics? Regretfully yes, and without disturbing the best systems with our considerations. The recent year 2020, and the current 2021, however, is placing us in front of problems related to the confinement of entire populations, with extreme isolation both for hospitalized patients and for patients in home quarantine. Actually, even patients with COVID-19 are never completely alone, but those who have the fortune, or misfortune, of having to stay in the hospital in recent months find around them as the only possible friends, to watch and, hopefully, to talk to, other equally unhappy patients. Relatives, friends and even the personal doctor, if there is one, are not allowed in for visiting and even for contributing, as more or less was usual everywhere. The patient's only connection with the outside world is a functioning smartphone.
Patients with COVID-19, or non-COVID-19 under current COVID-19 protective measures, stay alone in the hospital, and, at worst, die alone there. I do not want to talk about personal experiences, but I will only talk about the feelings of loved ones, or known ones or, simply, of my patients. The acute sense of injustice that patients and relatives feel concerns precisely this prolonged obligation to suffer and die alone.
The most directly related issue is that younger doctors are trained to proceed along stranded guidelines, which do not at all include interference from other patients, however much they are medically qualified. In general, it can also be justified, by medico-legal considerations: but what leaps to the eye is the annoyance of many doctors in having a patient who is too aware, and sometimes too impatient or with excessive demands for attention. All this seems to be tolerated, and not always, if the concerns and requests, or suggestions, refer to the patient himself: less so if they concern other patients. Perhaps it is an anthropological problem, or perhaps something else, but this situation is at least unusual in the hospitals that I know. Here, as an unwritten rule, nurses and doctors often if not always ask for the collaboration of the concurrently hospitalized health professional to monitor, as possible, on other patients. As always, it is requested to the more lucid and attentive patients in the same ward. Intervening in the diagnostic reasoning, even in urgency, of those who are on-duty is, of course, quite another thing. However, it must be done, without hesitation, gracefully and promptly. Usually our trainees learn to appreciate this real world school. If all this sounds excessive and difficult to implement in a context of ethical directives, it could be better received within a strategy of clinical risk analysis and management, with a focus to processes.
Guglielmo M. Trovato, MD
Professor of Medicine at the School of Medicine of the University of Catania (Italy)
References
1) Taylor-Robinson SD. Personal perspectives: having the time to observe the patient. J Med Ethics Epub ahead of print: [please include Day Month Year]. doi:10.1136/medethics-2020-107041
2) Trovato GM, Catalano D, Di Nuovo S, Di Corrado D. Perception of cultural correlates of medicine: a comparison between medical and non-medical students--the authoritarian health. Eur Rev Med Pharmacol Sci. 2004; 8:59-68. PMID: 15267119.
Tell me now, what would the Doctors and staff do in this situation if there wasn’t a supposed Covid diagnosis?
What is SOP ?
Why couldn’t they just follow that procedure with any and all PPE precautions?
I wouldn’t think they would just throw someone in that condition into a room full of equally suffering patients ?
Do they?
Somebody please explain this to me in Layman’s terms.
If these questions were already answered in the article then let me know, and I’ll do a closer read, but until then.....
Dear Editor,
having scanned the article by Julian S, philosopher in Oxford no less, in your journal's edition from Nov 2020 , I feel I need to comment: The mandate to prevent harm from others requires a reasonable amount of knowledge what the risk to self is. To use a narrative extract from an autoethnographic case study as example:
... what those people who experienced serious reaction to the covid vaccine are believed to have reacted to is an emulsifier called PEG -
polyethylenglycol which sounds harmless enough. I was tested for allergies comprehensively by a very thorough specialist in Ger in 1996
and that because of a series of very light reactions. I dare to assert that in the UK where I have lived for 20 years and worked in
multidisciplinary health settings, the first thing people would know about such an allergy would be if they suffered an anaphylactic shock.
Prior to that most people would only/at best have been prescribed cortisone.
I believe here enters what M. Fricker, UK philosopher in NY, calls epistemic injustice inherent in a system of health inequalities as prevalent in the UK and an approach to behaviourism in clinical practice I politely call blinkered. - So far my initial reaction to the article.
Coincidentally I then after I found the video interview where Dr Mary Ramsey for PHE declares the safety of vaccines, I felt prompted to do a little research and - surprise, surpri...
Dear Editor,
having scanned the article by Julian S, philosopher in Oxford no less, in your journal's edition from Nov 2020 , I feel I need to comment: The mandate to prevent harm from others requires a reasonable amount of knowledge what the risk to self is. To use a narrative extract from an autoethnographic case study as example:
... what those people who experienced serious reaction to the covid vaccine are believed to have reacted to is an emulsifier called PEG -
polyethylenglycol which sounds harmless enough. I was tested for allergies comprehensively by a very thorough specialist in Ger in 1996
and that because of a series of very light reactions. I dare to assert that in the UK where I have lived for 20 years and worked in
multidisciplinary health settings, the first thing people would know about such an allergy would be if they suffered an anaphylactic shock.
Prior to that most people would only/at best have been prescribed cortisone.
I believe here enters what M. Fricker, UK philosopher in NY, calls epistemic injustice inherent in a system of health inequalities as prevalent in the UK and an approach to behaviourism in clinical practice I politely call blinkered. - So far my initial reaction to the article.
Coincidentally I then after I found the video interview where Dr Mary Ramsey for PHE declares the safety of vaccines, I felt prompted to do a little research and - surprise, surprise: The first academic paper I found, from 2016, states that allergies to PEG are likely underdiagnosed.
See: https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0172-7
Would it be fair to say that, given Dr Ramsay's position she could or even should have known of these findings? If at least one of those points is answered in the affirmative, then we have here a situation where, I am inclined to argue, an overcoming of epistemic injustice is actively prevented. Trustworthiness of a public authority rests on credibility, and that, like 'following the science' means in my understanding weighing the evidence one can reasonably have access to - not denying it.
The author asserts that coercion to vaccinate is ethically analogous to mandatory seatbelts or the use of physical force to remove a dangerous substance from a child. This is a false analogy. Wearing seatbelts while driving or removing a dangerous toy from a child does not alter anyone’s individual constitution, but vaccines do, permanently, and with largely unknown long-term consequences. Vaccination is an intimate, deeply invasive and permanent medical procedure, not just a behavioural preference. The same flawed comparison could be used to support mandatory abortion or coercive organ harvesting if these procedures were deemed in the interest of public health: a repugnant conclusion.
Regarding seriousness of Covid-19 as a public health issue, the author ignores the fact that Covid-19 deaths are recorded in a non-standard way which precludes meaningful assessment of the true public health impact of this disease in comparison to other respiratory infections. Acording to the WHO https://www.who.int/classifications/icd/Guidelines_Cause_of_Death_COVID-... guidelines, “A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness [...] COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.” The Office of Nat...
The author asserts that coercion to vaccinate is ethically analogous to mandatory seatbelts or the use of physical force to remove a dangerous substance from a child. This is a false analogy. Wearing seatbelts while driving or removing a dangerous toy from a child does not alter anyone’s individual constitution, but vaccines do, permanently, and with largely unknown long-term consequences. Vaccination is an intimate, deeply invasive and permanent medical procedure, not just a behavioural preference. The same flawed comparison could be used to support mandatory abortion or coercive organ harvesting if these procedures were deemed in the interest of public health: a repugnant conclusion.
Regarding seriousness of Covid-19 as a public health issue, the author ignores the fact that Covid-19 deaths are recorded in a non-standard way which precludes meaningful assessment of the true public health impact of this disease in comparison to other respiratory infections. Acording to the WHO https://www.who.int/classifications/icd/Guidelines_Cause_of_Death_COVID-... guidelines, “A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness [...] COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.” The Office of National Statistics UK, for example, counts all mentions of Covid-19 on death certificates as Covid-19 deaths, irrespective of whether Covid-19 is the underlying cause of death (see Note 5 in the ONS Spreadsheet). https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... Due to this definition ambiguity, it is unclear how many people died from infection with SARS-CoV-19 as the underlying cause. On the other hand, judging by the excess deaths in UK due to respiratory illness, it is doubtful whether anyone would notice that there is a pandemic if not for the associated media campaign and the unprecedented, draconian counter-measures. The fact that Covid-19 is characterised as a serious global threat based on potentially misleading mortality statistics automatically disqualifies any ethical justification of coercive measures to vaccinate against Covid-19, due to potential disagreement about the alleged normative facts. On the other hand, I do agree with the author that mandatory seatbelts to prevent Covid-19 would be ethically permissible, although probably ineffective.
On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
I shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
ARISTOTLE ON DISTRIBUTIVE JUSTICE AND WOMEN
Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, th...
On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
I shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
ARISTOTLE ON DISTRIBUTIVE JUSTICE AND WOMEN
Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, the only difference is sex. Sex cannot of itself make a difference to the capacity or performance of voting—it involves a mere chromosomal or anatomical difference. Unless one could point to an inherent property that tracked with sex that affected ability to vote, then this violates Aristotle’s principle and is unjust discrimination.’2
Distributive justice, for Aristotle seems to be about treating like people rather than like cases alike. The focus, too, is on the distribution of burdens and benefits between different people of the same category or status rather than on the just treatment of people of different categories or statuses. Chroust and Osborn say of ‘Aristotle’s Conception of Justice’:
‘Justice and Equality, which for the purpose of comparison always presupposes a duality, requires, therefore, at least four different factors: namely, two conflicting claims and two claiming persons.6 should these two persons be of unequal rank they cannot be treated alike," for the principle of Equality demands that only equals be treated equally." In this sense Equality is always proportionate equality - that is to say, it is a form of Justice which allots burdens according to the individual's ability to carry them and accords sup- port in amounts which vary with the needs of the individuals - and is called "distributive Justice." ’3
Fundamental to Aristotle’s and, I would suggest, any tenable theory of distributive justice is the notion that when x is justly given to A but not to B, A (in some sense or other) merits or deserves to receive it more than or rather than B. This merit or desert consists in the nature of and relationship between A, B and x. For instance, Aristotle would contend that scarce flutes should be given to those who can play flutes rather than to those who cannot and to the best flute players rather than to the less talented ones if there are not enough flutes to provide to provide all citizens with one.
To the best of my knowledge, he did not ever say that flutes should be given to all the members of the category or categories of citizens which had the highest proportion of good flute players. Proxies for just criteria do not seem to feature in his scheme nor do they have an obvious logical place in any tenable theory of distributive justice. For instance, it would hardly be just or fair, no matter how efficient and expedient it might be if a lecturer gave grades to the essays of students on the basis of the social categories to which they belonged on the grounds that students in particular social categories tend to get particular grades.
One might readily assume that the example that Savulescu and Cameron give of discrimination on the basis of sex is Aristotle’s own one or, at the very least, one he would obviously agree with. This is not the case.
According to Stefan Gosepath, writing in the Stanford Encyclopedia of Philosophy:
‘When two persons have equal status in at least one normatively relevant respect, they must be treated equally with regard to this respect. This is the generally accepted formal equality principle that Aristotle formulated in reference to Plato: “treat like cases as like” (Aristotle, Nicomachean Ethics, V.3. 1131a10-b15; Politics, III.9.1280 a8-15, III. 12. 1282b18-23). Of course the crucial question is which respects are normatively relevant and which are not.’4
Not all people should be treated equally, according to Aristotle, but only those of equal status. He does not seem to regard men and women to be persons of equal status. The following are among his famous quotes about women:5
Aristotle, Politics: "[T]he male, unless constituted in some respect contrary to nature, is by nature more expert at leading than the female, and the elder and complete than the younger and incomplete."
Aristotle, Politics: "[T]he relation of male to female is by nature a relation of superior to inferior and ruler to ruled."
Aristotle, Politics: "The slave is wholly lacking the deliberative element; the female has it but it lacks authority; the child has it but it is incomplete."
In The Internet Encyclopedia of Philosophy, Wayne P. Pomerleau writes
‘Given natural human inequality, it is allegedly inappropriate that all should rule or share in ruling. Aristotle holds that some are marked as superior and fit to rule from birth, while others are inferior and marked from birth to be ruled by others. This supposedly applies not only to ethnic groups, but also to the genders, and he unequivocally asserts that males are “naturally superior” and females “naturally inferior,” the former being fit to rule and the latter to be ruled. The claim is that it is naturally better for women themselves that they be ruled by men, as it is better for “natural slaves” that they should be ruled by those who are “naturally free.” 6
BREAST SCREENING FOR CANCER AND UNJUST DISCRIMINATION
Savulescu and Cameron write:
‘Discrimination is not always unjust. If there is a morally relevant difference, it may be acceptable. The government invests millions in screening women for breast cancer, but not men, even though breast cancer does occur in men. The reason for this is that breast cancer is much more likely in women. So, you will save more lives with the limited resource the government has available for prevention and treatment of breast cancer if you (justly) discriminate between men and women in this way.
This is not sexist because there is a morally relevant difference sufficient to justify different treatment: the probability of developing breast cancer. However, if there were a better, more accurate proxy for breast cancer risk besides sex, say some genetic mutation, then to continue to discriminate on the basis of sex would be unjust, all else being equal.’7
It is certainly true that discrimination is not always unjust. However, it is not true that all discrimination that can be morally justified is not unjust. Discrimination requires not merely a moral justification but a moral justification of a particular sort in order to render discrimination just.
Justice pertains to the treatment of people rather than cases. For instance, to use an example of my own choosing, lecturers who are acting in their capacity as private citizens, are not morally obliged to treat other private citizens impartially when, say, they are inviting guests to a dinner party. They might, without acting unjustly, discriminate between them on the basis of their personal preferences and prejudices. However, when they are acting qua lecturers and, for instance, marking the essays of their students, they are morally obliged to do so impartially and to give the same marks to essays that are equally good and proportionately more or less marks to those that are proportionately better or worse.
Acting justly does not merely mean treating their students the same unless there is a moral justification for treating them differently. It means treating them differently only when the difference in treatment is morally justified by a corresponding and proportionate difference pertaining to the merits of the essays that are submitted by them. In other words, the allocation of different treatment, of, say, benefits and burdens, is just or unjust regardless of the consequences of that particular allocation. The virtue of distributive justice does not lie in the consequences of any particular distribution of burdens and benefits but in its appropriateness.
There is a difference between morally justifying an action or policy and morally justifying it as a just one. Justice is not the only moral virtue. For instance, taxation is necessary to finance the operations of the state. If, somehow, it is not possible to formulate and implement a just and fair system of taxation, it might be morally justifiable to collect the necessary taxes unjustly and unfairly. Similarly, in the dire extreme emergencies that wars and, possibly, pandemics, can create, unjust and unfair actions and policies might, arguably, be morally justifiable.
There is, of course, a difference between successful and unsuccessful attempted justifications. To offer a moral justification for an action or policy is not the same as actually morally justifying it.
Just as lecturers in their role as lecturers have a moral duty to treat their students as students impartially, and their students have a corresponding moral right to receive such impartial treatment, the state, its agencies and agents have a similar moral duty to treat all citizens impartially and they each have a moral right to receive such impartial treatment and equal due consideration. What such impartiality consists of is often debatable and typically non determinate. In many cases, for instance, with regard to general policy decisions such as whether and where to build particular roads and bridges or, say, whether or not to adopt particular foreign policies, it appears to have little if any practical political relevance. However, where the distribution of benefits and burdens which are individually consumed or borne is concerned, the significance of the matter and its practical relevance grow hugely.
As a matter of justice, in the distribution of burdens and benefits that are enjoyed or borne by individual citizens, the state, its agencies and agents have a moral duty to treat individual citizens impartially. The citizens individually have a moral right to receive such impartial treatment. This means treating them the same unless the differences in treatment between particular individual citizens is purposefully and consciously related to morally relevant and proportionate differences between them. It means too, I suggest, giving explicit and implicit request to receive such benefits and to be spared such burdens equal and appropriate consideration.
If some particular people are, say, known to have cancer of a particular sort, they have a need for treatment for it which other people are not known to have. They could reasonably be said to, in some sense, deserve to receive scarce appropriate treatment rather than those who are not known to have such a need. It would be plausible to say that it would be just to discriminate in their favour in the allocation of NHS health treatment that was appropriate to their needs.
However, it would not be just to allocate such treatment only to those people in some arbitrarily demarcated category – the ‘elderly’, for instance – which had the highest proportion of sufferers from cancer. To give such treatment to all members of such a category would be not be just. Proxy justice is not justice any more than fools’ gold is gold.
Screening for cancer in general or cancers in particular is not a need in the same sense that treatment for them is. Some people might have a psychological need of such screening but there is no obvious reason for restricting the allocation of the procedure solely to them. The real or supposed benefits of screening for breast cancer could be enjoyed by any and all citizens. People who are women, people who are men, people who are both and people who are neither might all get and can all suffer from the fear that they will get breast cancer. Each and all of them can have a legitimate interest in having and knowing the results of such a scan. In the planning of their own lives and with regard to the thoughts and feeling with those with whom they interact, this information can be, or seem to them to be, important. That a person belongs to a category that has few or, even, hardly any members who will get breast cancer need not make the results of a screen test for breast cancer of any less significance to that person.8,9
To restrict free NHS breast screening for cancer to women is unjust discrimination.10 The likelihood of saving more lives by devoting a particular amount of resources to the screening solely of women rather than, indiscriminately, to those who want to receive it might (or might not) be a moral justification of the discrimination but that would not automatically make it just. The differences in treatment are not justified as deserved differences. Similarly, to give higher marks to the essays of male or female students might, in some circumstances, have a morally desirable outcome. That might (or might not) morally justify the discrimination but it would not thereby render it just.
Suppose that it were discovered that the incomes of the fathers of students was a reliable proxy for the allocation of the likely worth of their essays. It would be very wrong to allocate marks to essays on such a basis rather than reading them no matter how accurate and cost-effective such a procedure turned out to be. We could not say that it was slightly just or as just as we could manage. Proxies might be useful with regard to expedience, but they have no proper role in the exercise of justice.
Similarly, too, the difference in treatment of elderly people by the state that is implied by the proposed selective lockdown policy of Savulescu and Cameron is unjust. The difference in treatment is not a deserved difference even if it were to be successfully morally justified on grounds other than justice.
We can typically choose to waive our moral rights to benefits that we are offered. Thus, for instance, women are not compelled to have free screening for breast cancer on the NHS. Burdens, penalties and punishments rather than benefits are compulsory and they are more usually more difficult to justify than the allocation of benefits. In this regard, a coercive selective lockdown of the elderly is fundamentally different from and even more morally abhorrent than a selective, sexually discriminatory distribution of NHS. Elderly people do not in any sense deserve such treatment any more than other people do no matter how beneficial Savulescu and Cameron suggest that it might be for the NHS or society in general.
If there is a second wave of COVID-19, infection, not all elderly people will catch it and not all of those who do will require intensive, scarce and expensive hospital treatment whether or not there is a lockdown of any sort. Similarly, not all of those who catch it and require intensive, scarce and expensive hospital treatment will be elderly. If all citizens should be treated the same unless they are more likely to require intensive, scarce and expensive hospital treatment if the catch Covid-19, it follows that, as a matter of justice, those who are likely to require such treatment should be treated differently. Not all who are elderly should be treated the same and not all who are non-elderly should be treated the same. Those who are elderly but would not require intensive, scarce and expensive hospital treatment should be treated differently from those who are elderly and would do so. The same can be said for those who are non-elderly.
However, it would be, in my view, unjust to lockdown those who would require intensive, scarce and expensive hospital treatment. They do not deserve to be treated thus differently to obviate their need for such treatment. If we want to deviate from the principle of the allocation of NHS treatment on the basis of medical need, we should do so without selectively prohibiting potentially needy people from coming and going from their homes as they please.
The argument of Savulescu and Cameron which I have considered is unconvincing. It is based on an under-developed, underspecified and implausible account of distributive justice.
REFERENCES
1 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
7 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
8 McLachlan HV. A proposed non-consequentialist policy for the ethical distribution of scarce vaccination in the face of an influenza pandemic. J Med Ethics May 2012, 38 (5) 317-318.
9 McLachlan HV. On the random distribution of scarce doses of vaccine in response to the threat of an influenza pandemic: a response to Wardrope. J Med Ethics Feb 2015, 41 (2) 191-194.
10 As my wife, Sheila, has pointed out to me, the allocation of breast screening in the UK is also unjustly ageist.
While the authors are right to conclude that any compulsory medical intervention/vaccination could only be justified if the intervention is safe, effective, proportional and necessary, the moral dilemma really only starts here.
Who should have the right to determine what is proportional and necessary? Furthermore, the safety and efficacy in themselves will be disputed. We know this from existing vaccine controversies that lead parents to decline vaccines for their children. They do not trust the data produced by the manufacturers and they do not trust anyone who has industry funding or other potential conflicts of interest. Clearly the only reason why a parent would decline a medical intervention is because they fear that it could harm their child.
Although a Covid19 vaccine would not mainly be aimed at children, as in routine childhood immunisations, but at everyone, the question of safety and efficacy remains and invariably determines the question of proportionality as well. In fact it will be even more difficult, due to the shorter development times, shorter trial lengths and shorter follow-ups we can expect, as well as the limited time the virus is expected to be around in sufficient parts of the population that would allow for meaningful field trials.
Safety and efficacy have always been at the heart of the debate. We know from our work with parents at Consent (https://consent-charity.org.uk) that any...
While the authors are right to conclude that any compulsory medical intervention/vaccination could only be justified if the intervention is safe, effective, proportional and necessary, the moral dilemma really only starts here.
Who should have the right to determine what is proportional and necessary? Furthermore, the safety and efficacy in themselves will be disputed. We know this from existing vaccine controversies that lead parents to decline vaccines for their children. They do not trust the data produced by the manufacturers and they do not trust anyone who has industry funding or other potential conflicts of interest. Clearly the only reason why a parent would decline a medical intervention is because they fear that it could harm their child.
Although a Covid19 vaccine would not mainly be aimed at children, as in routine childhood immunisations, but at everyone, the question of safety and efficacy remains and invariably determines the question of proportionality as well. In fact it will be even more difficult, due to the shorter development times, shorter trial lengths and shorter follow-ups we can expect, as well as the limited time the virus is expected to be around in sufficient parts of the population that would allow for meaningful field trials.
Safety and efficacy have always been at the heart of the debate. We know from our work with parents at Consent (https://consent-charity.org.uk) that any medical intervention to which they do not give their voluntary and informed consent comprises a huge emotional conflict; one which can become almost an existential threat, psychologically, if they feel forced into allowing or accepting a medical intervention which they have, rightly or wrongly, come to believe to be dangerous. One can imagine the resistance this will induce. People will consider deregistering children from schools and giving up their careers in order to avoid the perceived threat.
How do we address this questions of safety? How can people be made to trust the data? Do we have a moral right to mandate, if we have made no effort to convince? Are we willing to do what it takes? In the long term the answer may well have to be a completely independent body to conduct trials, independent both of industry and politics.
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 MoreEven when there is no reason to doubt the truth of what patients say, it does not necessarily follow that clinicians must do exactly what patients want despite the risks. Is Priest’s line of thought here, in part at least, analogous to that of Minerva (1) and therefore open to a similar critique as that of Saad (2) who coined the term Patient Preference Absolutism to describe such a position?
1. Minerva F. Cosmetic surgery and conscientious objection. Journal of Medical Ethics 2017;44:230- 233.
2. Saad T C Mistakes and missed opportunities regarding cosmetic surgery and conscientious objection Journal of Medical Ethics 2018;44:649-650
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 MoreI read with great attention and not a little emotion the short article of Clinical Ethics by SDTR [1]. The narrative and flat form fails to hide the author's strong ethical commitment. Few points, in my view, deserve a greater focus in the challenging and highly contributing considerations.
Show MoreThe core of this contribution is the question: “when as a hospitalised medically qualified patient, one sees fellow patients in difficulty, or deteriorating clinically, unnoticed by medical staff, the question of whether it is ethical to intervene arises”.[1]
The issue is complex and is very much about the mutual assistance that patients (may) give each other, as have often given each other, when confined to a hospital ward, on a desert island, in a prison, in a concentration camp, in a college. This aspect of natural solidarity, observable also in ethology in many animal species, even in captivity, can come into brutal contrast not so much with "education", which concerns cultural and social aspects of shared ethics, but more with "instruction", also intended as training and usual professional activity. Actually, impact of curricular studies of medicine on youngsters is complex, but seems to modify only some and limited aspects of previously acquired thoughts and feelings on health and disease. [2] Are there deontological appropriate rules of conduct for doctors that can be immediately contrary to elementary ethics? Regretfully yes, and without dist...
Tell me now, what would the Doctors and staff do in this situation if there wasn’t a supposed Covid diagnosis?
What is SOP ?
Why couldn’t they just follow that procedure with any and all PPE precautions?
I wouldn’t think they would just throw someone in that condition into a room full of equally suffering patients ?
Do they?
Somebody please explain this to me in Layman’s terms.
If these questions were already answered in the article then let me know, and I’ll do a closer read, but until then.....
Thank You
Dear Editor,
Show Morehaving scanned the article by Julian S, philosopher in Oxford no less, in your journal's edition from Nov 2020 , I feel I need to comment: The mandate to prevent harm from others requires a reasonable amount of knowledge what the risk to self is. To use a narrative extract from an autoethnographic case study as example:
... what those people who experienced serious reaction to the covid vaccine are believed to have reacted to is an emulsifier called PEG -
polyethylenglycol which sounds harmless enough. I was tested for allergies comprehensively by a very thorough specialist in Ger in 1996
and that because of a series of very light reactions. I dare to assert that in the UK where I have lived for 20 years and worked in
multidisciplinary health settings, the first thing people would know about such an allergy would be if they suffered an anaphylactic shock.
Prior to that most people would only/at best have been prescribed cortisone.
I believe here enters what M. Fricker, UK philosopher in NY, calls epistemic injustice inherent in a system of health inequalities as prevalent in the UK and an approach to behaviourism in clinical practice I politely call blinkered. - So far my initial reaction to the article.
Coincidentally I then after I found the video interview where Dr Mary Ramsey for PHE declares the safety of vaccines, I felt prompted to do a little research and - surprise, surpri...
The author asserts that coercion to vaccinate is ethically analogous to mandatory seatbelts or the use of physical force to remove a dangerous substance from a child. This is a false analogy. Wearing seatbelts while driving or removing a dangerous toy from a child does not alter anyone’s individual constitution, but vaccines do, permanently, and with largely unknown long-term consequences. Vaccination is an intimate, deeply invasive and permanent medical procedure, not just a behavioural preference. The same flawed comparison could be used to support mandatory abortion or coercive organ harvesting if these procedures were deemed in the interest of public health: a repugnant conclusion.
Regarding seriousness of Covid-19 as a public health issue, the author ignores the fact that Covid-19 deaths are recorded in a non-standard way which precludes meaningful assessment of the true public health impact of this disease in comparison to other respiratory infections. Acording to the WHO https://www.who.int/classifications/icd/Guidelines_Cause_of_Death_COVID-... guidelines, “A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness [...] COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.” The Office of Nat...
Show MoreThis study, https://doi.org/10.1126/scitranslmed.3006175, showed that the placebo effect still worked when patients were informed that they were receiving the placebo.
If this is generally true, there is no need to move from honesty.
On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
Show MoreI shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
ARISTOTLE ON DISTRIBUTIVE JUSTICE AND WOMEN
Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, th...
While the authors are right to conclude that any compulsory medical intervention/vaccination could only be justified if the intervention is safe, effective, proportional and necessary, the moral dilemma really only starts here.
Who should have the right to determine what is proportional and necessary? Furthermore, the safety and efficacy in themselves will be disputed. We know this from existing vaccine controversies that lead parents to decline vaccines for their children. They do not trust the data produced by the manufacturers and they do not trust anyone who has industry funding or other potential conflicts of interest. Clearly the only reason why a parent would decline a medical intervention is because they fear that it could harm their child.
Although a Covid19 vaccine would not mainly be aimed at children, as in routine childhood immunisations, but at everyone, the question of safety and efficacy remains and invariably determines the question of proportionality as well. In fact it will be even more difficult, due to the shorter development times, shorter trial lengths and shorter follow-ups we can expect, as well as the limited time the virus is expected to be around in sufficient parts of the population that would allow for meaningful field trials.
Safety and efficacy have always been at the heart of the debate. We know from our work with parents at Consent (https://consent-charity.org.uk) that any...
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