eLetters

465 e-Letters

  • Withdrawal and Withholding treatment in terminal illness: Islamic Perspective

    Withdrawal and Withholding treatment in terminal illness:
    Islamic Perspective

    Withholding or withdrawing life support is still an area of controversy. Its applicability is weighed with benefits and risks, and how futile the treatment is for the terminally ill patient.
    Unfortunately, many elder patients with chronic illness spend their last few weeks or months in hospitals. Life support is not required if it prolongs the agony and suffering associated with final stages of a terminal illness. When considering end-of-life decision making, both withholding and withdrawing life support are considered to be ethically equivalent. (1)
    Issues arising from the withdrawal and withholding treatment have not reached total consensus amongst the Muslim jurists. However, article 63 of the Islamic code of medical ethics
    (Code of Conduct1981) stated that, “the treatment of a patient can be terminated if a team of medical experts or a medical committee involved in the management of such patient are satisfied that the continuation of treatment would be futile or useless.” It further stated that “treatment of
    patients whose condition has been confirmed to be futile by the medical committee should not be commenced.” (2,3)
    The Permanent Committee for Research and Fatwa, Fatwa (Decree) No. 12086 (1989) is a landmark in regulating resuscitative measures, stopping of machines in cases thought to be not suitable for resuscitative measures. The decision shou...

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  • Ethical challenges in Scarce Resources Allocation in COVID-19 pandemic: Western and Islamic views

    We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
    The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
    During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
    Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
    Priority for limited resource...

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  • A LESSON TO BE LEARNT? HOW THE COVID-19 PANDEMIC COULD HAVE A POSITIVE IMPACT ON JUNIOR DOCTORS’ ETHICAL DECISION-MAKING.

    We were interested to read Corfield et al’s recent article on Foundation doctors’ confidence in dealing with ethical issues in the workplace(1), which felt particularly relevant to us – a fourth-year medical student and a Foundation doctor. The importance of medical law and ethics (MEL) has been emphasised by the current COVID-19 pandemic. Difficult decisions with complex ethical implications have had to be made at both clinical and managerial levels across the health service.

    Suddenly, junior doctors’ preparedness to deal with ethical dilemmas is framed in a new light. We took particular note of Corfield et al’s concluding remark which highlights the need for a supportive environment which fosters liberal discussion of ethical queries(1). It is well documented that the presence of rigid hierarchies within the clinical environment can deter junior doctors from raising uncertainties(2-4), a phenomenon likely to extend to those of an ethical nature.

    The COVID-19 pandemic represents an unprecedented challenge for medics regardless of their level of seniority, which has engendered a feeling of common endeavour with far-reaching consequences for practice. Interestingly, discussions with colleagues have echoed our perception that these changes have precipitated a less pronounced sense of hierarchy. This in turn has the potential to facilitate more open discussion of ethical issues including those generated by the crisis. In relation to the authors’ findings(1),...

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  • Complicating Condom Use in Casual Sex Encounters

    Dear editor,

    Shahvisi offers cogent arguments for men taking primary responsibility for unwanted pregnancy (1). I do not, in this letter, aim to argue against her conclusion. However, when discussing potential counterarguments to this position, she mentions that it is claimed that perhaps women would not trust men to use long-acting reversible contraceptives (LARCs). Shahvisi does well to point out the relevant data that reveals women in longer term relationships would, in fact, trust their partners to use LARCs (2,3). Yet in discussions of casual sexual encounters, she merely asserts that ‘barrier methods are in any case preferable’(1).

    I argue this is not trivially the case. The use of barrier methods is highly inconsistent, particularly in casual sex (4–8). Despite their role in preventing both sexually transmitted infections (STIs) and unwanted pregnancy, I would argue that this data shows that people’s condom preferences are not so clear cut. Preference for condom use is heterogenous and is tied to desires more abstract than seeking to prevent pregnancy, such as the desire to feel masculine or ‘clean’ (8). Additionally, condoms, the most popular barrier method, are 86% effective at preventing unwanted pregnancy in typical use (9). LARCs are more than 99% effective (10).

    It is my view that defeating the argument that women would not trust men to use LARCs in casual sexual relations thus needs more work. One argument might be that, in a world where...

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  • Looking after the carers: Front line clinicians fear for themselves and their families

    The COVID 19 pandemic piqued my interrogation of the balance of staff safety and duty of care to imperilled communities.

    Front line clinicians fear for themselves and their families. Despite our valorization by communities, I as a frontline emergency specialist have noticed a surge in absenteeism among well nursing staff that claim “mental health days off” to avoid catching corona and spreading it their kids. Their defence of fraudulently claimed sick paid leave is not risking passing on the corona-contagion to young children when they return from school or day care (they remain open in Australia).

    One commented that as non-parent, I should take up additional burden of COVID19 health care presentations. This increases the number of my daily encounters with, and the cross-infection risk posed by, patients being screened or treated for corona. Without the nurse, I now take every throat swabs as the patient coughs or gags. There are no hospital contingency plan to make up for unplanned shortfalls in clinical staff. “No kids at home sacrificed” clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our well colleagues that refuse to turn up for work.

    How do you cope if an epidemic disrupted daily life, closing schools, packing hospitals, and putting social gatherings, sporting events and concerts, conferences, festivals and travel plans on indefinite hold? As a frontline doctor, stayi...

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  • Pharmacists , 'unavoidable person beliefs' and Freedom of Conscience

    In Ireland, the Health (Regulation of Termination of Pregnancy) Act 2018 provides 'conscientious objection' for doctors and nurses (and their students and trainees). Conscientious objection under this legislation is not provided for pharmacists, pharmacy students or any other healthcare staff. The Irish state does not respect my inalienable human right to freedom of thought, conscience and religion, in this matter. My 'unavoidable personal beliefs' are unrecognised. As a pharmacist my dignity is not respected in the same way that the dignity of doctors and nurses and their students/trainees is respected in the Act.

    As an Irish pharmacist I am deeply concerned at the challenge to my right to freedom of conscience and consequently my dignity as a human being. The Irish State must ensure that I as a human being and a pharmacist can enjoy my human and constitutional right to freedom of thought, conscience, religion or belief on the basis of respect for my inherent human dignity. Pharmacists (and others) can have 'unavoidable personal beliefs'.

    The right to conscientious objection is not only based on the right to “freedom of conscience”, but also on Article 1 of the Universal Declaration of Human Rights which recognizes that all human beings “are endowed with reason and conscience.” This includes pharmacists.

  • What is a religious exemption?

    In his 2013 comprehensive and scholarly review, John Grabenstein (What the World's religions teach, applied to vaccines and immune globulins - https://doi.org/10.1016/j.vaccine.2013.02.026) noted that there are no scriptures associated with any of the World's major religions (Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam) that prohibit vaccines or vaccination. So no grounds for religious exemption can exist, because vaccines and vaccination do not contravene any religious code.

  • In response to: Confused out of care: unanticipated consequences of a ‘Hostile Environment’

    Glennerster and Hodson should be congratulated on their paper tackling a very important and sensitive issue (1). They have performed a thorough analysis of legal landscape with its consequences. I feel however, that their analysis of ethical implications is lacking. Also, doctors unintentionally become second victims in this paper, appearing as those who do not care.

    The United Kingdom is sadly not the only state that chose to pursue a “hostile environment” policy directed towards refugees and other migrants. Readers may recall the recent story of the Spanish humanitarian ship Open Arms who having rescued migrants in the Mediterranean Sea was denied entry into Malta and Italy (2). The rescue ships face fines of one million euros if they enter Italian coastal waters without prior permission under new legislation. Another sad example comes from Hungary, famous for building a fence along its border to keep out refugees and the toxic “Stop Soros” bill (3). A created hostility is not only a threat to life and health, but also a threat to our humanity. By ignoring vulnerability of refugees well described by the 1951 Convention (4), of which incidentally the UK is a signatory, we collectively threaten the very concept of dignity inherent in our humanity. A Polish writer and philosopher Stanisław Lem, once reflected on the roots of Holocaust perpetrated by the Nazi regime (5). He asserted that there occurred a complete reversal of moral compass for the German society. Cle...

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  • The challenge of pain

    Dear Editor,

    What stood out most for me about the findings of the paper by Derbyshire and Bockmann is that whatever our moral stance on abortion, there appears to be neuroscientific evidence that supports the distinct possibility of fetal pain before 24 weeks gestation. These findings challenge the common assumption that pain is mostly a “reflective” experience by including unreflective pain as worthy of reasonable concern (as in the case of animal pain). That consideration is one relevant factor which needs to feed into our reflections on how or whether certain abortions will be carried out.

    The RCOG in its latest report on fetal pain concluded that “The experience of pain needs cognitive, sensory and affective components, as well as the necessary anatomical and physiological neural connections.” (1) Years before, along the same lines, the House of Commons Science and Technology Committee reported that “while the evidence suggests that foetuses have physiological reactions to noxious stimuli, it does not indicate that pain is consciously felt, especially not below the current upper gestational limit of abortion...these factors may be relevant to clinical practice but do not appear to be relevant to the question of abortion law.”(2) Professor Derbyshire was a member of the Working Party which put this document together and was a key witness before the STC Committee but now, in light of his researches, rejects these confident conclusions.

    In the light...

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  • Induced Abortion and Fetal Pain

    Dear Editor,

    Understanding the complexity of induced abortion in context of society, culture, health and religion is a domain that should be explored. Many studies have reported ethical consideration of this issue which may be related to parenthood, rights of the fetus and mother, harms/benefits to the fetus and mother involved in abortion of the fetus.

    Fetal pain should always be put into consideration before deciding on fetal interventional procedures or deciding on aborting the fetus after 13 weeks of gestation and proper anaesthesia/analgesia should be given to the pregnant woman undergoing the procedure. The knowledge about the concept of fetal pain is important and the neurological aspects of the pain perception of the fetus should be known.

    Reference:
    1. Bandewar S. Exploring the ethics of induced abortion. Indian journal of medical ethics. 2005 Jan;13(1):18-21.
    2. Um YR. A study of the ethics of induced abortion in Korea. Nursing ethics. 1999 Nov;6(6):506-14.
    3. Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA. Fetal pain: a systematic multidisciplinary review of the evidence. Jama. 2005 Aug 24;294(8):947-54.

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