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.
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.
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.
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.
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
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.
---- https://pubmed.ncbi.nlm.nih.gov/10557112/
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...
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.
---- https://pubmed.ncbi.nlm.nih.gov/10557112/
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 procedures in all these areas are put forward. The proposals for the United Kingdom would meet the requirements of the European Convention on bioethical research and the recent government consultation paper on medical treatment and research in incompetent adults.
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),...
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), junior doctors who are either underprepared or overconfident when it comes to ethical reasoning, will each be more likely to be exposed to such discussion, leading to better ethical decision-making overall.
This could represent an important learning opportunity to be taken forward over the coming months, one that could promote more confidence and competence amongst Foundation doctors when tackling MEL issues.
References
1. Corfield L, Williams RA, Lavelle C, Latcham N, Talash K, Machin L. Prepared for practice? UK Foundation doctors’ confidence in dealing with ethical issues in the workplace. Journal of Medical Ethics. 2020 Apr 10.
2. Brennan PA, Davidson M. Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up. Bmj. 2019 Jul 2;366:l4461.
3. Care Quality Commission. Opening the door to change: NHS safety culture and the need for transformation. 19 Dec 2018. www.cqc.org.uk/openingthedoor.
4. Srivastava R. Speaking up—when doctors navigate medical hierarchy. New England Journal of Medicine. 2013 Jan 24;368(4):302-5.
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.
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...
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 any society and it is not a feature that is taken into account from the liberal perspective. The recognition of universal vulnerability suggests that the autonomy model will have to re thought (4).
Ethics has not paid attention to vulnerability for three possible reasons (5):
• Vulnerability is the antithesis of the individualistic ethics predominating in Western societies.
• Vulnerability is not addressed in ethics because philosophy ignores the body.
• Ethics has been prominently rationalist and therefore feelings have been displaced or have not been taken into account.
It is methodologically important not to define certain groups as (not) vulnerable by default (2). There are many potential sources of vulnerability, and each of these constitutes a different, overlapping layer. This metaphor of layers presents a contextual and variable concept of vulnerability, moving away from the fixed and static view (6). The vulnerability of professionals e.g. pharmacists remains invisible as it does not correspond with their social position. The sufferings (existential and moral) of pharmacists in particular are invisible, denied and ignored in the euthanasia/assisted suicide debates.
All forms of euthanasia and physician assisted suicide require lethal medications. The role of pharmacists in the pharmaceutical care/medication use process at the end of life is often ignored, written out or overlooked. In the main doctors and nurses are included in “conscientious objection” legislative protections. Pharmacists are often excluded from protection of their human right to freedom of conscience and the derived right of “conscientious objection”. Pharmacists in all working environments (pharmaceutical industry , community pharmacy, hospital pharmacy, palliative care pharmacy, long term care, care of people with disabilities including intellectual disabilities, general practice pharmacists, etc. ) will be part of the process (7).
We can understand our humanity in a broader sense only by recognizing our universal vulnerability and interdependence (8). Pharmacists and their patients and colleagues are vulnerable and autonomous. The end of life medication use process (natural death or intentional death ) is dependent on the involvement and expertise of pharmacists. Failure to recognise this makes individual pharmacists and the pharmacy profession vulnerable.
References
1. Liamputtong, P. Researching the Vulnerable: A Guide to Sensitive Research Methods; SAGE: London, UK; Thousand Oaks, CA, USA, 2007; 246p.
2. Societies 2020, 10(1), 5; https://doi.org/10.3390/soc10010005
3. Fineman, Martha A., The Autonomy Myth: A Theory of Dependency, New York, The New Press, 2004.
4. Rodriguez, Janet Delgalo. The Relevance of the Ethics of Vulnerability in Bioethics. The Ethics Forum. Volume 12, Issue 2–3, Automne 2017, p. 154–179 https://doi.org/10.7202/1051280
5. Hoffmaster, Barry, “What Does Vulnerability Mean?”, Hastings Center Report, vol. 36, no. 2, 2006, pp. 38-45.
6. Luna, Florencia, “Vulnerabilidad: la metáfora de las capas”, Jurisprudencia Argentina, IV, 1, 2008, pp. 60-67.
7. Flood, Bernadette. Pharmacists and assisted dying. BMJ 2020 https://www.bmj.com/content/368/bmj.m1139.full
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...
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 should be based on medical criteria and decided by at least three competent physicians. The family should be approached and the facts discussed fully with them. (4,5)
Mohiuddin et al stated that while the notions of futility greatly impact the bioethical discourse regarding withholding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. The justifying conditions appear to rely on physician assessment of the clinical
prognosis. (6)
• Hassan Chamsi-Pasha, Consultant Cardiologist, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
• Other Contributors:
o Majed Chamsi-Pasha, Senior Registrar, Internal Medicine.
o Mohammed.A. Albar, Director of Medical Ethics Center, International Medical Center.
References:
1. Al-Bar MA, Chamsi-Pasha H. Contemporary bioethics: Islamic perspective. New York
(NY): Springer; 2015.http://link.springer.com/book/10.1007/978-3-319-18428-9
2. Kassim, P. N., & Adeniyi, O. B. (2010). Withdrawing and withholding medical treatment: A comparative study between the Malaysian, English and Islamic law. Medicine and Law, 29(3), 443–461.
3. Code of Conduct drawn at the International Conference on Islamic Medicine held in Kuwait, 1981, known as “The Islamic Code of Medical Ethics,” p 67
4. Permanent Committee for Scholarly Research and Ifta. (1989). Ruling on resuscitating the patient if he is dead, his health condition is not fit for resuscitation or his disease is incurable. Fatwa number 12086. http://www.alifta.net/Fatawa/FatawaChapters.aspx?View=Page&PageID=299&Pa....
5. Chamsi-Pasha H, Albar MA. Ethical Dilemmas at the End of Life: Islamic Perspective. J Relig Health. 2017;56(2):400‐410. doi:10.1007/s10943-016-0181-3
6. Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth. 2020;31(1):29‐46. Published 2020 Mar 22. doi:10.1080/11287462.2020.1736243
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 MoreOne 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.
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.
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...
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.
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
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.
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https://pubmed.ncbi.nlm.nih.gov/10557112/
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...
Show MoreWe 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),...
Show MoreWhile 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...
Show MoreThe 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...
Show MoreWithdrawal 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.
Show MoreUnfortunately, 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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