To the Editor:
It is crucial that hospital staff have ready access to background health
care information about patients who come into their care -- including end-
of-life care preferences -- that allow better decisions to be made.
However, it is important to incorporate the reality that chronically ill
and debilitated patients can at best, only achieve a return to the level
of health or function they had before they becam...
To the Editor:
It is crucial that hospital staff have ready access to background health
care information about patients who come into their care -- including end-
of-life care preferences -- that allow better decisions to be made.
However, it is important to incorporate the reality that chronically ill
and debilitated patients can at best, only achieve a return to the level
of health or function they had before they became really sick. If they
were previously housebound with significant cognitive impairment, I would
be reluctant to start aggressive treatment and then have to deal with the
difficult decision of whether to continue. To do everything for a non-
communicating bed-ridden patient confers legal protection to the treating
team but does the patient fearful of meeting his maker a gross disservice.
Such measures prolong physiological viability at the expense of meaningful
life.
Unlike the inhumanely excessive and overly aggressive treatment
demanded by desperate patients, and complied with by the ICU, there is
often all-round agreement that symptom alleviation, with a focus on pain
reduction, maximising physical comfort and support of the psychological
well-being of both patient and family, is the clinically rational and
humane course to pursue. Before the acute worsening, and in consultation
with their usual treating physician, partners, children and families will
have had to opportunity to discuss and contemplate at length a fundamental
shift of objective to comfort care, preservation of dignity and symptom
palliation.
There is usually time to come to a realization that premorbid or
disease-related quality of life is poor and more aggressive treatment
would be futile. Most of us believe that dying at an old and infirm age
is not something to be raged against or resisted at all cost. For all of
us and every day, life dies at a varied pace. Some race into the abyss of
oblivion and the healthy are inching towards the precipice. Alastair Reid
yields a truthful rebuttal to Dylan Thomas' "Do not go gentle into that
good night." "Curiosity", alluding to a cat's nine lives and a dog's
contentment with its allocated years, is an enjoinder to life as the
prelude to death.
"...to tell the truth; and what cats have to tell
on each return from hell
is this: that dying is what the living do,
that dying is what the loving do,
and that dead dogs are those who never know
that dying is what, to live, each has to do."
We need to bear in mind Kafka's "The meaning of life is that it
stops." The question arises of health resources wasted in futile clinical
care being made available elsewhere, and the substantial opportunity costs
entailed in expensively futile critical care.
The algorithm for equitable distribution of expensive health care
should include probability of meaningful survival, quality adjusted life
years of remaining alive from medical treatment, and the loss of scarce
critical care beds to a competing patient with better prognosis.
To the Editor:
The rights to unrestrained free speech in Australia, including the
abolition of the ban on hate speech in the Racial Discrimination Act that
makes it it unlawful to "offend, insult, humiliate or intimidate" a person
or group on the basis of their "race, colour or national or ethnic
origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for
the rece...
To the Editor:
The rights to unrestrained free speech in Australia, including the
abolition of the ban on hate speech in the Racial Discrimination Act that
makes it it unlawful to "offend, insult, humiliate or intimidate" a person
or group on the basis of their "race, colour or national or ethnic
origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for
the recently arrived, with children at higher risk of its long-term
adverse effects. As a child growing up in 1980s Australia, I was daily
branded ''ching chong Chinaman''. As an intern in the early 1990's, I
looked after the child of a fellow student who had repeatedly hurled
racial abuse and spat at me as I left for home from school on the bus.
During the week of typhoon Haiyan in late 2013, a man mimicked paddling a
kayak to a Filipino colleague while heckling him to ''row back to where
you came from''. A would-be parliamentarian declared that asylum seekers
were clogging up traffic in western Sydney in the lead up to our most
recent Federal Elections (2013).
None of these personal or very public instances of race-based
vilification were taken seriously enough to court on the basis of injury
to reputation and defamation. The effort and expense required to
instigate and follow through legal proceedings compels most non-majority
non-white Australians to take such insults and threats on the chin. This
aids and abets strong electoral support for Australia's already curtailed
foreign aid to be redirected from Indonesia if it did not allow boats to
be turned away from Australian shores. The inhumane treatment of asylum
seekers remains the biggest elephant in the room, racial prejudice
implemented in a systematic rollout.
How is an immigrant child to deal with unbridled permission to
express hateful abuse? Would its vehemence not be seared into his soul,
just as the vilification 30 years ago at a bus stop remains fresh and
alive in my memory? I am all for free speech, but racially motivated abuse
is threatening and hurtful to the progress of hardworking minorities who
just want to make a go of it in a new country.
Getting your message across to a patient and their family is
difficult and fraught with misunderstanding. Aside from not having enough
time and patience to explain complex diagnoses and sophisticated treatment
plans as well as ensuring that understanding has occurred, English may not
be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder
whether a family member or a p...
Getting your message across to a patient and their family is
difficult and fraught with misunderstanding. Aside from not having enough
time and patience to explain complex diagnoses and sophisticated treatment
plans as well as ensuring that understanding has occurred, English may not
be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder
whether a family member or a professional interpreter is capably relaying
acute concerns and nuances of complicated discussions to patients from a
non-English speaking background. The medical team cannot be sure that
questions posed by a patient in return are being faithfully rendered.
As communication is an iterative and interactive process, far more is
"lost in translation" in health care encounters when the several spoken
languages are necessary. Body language can be misinterpreted, with cross-
cultural diversity in health-seeking behavior and beliefs pose further
obstacles to effective communication.
There is no doubt that the ethical, moral and legal quandaries of
whether to withdraw ventilator-support from a child and pregnant adult
clearly dependent on machine-assisted breathing are stressful for, indeed
provoke strong emotions in, families and critical care staff.
Ongoing physiological support as decisions on treatment withdrawal
are being deliberated in courts of law necessarily delay the availability
of scarce intensive care beds to other seriously ill or injured patients
with far better prospects of meaningful recovery. These patients cannot
afford to wait for all-round resolution between families, clinicians and
courts. Surely the high cost of intensive care and the diversion of
hundreds of thousands of dollars from other health care programs bears
serious thought even in times of immense crisis. The health system cannot
afford the thousands of dollars spent each day in the support of a brain-
stem damaged person for whom futility is the eventual outcome. In the
unlikely event that one is weaned off the ventilator, the patient is still
condemned to full nursing care for the rest of her natural life.
I recently cared for an elderly man who had sustained a large brain
hematoma. The son, who had cared for an ailing father for years, stroked
his shock of white hair as he declined neurosurgical treatment on his
father's behalf. As he tearfully looked upon the face of his
uncomprehending father, the son was unwavering in his refusal. He believed
that the great man his father had once been was no longer there. We agreed
that surgery was not going to change that and they went home.
A truthful rendition of diagnosis, treatment and prognosis, as well
as ensuring that the family has understood, were necessary for my
patient's son to confidently make a decision aligned to his father's
wellbeing and priorities. My job was easier without the self-imposed
burden of trying to dictate treatment trajectory. I was satisfied that I
had not, by deception or persuasion, imposed what I believed to be in the
best interest of the patient. Doctors are human after all, with even our
most well-intentioned recommendations susceptible to the the beliefs and
values we hold dear.
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying...
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying more generally, wherever
intractable severe mental distress pertains. This point is also made by
psychiatrist Colin Brewer in his letter in response to the paper [1].
In establishing the case that patients with depression should not
necessarily be considered incompetent, Schuklenk and van der Vathorst's
paper contains the assumption that mental competence is a prerequisite for
access to assisted dying. While most prochoice ethicists take this
position to be axiomatically correct, I suggest that an insistence on
competence - at least as it is usually conceived in medicine - may lead to
unfair discrimination and unnecessary suffering amongst patients suffering
from a particular class of psychiatric disorder, namely those deemed to be
'psychotic'.
As Schuklenk and van der Vathorst describe, even the most prochoice
jurisdictions stipulate mental competence as a prerequisite for assisted
dying. So in the Netherlands, while patients suffering from TRD can obtain
assistance in dying, those with psychotic depression do not qualify,
because treatment decisions by these patients are considered to be often
'not arrived at competently and should be overridden/ignored'. The
fundamental assumption here - and it is a commonplace notion in medical
ethics - is that psychosis equates with mental incompetence. Presumably,
the basis for this position is that psychosis entails disordered or
delusional modes of thought.
TRD can be very severe, as is made very clear by Schuklenk and van
der Vathorst's paper; however, various forms of intractable psychosis can
be at least as -and in some cases possibly even more- difficult to endure.
Psychotic depression, as above, might be one such case; treatment-
resistant severe schizophrenia would also appear to be an extremely
difficult to endure form of psychosis, entailing great suffering - indeed
many of those affected end up committing suicide. While such patients (by
definition) suffer from disordered or delusional thinking, it is not clear
that the desire to end their lives should be deemed irrational.
As with TRD, denial of assisted dying to patients enduring
intractable psychosis is responsible for a great deal of unnecessary
suffering and amounts to unfair discrimination. I suggest that the
assumption 'psychotic = incompetent' should no longer be accepted
axiomatically. Prochoice medical ethicists ought to explore principled
ways by which our conceptions of 'competence' may be refined such as to
permit fair access to assisted dying for those afflicted by intractable
psychotic disorders.
REFERENCES.
1. Brewer, C. Depression is not the only treatment-resistant psychiatric
condition. eLetter, Journal of Medical Ethics, 2 June 2015.
TO THE EDITOR: Unexpected critical illness and the possibility of
death for which loved ones and relatives are unprepared leads to upheaval
and is destabilizing. In time-constrained settings where patients and
their families have not had end-of-life discussions about the use of
aggressive treatments, doctors face difficulties with overwhelmed and
unprepared patients and families. For these distressed families, it is
dif...
TO THE EDITOR: Unexpected critical illness and the possibility of
death for which loved ones and relatives are unprepared leads to upheaval
and is destabilizing. In time-constrained settings where patients and
their families have not had end-of-life discussions about the use of
aggressive treatments, doctors face difficulties with overwhelmed and
unprepared patients and families. For these distressed families, it is
difficult to raise the option of limited treatment in the first instance.
After acquiescing to a decision against full resuscitation they may feel
like their loved ones have been short-changed.
Partners and families should be told honestly about the prospects of
meaningful recovery even with maximal treatment. Life and organ support
therapies involve invasive painful procedures, are futile and often
require mind-fogging sedation to be tolerated. A calm rendition of
realistic chances does not equate to paternalism or coercion towards a
palliative treatment trajectory. We need to arrive at a decision together
-- one that is in the patient's best interest as far as is possible --
moderated by humanity, dignity, beneficence and non-malfeasance.
There is no doubt that the ethical, moral and legal quandaries of
whether to withdraw ventilator- and organ support are stressful for,
indeed provoke strong emotions in, families and critical care staff.
Ongoing physiological support as decisions on treatment withdrawal are
being deliberated in courts of law necessarily delay the availability of
scarce intensive care beds to other seriously ill or injured patients with
far better prospects of meaningful recovery. These patients cannot afford
to wait for all-round resolution between families, clinicians and courts.
Surely the high cost of intensive care and the diversion of hundreds of
thousands of dollars from other health care programs bears serious thought
even in times of immense crisis. The health system cannot afford the
thousands of dollars spent each day in the support of a patient for whom
non-meaningful survival, futility and much delayed death is the eventual
outcome. In the unlikely event that one is abel to be weaned off the
ventilator, the patient is still condemned to full nursing care for the
rest of her natural life.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
It remains controversial whether overweight and obesity confer
protection when one becomes afflicted with a chronic disease. The debate
would benefit from a shift in focus from susceptibility to more serious
iterations of a whole range of chronic medical problems, to the obese
sustaining higher acute risks from anaesthetic, pregnancy and post
operative complications. They are more difficult to resuscitate in trauma
and...
It remains controversial whether overweight and obesity confer
protection when one becomes afflicted with a chronic disease. The debate
would benefit from a shift in focus from susceptibility to more serious
iterations of a whole range of chronic medical problems, to the obese
sustaining higher acute risks from anaesthetic, pregnancy and post
operative complications. They are more difficult to resuscitate in trauma
and critical illness. Life-sustaining procedures such as intubation and
central venous access pose an anatomical challenge. Due to their thickset
habitus, even the longest chest drains could fail to reach large clots
pressing on lungs in major trauma. The treat of loss of life and limb with
acute injury and serious illness could be far more effective message than
low grade hazard spread over years to decades.
On another note, society's obsession with physical apperance and
attractiveness remains a fixture. Dieting, weight consciousness, anxiety
about body weight/shape and widespread hostility to obesity are
fundamental themes in contemporary life. There is tension between trying
to control our body weight in the midst of unprecedented access to
unhealthy foods. The impulse to ridicule and publicly monitor the body
shape has its basis in the highly visible markers of overweight
transgressing aesthetic standards and signalling pathology and disease.
Seeing fatness leads to the negative reading of fat bodies.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Adjunct associate professor, School of Public Health and Social Work
O Block, Room O-D610
Victoria Park Road
Kelvin Grove, Brisbane QLD 4059
Queensland University of Technology, Brisbane
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
To the Editor: Harassment and bullying are unacceptable in any
workplace, let alone the health professions whose calling purportedly
subscribe to healing, compassion and humanity. The highly publicised
examples of sexism and exploitation serves notice to perpetrators fuelled
by the perverse incentive of hierachical authority gradients. It goes
without saying that we need a paradigm shift in standing up to the
inertial s...
To the Editor: Harassment and bullying are unacceptable in any
workplace, let alone the health professions whose calling purportedly
subscribe to healing, compassion and humanity. The highly publicised
examples of sexism and exploitation serves notice to perpetrators fuelled
by the perverse incentive of hierachical authority gradients. It goes
without saying that we need a paradigm shift in standing up to the
inertial stance of "it has always been thus, and ever will be." However,
supervisors and senior staff still need a remit to act as fair and
assertive counsellors to help underperforming and impaired junior doctors
when poor attitudes and errors of diagnosis and treatment lead to harm in
patient care. One wonders whether the recent media frenzy swirling around
sexism, bullying and exploitation within the surgical specialities in
training hospitals and through the two decades I have practiced as a
doctor holds a negative sting in its tail. An unintended consequence that
erodes our ability to train and graduate the competent specialist is that
supervisors of training are now much more likely to walk on eggshells when
it comes to fair-mindedly assessing junior staff not truly suited to
advanced training in their chosen specialty, possess negative attitudes
and are debilitated in their home and work lives. All of us must act
against the inertia of institutionalised abuse and the intergenerational
transference of the "we all go through it" ethos, but I fear training
standards will be allowed to lapse and that supervisors will try avoid any
necessary but difficult conversations and interventions with a trainee
that is not genuinely performing to a minimum standard.
More than the bi- and tri- of parenthood, the equity and justice of
paid parental leave, same sex parents and gay marriage are ethical and
pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face
in sustaining a career and raising their children. However, we neglect to
mention that the childless in society already subsidize and assist with
the...
More than the bi- and tri- of parenthood, the equity and justice of
paid parental leave, same sex parents and gay marriage are ethical and
pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face
in sustaining a career and raising their children. However, we neglect to
mention that the childless in society already subsidize and assist with
the home and work lives respectively of women who choose to become
mothers. Having children is routinely portrayed as a long financial
sacrifice for, and discrimination against, women who choose to take time
off from the workforce to have families. In most advanced economies, the
whole of dependent childhood is already heavily subsidised by advantageous
tax concessions, free schooling, affordable childcare and long stretches
of generously paid parental (including fatherhood) leave.
The childless worker is expected to assume the additional
responsibilities left behind by new mothers departed for the home front.
Parents use sick leave entitlements to look after children when they
cannot get babysitters. Every election cycle in Australia, baby bonuses
and family incentives are trotted out to this voter demographic.
Yet what protects those of us who choose to not reproduce? Unlike
food, water, shelter and warmth, having a child is not necessary for our
physical wellbeing. Most parents in later life see it as a positive life-
enhancing journey rather than a costly punishment. Adult children
represent a return on a parents' investment in having a carer in frailty
and old age. Children are the embodiment of a parent's genetic legacy and
a darwinian imperative.
The deliberately childless being burdened with the additional work
that new mothers displace to them also represents discrimination of those
expected to share indirectly the upkeep of other's children. The argument
that society and the workplace has deterred women from having families
should also take into account that until babies become independent tax
funding adults, they are represent a largely subsidized lifestyle choice
exercised by aspiring parents-to-be.
Ireland, by becoming the first nation to approve same-sex marriage by
referendum, powerfully bolsters the quest for gay equality, a movement
that has achieved a string of victories around the world over the past
decade but remains a distant goal in Australia, where leaders of both
political strips have either embraced vibrant opposition to it (Abbott and
company) or asked for a parliamentary conscience vote (some of the
Opposition). Until we let Australia speak by popular vote, these
approaches enable the entrenchment of less than tolerant attitudes of
those in power in Canberra. It smacks of "Aussie, Aussie, Aussie, No! No!
No!"
May 2015 marks Ireland 's emergence into the fraternity of 19 nations
that have legalised same-sex marriage, eroding the entrenchment of
discrimination based on outdated arguments. There is no evidence that it
undermines the union between man and woman and that gay marriage erodes
the sanctity of "traditional" procreation. The importance of biological
ties and of motherhood and fatherhood is now more absurd as an argument to
deny a fundamental human right to two men or two women who want to
formalise their lives together in a recognised union.
The outcome in Ireland sends an unmistakable signal to politicians
and religious leaders in Australia and around the world who continue to
harbour negative views against gays and lesbians. It also should offer
hope to sexual minorities in Russia, the Arab world and many African
nations where intolerance and discriminatory laws remain widespread. The
tide is shifting quickly. Even in unlikely places, love and justice will
continue to prevail.
I encourage Cutas to assess, in future, the influence of paid
parental leave (and its societal equity), the gender composition of
parents, and the formalisation of marriage (and legalisation of same sex
marriage) in children's development and welfare.
Respect for citizens' rights to confidentiality have come a long way
over the past decade or so in the UK but not without resistance in some
parts of the medical establishment. Along with and allied to
confidentiality, respect for a person's right to know what is being said
about them (access to files) has been something of a struggle and still is
for those who are incarcerated in prisons or hospitals. 'Secrecy' rather...
Respect for citizens' rights to confidentiality have come a long way
over the past decade or so in the UK but not without resistance in some
parts of the medical establishment. Along with and allied to
confidentiality, respect for a person's right to know what is being said
about them (access to files) has been something of a struggle and still is
for those who are incarcerated in prisons or hospitals. 'Secrecy' rather
than 'confidentiality' is historically one way of maintaining a very
unequal balance of power. In institutions it encourages abuse of
vulnerable people. Secrecy is a different concept to confidentiality and
should not be part of a professional relationship. The limits to
confidentiality when spelt out honestly and not fudged in order to extract
information should not be a huge issue when people are in prison or
psychiatric institutions. It would be useful to hear from people who have
spent time in them when they feel safe enough to speak publicly, even if
anonymously. The few one sided documentaries viewed by the public are
highly controlled versions of for example life in Broadmoor high security
hospital or in prisons. It is rare to read any first hand accounts
alongside those of professionals. Their perspective would be interesting.
Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options....
Dear Editor. I do occasional psychiatric assessments for people
contemplating medically-assisted rational suicide (MARS) in Switzerland
and broadly agree with Schuklenk and van der Vathorst's arguments.
Usually, my role is limited to assessing mental capacity and excluding the
existence of a treatable psychiatric condition that might be influencing
the patient's decision to include MARS in the list of acceptable options.
Most of these patients have conditions such as motor neurone disease or
early dementia in which death within six months would not be expected.
Recently, I was asked to see a patient with purely psychiatric diagnoses
and have thus been thinking very hard about the issues discussed in their
paper.
It seems difficult to argue that intractable mental distress is
intrinsically less worthy of our concern than intractable somatic
distress. Most people who kill themselves do so as a result of
psychological rather than physical distress. Much of that distress proves
to be transient and/or tractable (and frequently aggravated by various
intoxications) but some of it is neither. The largest and most
comprehensive survey of suicides in a single 'western' country during the
entire 20th century [1] concluded that many suicides were due to eminently
'understandable' combinations of circumstance and personality or world-
view. Obvious mental illness was a less important factor.
The present era of DSM-5 imperialism is associated with sometimes
ludicrous claims for the effectiveness of antidepressants, despite
consistent evidence that placebo and non-specific mechanisms are much more
prominent than pharmacological ones. Personality disorders are, almost by
definition, resistant to both drugs and psychotherapy. When someone has
reached their mid-thirties without relief and despite such appropriate
interventions as exist, psychiatry should perhaps show a little
therapeutic humility.
Much of the organised opposition to MARS is religious and I think it
goes back to the Augustinian view that suicide is a worse sin than
homicide because it implied criticism of the world that God had created
[2] - a position that led to the ritual desecration of the corpse until
1825 in Britain. Even today, both the main churches officially deny
Christian burial in consecrated ground to suicides, though the Church of
England voted this year to revoke the relevant Canon Law. They get round
the prohibition in practice by claiming that all suicides must have been
suffering from insanity. The official position of psychiatry seems rather
similar.
REFERENCES.
1.Weaver J. Sorrows of a Century: interpreting suicide in New Zealand 1900
-2000.Montreal. McGill-Queen's university press. 2014.
2. Brewer C. Christian attitudes to suicide. In: C Brewer and M Irwin
Eds. I'll See Myself Out, Thank You. Thirty personal views in support of
assisted suicide. Newbould on Stour. Skyscraper. 2015
To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they becam...
To the Editor: The rights to unrestrained free speech in Australia, including the abolition of the ban on hate speech in the Racial Discrimination Act that makes it it unlawful to "offend, insult, humiliate or intimidate" a person or group on the basis of their "race, colour or national or ethnic origin," could incite race based abuse.
Racial discrimination and vilification remains a prescient worry for the rece...
Getting your message across to a patient and their family is difficult and fraught with misunderstanding. Aside from not having enough time and patience to explain complex diagnoses and sophisticated treatment plans as well as ensuring that understanding has occurred, English may not be the patient's first language.
As a hospital doctor, even when using non-technical terms, I wonder whether a family member or a p...
Dear Editor.
Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.
Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying...
TO THE EDITOR: Unexpected critical illness and the possibility of death for which loved ones and relatives are unprepared leads to upheaval and is destabilizing. In time-constrained settings where patients and their families have not had end-of-life discussions about the use of aggressive treatments, doctors face difficulties with overwhelmed and unprepared patients and families. For these distressed families, it is dif...
It remains controversial whether overweight and obesity confer protection when one becomes afflicted with a chronic disease. The debate would benefit from a shift in focus from susceptibility to more serious iterations of a whole range of chronic medical problems, to the obese sustaining higher acute risks from anaesthetic, pregnancy and post operative complications. They are more difficult to resuscitate in trauma and...
To the Editor: Harassment and bullying are unacceptable in any workplace, let alone the health professions whose calling purportedly subscribe to healing, compassion and humanity. The highly publicised examples of sexism and exploitation serves notice to perpetrators fuelled by the perverse incentive of hierachical authority gradients. It goes without saying that we need a paradigm shift in standing up to the inertial s...
More than the bi- and tri- of parenthood, the equity and justice of paid parental leave, same sex parents and gay marriage are ethical and pragmatic considerations that matter to society at large.
The press rightly highlight the workplace obstacles that women face in sustaining a career and raising their children. However, we neglect to mention that the childless in society already subsidize and assist with the...
Respect for citizens' rights to confidentiality have come a long way over the past decade or so in the UK but not without resistance in some parts of the medical establishment. Along with and allied to confidentiality, respect for a person's right to know what is being said about them (access to files) has been something of a struggle and still is for those who are incarcerated in prisons or hospitals. 'Secrecy' rather...
Dear Editor. I do occasional psychiatric assessments for people contemplating medically-assisted rational suicide (MARS) in Switzerland and broadly agree with Schuklenk and van der Vathorst's arguments. Usually, my role is limited to assessing mental capacity and excluding the existence of a treatable psychiatric condition that might be influencing the patient's decision to include MARS in the list of acceptable options....
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