I read with interst the article by Cherniack [1] in October's issue.
He questions whether or not more elderly people die with a DNR order
beccause they are actually choosing to do so, and reviews evidence of
doctors and patients knowledge and attitudes towards CPR decision making.
It is all very well talking about whether a patient would want to be
resuscitated and Cherniack feels more studies...
I read with interst the article by Cherniack [1] in October's issue.
He questions whether or not more elderly people die with a DNR order
beccause they are actually choosing to do so, and reviews evidence of
doctors and patients knowledge and attitudes towards CPR decision making.
It is all very well talking about whether a patient would want to be
resuscitated and Cherniack feels more studies should be done regarding
how elderly people would prefer to be asked, but one has to look at
whether CPR is actually going to benefit them or not. I agree that doctor
and patient education is important, but I wonder whether emphasis should
be placed on education to explain when resusciation would not need to be
discussed with patients because it would be unlikely to benefit the
patient (medically futile) and explain when it would need to be
discussed, when it is likely to benefit the patient or when there is
uncertainty on the outcome.
It is not a question of ignoring a patient's wishes, or age
disccrimmination or denying patient autonomy, but to aim to promote the
principles of beneficence and non-maleficence, and to do what is in the
best interests of our patients.In other aspects of medicine we do not
discuss treatments that will not be successful and CPR should be treated
in the same way.
The discussion of this couples desire to have a deaf child is very reminiscent of a case we invented, published in Tough Decisions: Cases in Medical Ethics 2nd ed. Freeman J and McDonnell K Oxford Press 2001. The
case explored the genetic issues in the desire of a deaf couple to have a
deaf child. Most genetic manipulations are to avoid a genetic disorder,
this, and the lesbian couple show that genet...
The discussion of this couples desire to have a deaf child is very reminiscent of a case we invented, published in Tough Decisions: Cases in Medical Ethics 2nd ed. Freeman J and McDonnell K Oxford Press 2001. The
case explored the genetic issues in the desire of a deaf couple to have a
deaf child. Most genetic manipulations are to avoid a genetic disorder,
this, and the lesbian couple show that genetics can be manipulated to
produce such defects.
I read Dr Cherniack's article regarding DNR orders with interest.[1] One
of the problems with DNR orders is the patients’ assumption that if there
is no DNR order they will survive resuscitative efforts. This of course is
far from the truth. In my hospital these have been modified to "do not
attempt to resuscitate orders". One cannot be truly autonomous without
being informed. Long term survival, as measu...
I read Dr Cherniack's article regarding DNR orders with interest.[1] One
of the problems with DNR orders is the patients’ assumption that if there
is no DNR order they will survive resuscitative efforts. This of course is
far from the truth. In my hospital these have been modified to "do not
attempt to resuscitate orders". One cannot be truly autonomous without
being informed. Long term survival, as measured only by being alive,
following in-house cardiac arrest, is about 15 % over all age groups.[2] In
sick elderly patients over 70 years of age who survive a cardiac arrest,
the subsequent hospital mortality approaches 100 %. This fact and concerns
about harm influence physician’s attitudes, particularly where the general
public have wildly unrealistic expectations of the results of
resuscitation as mentioned in the paper.[3] Significant neurological
disability is common following cardiac arrest: up to 50 % of the survivors
of CPR in one study.[4] Medical staff are clearly aware of hazards of
resuscitation, doctors have been demonstrated to be highly selective as to
when they would wish resuscitation to take place for themselves [5] and in
one group of emergency workers few were found who were willing to undergo
full resuscitation as "currently practised".[6] Whilst age per se is not
necessarily a predictor of poor outcome of intensive care [7] advancing age
is associated with an increasing incidence of systemic diseases, which do
predict poor outcomes following arrest.[8,9]
As a society we seem to strive to prevent death pursuing the next
line of treatment at any cost and this struggle against disease has been
described as "trench warfare against death".[10] Patients and their
relatives expect physicians, as fiduciary agents, to do everything in
their power to help cure them and save their lives but there comes a point
where not doing something is the better thing to do. Physicians tend to
endeavour to do all that they can, as Morreim puts it " embracing a
technological imperative that favours action over inaction".[11] However,
the fact that we would not wish it upon ourselves says a great deal about
what we think of resuscitation in the sick elderly patient. Dr Cherniack
comments that when information about CPR is presented more negatively then
fewer elderly will chose it. He seems to imply that one could be more
positive if only one wanted to. I fail to see how one can be positive
about brain damage, a stay on ITU and the near certainty of death. In
certain circumstances CPR is simply harmful. Outcome statistics and the
high incidence of morbidity have led one group to conclude that, "treating
our elders this way is maleficient.[12]
It is a mute whether there is any moral obligation to discuss
treatment options that are not really treatment options, particularly
where the potential to do harm far outweighs any benefit. Survivors of
resuscitation are transferred to intensive care units. Patients who have
spent time on Intensive Care Units report nightmares, depression, high
levels of distress and up to 40 % have recollection of pain.[13,14] Is
this a beneficent act if survival is not a realistic possibility? I think
not but of course a vitalist would disagree. By all means we should
ensure that we respect patients autonomy by asking their preferences, but
we have to be totally frank about outcomes. To not do so would be to
infringe patient’s autonomy as much as disregarding their preferences.
References
(1) Cherniack EP. Increasing use of DNR orders in the elderly worldwide: whose choice is it? J Med Ethics 2002;28:303-307.
(2) Juchems R, Wahlig G, Frese W. Influence of age on the survival rate of out-of-hospital and in-hospital resuscitation. Resuscitation 1993; 26(1): 23-9
(3) Godkin M, Toth E. Cardiopulmonary resuscitation and older adults
expectations. Gerontologist 1994;34:797-802
(4) Jaffe AS, Landau WM.Death after death: the presumption of informed
consent for cardiopulmonary resuscitation--ethical paradox and clinical
conundrum. Neurology 1993;43(11): 2173-8
(5) Hillier TA, Patterson JR, Hodges MO, Rosenberg MR. Physicians as
patients. Choices regarding their own resuscitation. Arch Intern Med 1995;
155(12): 1289-93
(6) Hauswald M, Tanberg D. Out-of-hospital resuscitation preferences
of emergency health care workers. Am J Emerg Med 1993;11(3):221-4
(7) Chelluri L, Pinksy M, Donahoe M, Grenvik A. Long-term outcome of
critically ill elderly patients requiring intensive care. JAMA 1993;269(24):
3119-3123
(8) Bialecki L, Woodward RS. Predicting death after CPR: experience at
a non-teaching community hospital with a full time critical care staff.
Chest 1995;108:1009-17
(9) Gordon M, Cheung M. Poor outcome of on site CPR at a multi level
geriatric facility: three and a half years experience at the Baycrest
Centre for Geriatric Care. Journ Am Geriat Soc 1993;41:163-6
(10) Callahan D.Death and the Research Imperative. New Engl J Med 2000;342:645-656
(11) Morreim E. Balancing Act: The New Medical Ethics of Medicines New Economics. 1995 Georgetown University Press, p 13.
(12) Hilberman M, Kutner J, Parsons D, Murphy D. Marginally effective
medical care: ethical analysis of issues in CPR. Journal of Medical Ethics 1997;23:361-367
(13) Leng C, Lawson A. Pain Management in Intensive Care, Recent Advances in Anaesthesia. 1998 London:Churchill Livingstone.
(14) Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions,
and the development of acute post traumatic stress disorder-related
symptoms after intensive care. Crit Care Med 2001;29(3): 573-80
Dr Lewis raises the important issue of what the rules of debate should be in electronic correspondence.[1]
As an editor, I feel as if I am caught in the maelstrom of evolution. The web has radically changed the nature of debate and the
presentation of information and knowledge. It is not clear to me how and whether it should be controlled. My general approach has
been to let the experiment run in a free way and look...
Dr Lewis raises the important issue of what the rules of debate should be in electronic correspondence.[1]
As an editor, I feel as if I am caught in the maelstrom of evolution. The web has radically changed the nature of debate and the
presentation of information and knowledge. It is not clear to me how and whether it should be controlled. My general approach has
been to let the experiment run in a free way and look at the results. Then it will be clearer what rules are required.
Electronic correspondence, for me, is different to scholarly debate. It takes advantage of the web's accessibility to give people the
opportunity to express their own views and to see the range of views on a particular issue. At present, the JME operates the
principle that it will publish electronically any response which is not libellous or harmful in other ways. Electronic letters which
contribute significantly to the debate (such as Dr Lewis's letter) may be selected for publication in the paper copy of the Journal.
The core business of a journal such as the JME should be the publication of scholarly articles which contribute to knowledge.
But for a medical ethics journal, it should also be engaging and relevant to professionals and non-professionals. We have
introduced a Current Controversy section which reports an issue of contemporary interest and we solicit off the cuff comment
from people who may have an interesting view on that topic. Electronic correspondence should serve a similar function: to
increase people’s interaction with the Journal and with others.
Professor Julian Savulescu
Uehiro Chair in Applied Ethics
University of Oxford
Reference
(1) Lewis W. A call for rules of engagement [electronic response to Boyd KM, The law, death, and medical ethics: Mrs Pretty and Ms B]. jmedethics.com 2002 emjonline.com
2002 http://jme.bmjjournals.com/cgi/eletters/28/4/211#19
At the time of writing there appears to have been no electronic
submissions to the Journal of Medical Ethics. It seems appropriate,
therefore, to begin electronic correspondence with a consideration of some
of the ethical implications of this new form of ethical dialogue.
I have posted this response to Kenneth Boyd’s editorial on ‘Mrs.
Pretty and Ms B’ [1] as this article may provoke debate...
At the time of writing there appears to have been no electronic
submissions to the Journal of Medical Ethics. It seems appropriate,
therefore, to begin electronic correspondence with a consideration of some
of the ethical implications of this new form of ethical dialogue.
I have posted this response to Kenneth Boyd’s editorial on ‘Mrs.
Pretty and Ms B’ [1] as this article may provoke debate far beyond the
medical and ethical establishment. This issue may be of tremendous concern
to patients or their carers who are presently suffering in circumstances
similar to those described.
The electronic response forum of the BMJ has been in operation for
over four years.[2] An editorial in the BMJ on physician assisted suicide
[3] has attracted 125 responses at the time of writing. An important
feature of electronic responses, particularly on items that generate a lot
of debate, is that the contributions often refer to each other. These
responses range from the scholarly and meticulously argued to distressing
personal accounts of suffering. As both an avid reader of rapid responses
to the BMJ and a physician, I consider both sorts of contributions to be
valuable, but increasingly feel uncertain about what my written response
to them should be when I wish to enter into dialogue with the author. I
feel on sure ground when considering the scholarly submission that is
clearly intended as a contribution to a peer reviewed journal, and have no
qualms at drawing up a response to point out its weaknesses. Equally, as a
family doctor, I hope that I am able to approach distressing accounts of
suffering with a degree of empathy. However, it is sometimes the case that
submissions clearly showing distress also contain dubious argument that
any peer review process would severely deal with.[4] Where accounts of
suffering alongside dubious arguments are posted from patients I
personally feel squeamish about responding, finding myself caught between
the roles of vituperative reviewer and empathic listener.
As an editorial in the BMJ on the subject of electronic responses has
noted, "We've begun to capture the opinions and experience of patien...
and publish just about anything that isn't libellous or doesn't breach
patient confidentiality."[2] Inevitably, such a broad range of responses
will produce many that deserve to be challenged. Merely to ignore dubious
argument infers that such opinions are correct. Furthermore, it is
astonishingly easy to post an electronic response, and the process
contains no warning that opinions expressed may be severely challenged. We
should consider what the rules of debate on this journal of medical ethics
web site should be.
To prevent any misunderstanding, I wish to state that this response
does not issue out of intense personal suffering, and that I am prepared
for the most stringent peer review of its contents. Say anything in
response, but please don’t ignore me.
References
(1) Boyd, KM. Mrs. Pretty and Ms B. J Med Ethics 2002;28:211-212.
(2) Delamothe T, Smith R. Twenty Thousand Conversations. BMJ 2002;324:1171-1172.
(3) Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080.
(4) McCracken L. It is time to learn the Hippocratic Oath indeed [electronic response to Roddy E et al. On Hippocrates .] bmj.com 2002 http://bmj.com/cgi/eletters/325/7362/496/a#25093 (accessed 3rd Aug 2002)
The basic principles of law applied in Brazil follow the Roman Right. The
medical ethics and bioethics approach generally
implies that doctors must respect patient confidentiality, even in a potentially risky situation, where, for example, someone with HIV does not tell his/her partner and the physician is aware of the patient's infection. Some have attempted to prosecute those who knowingly transmit HIV, b...
The basic principles of law applied in Brazil follow the Roman Right. The
medical ethics and bioethics approach generally
implies that doctors must respect patient confidentiality, even in a potentially risky situation, where, for example, someone with HIV does not tell his/her partner and the physician is aware of the patient's infection. Some have attempted to prosecute those who knowingly transmit HIV, but the Brazilian courts, at present, do not accept this. Brazil has a strong programme for prevention of HIV transmission and even for treatment - for example, antiretroviral drugs are given free to all citizens who need them. Prevention is the goal: lawyers and doctors here don't agree with legal measures as a means of stopping viral transmission, only as an issue of venegence. But there remains a critical point: the rise od HIV transmission to healthy women by their husbands, who have been infected through exrtamarital sex, and who do not use a condom at home. In this situation there may be a case for legal proceedings or even imprisonment.
At present, we are unable to do this, but time will show us the reaction of Brazilian society to this point.
Dr Shaw makes some interesting points in discussing the doctrine of
double effect.[1] However, I am unsure as to the validity of his
conclusions. He states that the doctrine "permuits the use of drugs which
relieve the distress of dying, evene when they hasten death." However, if
opiates are in mind here, then the dose could and should be closely
monitored - up or down - to fully palliate pain. They do...
Dr Shaw makes some interesting points in discussing the doctrine of
double effect.[1] However, I am unsure as to the validity of his
conclusions. He states that the doctrine "permuits the use of drugs which
relieve the distress of dying, evene when they hasten death." However, if
opiates are in mind here, then the dose could and should be closely
monitored - up or down - to fully palliate pain. They do not hasten death
except when used carelessly, irresponsibly or to end life deliberately,
which under the doctrine remains murder. On this basis, I wonder whether
it is unethical not to provide a readily available, properly funded
palliative care service to prevent such misuses.
Shaw's arguments surrounding surgery seem strange. Laparoscopy or
laparotomy are in themselves good, necessary procedures (for example in
the staging of gastric carcinoma[2]). One might say that the robber
stabbing his victim is taking a potentially good action - laparotomy - and
using it in an evil fashion, perhaps akin to using diamorphine for
deliberate kiling.
While autonomy is regarded as one of the key ethical principles,[3]
is it necessary to make this the touchstone of medical decision making?
For the "patient's own ethical evaluation of a method or an outcome" to
determine it good or bad presupposes a fully informed decision by a fully
competent patient. The doctor may not or may not be able fully to inform
the patient, who may not be in a state of mind, because of physical or
psychiatric illness, to take this and make an appropriate, balanced and
final judgment. It also mandates the doctor to do whatever the patient
requests. Finally, it views the patient in isolation, rather than as part
of a family or society group. This does not mean that the doctor should
become the absolute arbiter but rather that decisions should be reached by
consensus: the doctor providing professional knowledge, the patient their
knowledge of their illness, and both bringing their feelings and
aspirations.
Arguments are again forced in the section on abortion. A mother with
eclampsia will be at least 20 weeks or post partum [4] and therefore needs
delivery not abortion, attempting to sasve both lives. This may be the
answer to the problem Dr Shaw sees here: with a preegnent woman, we act to
save both lives if at all possible, by the delivery of the child. Thus an
induced labour or Caesarean section is allowable but deliberate
methotrexate administration is not.
Despite its problems, the doctrine of double effect remains a useful
tool in differentiating superficially similar issues, particularly at the
beginning and end of life.
References
(1) Shaw AB. Two challenges to the double effect doctrine:
euthanasia and abortion. J Med Ethics 2002;28: 102-4.
(2) Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines
for the management of oesophageal and gastric cancer. Gut 2002;50 (suppl V): v1
-v23
(3) Gillon R. Philosophical medical ethics. 1986. Chichester, UK:
John Wiley & Sons.
(4) Higgins JR, de Swiet M. Blood-pressure management and
classification in pregnancy. Lancet 2001;357: 131-5.
Water used to be free. More than two-thirds of the planet is covered
with water. Yet, American consumers (particularly) pay more for a bottle
of water than they do for a soda, a bottle of juice, or even a beer (and
yet all of these products are 90 % or more water in the first place). Cars
cost more nowadays than a house did on twenty years ago. I remember going
to see Star Wars (1977) for only about $...
Water used to be free. More than two-thirds of the planet is covered
with water. Yet, American consumers (particularly) pay more for a bottle
of water than they do for a soda, a bottle of juice, or even a beer (and
yet all of these products are 90 % or more water in the first place). Cars
cost more nowadays than a house did on twenty years ago. I remember going
to see Star Wars (1977) for only about $2.50. Now it costs three hundred
percent more for the same seating space in the same, old theatre to see
the most recent installation of Star Wars. Turn of century homes in
Brooklyn, dilapidated and leaking, with old pipes, lead paint, improper
wiring, and wood rot, are selling for half a million dollars!
In America, it seems, everything is has its price and that price
increases annually. While unethical from a Judeo-Christian point of view
where we should help the less fortunate, the selling of organs for major
profit is well within the realm of expectations for a nation too bent on
money, wealth, and insta-win lotteries.
Professor Williamson makes a valid point about the term "research fraud" and I agree that the term covers a number of different categories of unethical behaviour. I also pointed out that "Research fraud can take many forms" in the discussion section of my paper. For the purposes of my article I stated that consultants who had answered "Yes" to questions 1,2 or 3 of table 1 had reported "observed misconduct" and...
Professor Williamson makes a valid point about the term "research fraud" and I agree that the term covers a number of different categories of unethical behaviour. I also pointed out that "Research fraud can take many forms" in the discussion section of my paper. For the purposes of my article I stated that consultants who had answered "Yes" to questions 1,2 or 3 of table 1 had reported "observed misconduct" and I stand by this conclusion. The dictionary on my bookshelf (Concise Oxford Dictionary (6th Ed.)) defines "misconduct" as "improper conduct, esp. adultery; bad management" and I think that what the consultants were reporting in the questionnaire fits this definition. The same dictionary includes in its definition of "fraud" the phrases " use of false representations to gain unjust advantage" and "person or thing not fulfilling expectation or description". The behaviour described in questions 1,2 and 3 (i.e. inappropriate authorship, omission of names of contributors who made a substantial contribution, and the intentional alteration of data for publication) fits this definition. In the article I tried to use the term "fraud" as a more general term than "misconduct" and I apologise if this caused confusion. However, I think that the majority of readers (and certainly the majority of my colleagues) would have had something approaching the above definitions in mind when they read the article (although several colleagues have told me to get a more up to date dictionary!). Whilst I acknowledge that Prof. Williamson makes a valid point, I do think there is a danger of any rational discussion becoming bogged down in semantics and I think that it is clear from my article what the initial data was and how I have derived my variables.
Prof. Williamson dismisses the medical consultants (not cleaners!) who answered yes to questions 1 and 2 as having "more often delusions of grandeur" on their part. That is a point of view - but I suspect the majority of respondents to my questionnaire do not share it. Indeed I think his attitude risks sweeping a very real problem under the carpet and, whilst I am aware of attempts to standardise authorship, I think this is a problem which requires further investigation.
I find the overall tone of this letter and phrases such as "into fairyland" and "give me a break" inflammatory and this, unfortunately, distracts from some valid points.
The main criticism of Prof. Williamson appears to be that he has learnt nothing new from my paper. The original idea for this study came after a lively discussion in a bar about the prevalence of research fraud (a subject of which I knew very little). After this discussion I did a literature search and could find only a few references to research fraud and misconduct. I decided to perform the study in an attempt to answer the questions I had. I wish that Prof. Williamson had been present at the original discussion - he could have saved me a lot of trouble! On a more serious note, I am sure that the Professor is aware that in the "hierarchy of evidence" questionnaire surveys rank higher than anecdotal evidence and personal experience (although only just!). The value of my article is that it adds evidence to a subject in which there is a marked paucity of hard facts.
I am sorry that Prof. Williamson was unimpressed with my paper. Unfortunately, the very nature of the subject of research fraud/misconduct mitigates against good quality research. I am sure that readers would welcome any double-blinded RCTs on the subject and, if the Professor wishes to carry out some research in this area I am sure that the scientific community would welcome it.
Dear Editor
I read with interst the article by Cherniack [1] in October's issue. He questions whether or not more elderly people die with a DNR order beccause they are actually choosing to do so, and reviews evidence of doctors and patients knowledge and attitudes towards CPR decision making.
It is all very well talking about whether a patient would want to be resuscitated and Cherniack feels more studies...
Dear Editor
The discussion of this couples desire to have a deaf child is very reminiscent of a case we invented, published in Tough Decisions: Cases in Medical Ethics 2nd ed. Freeman J and McDonnell K Oxford Press 2001. The case explored the genetic issues in the desire of a deaf couple to have a deaf child. Most genetic manipulations are to avoid a genetic disorder, this, and the lesbian couple show that genet...
Dear Editor
I read Dr Cherniack's article regarding DNR orders with interest.[1] One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these have been modified to "do not attempt to resuscitate orders". One cannot be truly autonomous without being informed. Long term survival, as measu...
Dr Lewis raises the important issue of what the rules of debate should be in electronic correspondence.[1]
As an editor, I feel as if I am caught in the maelstrom of evolution. The web has radically changed the nature of debate and the presentation of information and knowledge. It is not clear to me how and whether it should be controlled. My general approach has been to let the experiment run in a free way and look...
Dear Editor
At the time of writing there appears to have been no electronic submissions to the Journal of Medical Ethics. It seems appropriate, therefore, to begin electronic correspondence with a consideration of some of the ethical implications of this new form of ethical dialogue.
I have posted this response to Kenneth Boyd’s editorial on ‘Mrs. Pretty and Ms B’ [1] as this article may provoke debate...
Dear Editor
The basic principles of law applied in Brazil follow the Roman Right. The medical ethics and bioethics approach generally implies that doctors must respect patient confidentiality, even in a potentially risky situation, where, for example, someone with HIV does not tell his/her partner and the physician is aware of the patient's infection. Some have attempted to prosecute those who knowingly transmit HIV, b...
Dear Editor
Dr Shaw makes some interesting points in discussing the doctrine of double effect.[1] However, I am unsure as to the validity of his conclusions. He states that the doctrine "permuits the use of drugs which relieve the distress of dying, evene when they hasten death." However, if opiates are in mind here, then the dose could and should be closely monitored - up or down - to fully palliate pain. They do...
Dear Editor
The authors should be congratulated with this paper which again shows how important it is to get ones facts right, before passing ethical judgement.
Dear Editor
Water used to be free. More than two-thirds of the planet is covered with water. Yet, American consumers (particularly) pay more for a bottle of water than they do for a soda, a bottle of juice, or even a beer (and yet all of these products are 90 % or more water in the first place). Cars cost more nowadays than a house did on twenty years ago. I remember going to see Star Wars (1977) for only about $...
Professor Williamson makes a valid point about the term "research fraud" and I agree that the term covers a number of different categories of unethical behaviour. I also pointed out that "Research fraud can take many forms" in the discussion section of my paper. For the purposes of my article I stated that consultants who had answered "Yes" to questions 1,2 or 3 of table 1 had reported "observed misconduct" and...
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