I read 'Why we should not seek individual informed consent for
participation in health services research' with weary disbelief. The
arguement made by the authors that UK citizens are members of the NHS and
as such are required to give up their medical records and choice about
whether to particpiate in research, displays a lack of understanding about
the citizen's relationship to the NHS.
I read 'Why we should not seek individual informed consent for
participation in health services research' with weary disbelief. The
arguement made by the authors that UK citizens are members of the NHS and
as such are required to give up their medical records and choice about
whether to particpiate in research, displays a lack of understanding about
the citizen's relationship to the NHS.
The idea that we are members of the NHS is laughable. Members of an
organisation have expectations, rights and indeed obligations. However
although the health service is funded by all tax payers - in effect the
entire population, we appear to have few enforceable rights. No right to
treatment. No right to an appointment at a convenient time. No right to
say who can see our clinical records. No expectation that we will be seen
promptly at the local A+E department if we are hurt. The vision offered by
the authors, that we give up autonomy if we are lucky enough to be
treated,amounts to a one-sided contract.
Yes, the NHS has a loyal following. Patients support the front line
staff who do a fantasic job for little pay and who all too often put up
with poor working conditions. On the other hand ,they are less than
impressed with the managment of the service. All too often the
administration of the health service lets us all down and indeed some
initiatives have the effect of undermining the trust that patients can
place in the NHS. Undermining both patient confidentiality and the limited
autonomy we have within the service appears to be designed to cause a
further loss of faith.
It appears that the authors believe that NHS services are a gift
within their power to allocate or withhold as they please depending upon
whther the patient is prepared to accept the conditions they seek to
impose. The argument is not only nonsensical, but flies in the face of the
oft stated government initiative to give patients greater choice and a
voice within the NHS.
Without intervention, a small preponderance of female over male infants will be born, and female children will have a slightly higher
chance of living to maturity. Thereafter, the female population will
decline relatively sharply in consequence of death in childbirth.
Historical evidence indicates that throughout the recorded history of
Britain, there was a relative scarcity of women and men dominated...
Without intervention, a small preponderance of female over male infants will be born, and female children will have a slightly higher
chance of living to maturity. Thereafter, the female population will
decline relatively sharply in consequence of death in childbirth.
Historical evidence indicates that throughout the recorded history of
Britain, there was a relative scarcity of women and men dominated social
structures. This situation was only reversed in the early decades of the
twentieth century, a time when three generations of young men had gone, in
succession, to be soldiers. These wars were chiefly fought abroad, and
too few returned to provide husbands for all the available women.
It is no coincidence that this era also saw the real beginning of
equality for women. Circumstances dictated that women undertake roles
previously considered male, and events proved their ability to do so. The surplus women continued in working careers, perforce, providing role
models for those who came after. All the protests of the suffragettes
were less effective than this brutal gender imbalance.
Dickens’ assertion that the present scarcity of girls in India, due
to sex selection before and after birth, will lead to a future increased
social value for daughters, may be true. However, this will in no way
reverse the force of male dominance, since to have value as a wife and a
mother is not necessarily to have value as a person. On the contrary, a
shortage of wives and mothers will reduce opportunities for these future
women to be anything else. Their chance of escaping the present lot of
their mothers will be significantly less.
In the developed world, the birth rate is falling below replacement
levels. A first male child is still preferred and a family of less than
two children cannot be balanced. To this day, equality of the sexes has
not been fully achieved. The injustice and oppression Dickens complains
of are present least of all in prohibitions on sex selection.
I must disagree with the view that there is no substantial difference between the withdrawal of a gastrostomy tube and the prescribing of drugs to end an life. I see no ethical or compassionate dimension in allowing slow starvation. To administer a measured overdose of Morphine, or such,
is much kinder. The person dies with dignity and in the minimum of pain.
I must disagree with the view that there is no substantial difference between the withdrawal of a gastrostomy tube and the prescribing of drugs to end an life. I see no ethical or compassionate dimension in allowing slow starvation. To administer a measured overdose of Morphine, or such,
is much kinder. The person dies with dignity and in the minimum of pain.
How passive killing with no regard to compassion is considered preferable
to actively ending suffering baffles me.
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.
Dear Editor
I read 'Why we should not seek individual informed consent for participation in health services research' with weary disbelief. The arguement made by the authors that UK citizens are members of the NHS and as such are required to give up their medical records and choice about whether to particpiate in research, displays a lack of understanding about the citizen's relationship to the NHS.
The id...
Dear Editor
Injustice and oppression lie in prohibition not for birth of a first child, but of a second or later child.
B.M. Dickens
Dear Editor
Without intervention, a small preponderance of female over male infants will be born, and female children will have a slightly higher chance of living to maturity. Thereafter, the female population will decline relatively sharply in consequence of death in childbirth. Historical evidence indicates that throughout the recorded history of Britain, there was a relative scarcity of women and men dominated...
Dear Editor
I must disagree with the view that there is no substantial difference between the withdrawal of a gastrostomy tube and the prescribing of drugs to end an life. I see no ethical or compassionate dimension in allowing slow starvation. To administer a measured overdose of Morphine, or such, is much kinder. The person dies with dignity and in the minimum of pain.
How passive killing with no regard to co...
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...
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