Dear Editors, I read with interest the recent article on the ethics of doctor's strikes.1 I accept most of the arguments expressed in the article, however, there is one shortcoming to the framework: its under-analysis of the role that the social context can have when evaluating the ethics of doctors strikes.2 I contend that there is a need to contextualise industrial disputes of this nature, namely, reflecting on and evaluating the nature of the healthcare system, its values and vision, and its relationship to the prevailing socio-political landscape. Such an approach would offer a more integrated ethical understanding of doctors decision to strike and extend the value of the ethical framework being proposed. Roberts does attempt to contextualise the strike, by referring to the 'party line' adopted by various government officials and departments that the junior doctor strike exposes patients to serious harm 1(p.3), and how the media can be used to promote the government position. However, the link between the doctors' actions and the social context is not properly formulated. Healthcare systems can be categorised into four basic models- Beveridge model (UK), the social insurance model (e.g. Germany), the national insurance model (e.g. Canada) and a market driven model (e.g. India).3 Each of these systems employ different principles of healthcare. It would be worth incorporating this dimension of health care to an ethical framework for evaluating doctors' strikes. In this article the NHS and the Department of Health are framed as the doctors 'employers'. While this is factually correct, it is worth remembering that the Department of Health and the NHS are also significant social institutions, key apparatuses of the UK welfare state and custodians of its principles of universality, equality and justice.4 In this particular case, it would be appropriate to check the actions of the government and that of the doctors decision to strike against these principles.5 The NHS has undergone a period of profound restructuring and reorganisation under the austerity driven focus of a conservative coalition government (2011-2016) and more recently a majority conservative government (2016-present).6 The 'better outputs with fewer resources'8 logic of austerity calls into question whether equality, access and quality of health services can be achieved when fiscal rectitude rather than universality is the operational mode.7 9 In the UK the annual health spend per capita in real terms is slowly recovering from -1.3% in 2010(compared with 0.1% for the OECD average for the same year). In 2013 the figure was 0.6 %, however, this was still behind the 1.0% average for the OECD. 6 This concerted strategy to underspend in the area of healthcare also included a two year policy of pay freezes and staff redundancies.6 It is clear that these political decisions have had an impact on the delivery of healthcare, impacting of the range of services provided and the working conditions for staff. Austerity then not only amplifies health inequalities of society and but also erodes at the 'the very principle of relatedness and mutuality'10 that defines these public health services and initiatives. Incidentally, this belief in state responsibility for the health of UK citizens has proved a rallying call for some of the striking doctors. During the escalation of the industrial strikes in April 2016, a make- shift banner was posted on the wall of a NHS hospital near my place of work. It read: 'The NHS will last as long as there are folk left with faith to fight for it- Aneurin Bevan'. This poster betrays the striking doctors' sympathy with the ethical vision of the founding father of the NHS and adds further legitimacy to their actions. It would appear that the values of the healthcare system and the type of priority it is given or not by a government are also important factors to consider when evaluating the reasons why doctors strike. I think that this amendment is worth making and highlighting for consideration.

REFERENCES 1 Roberts AJ. A framework for assessing the ethics of doctors' strikes, J Med Ethics Published Online First: 20 May 2016 doi:10.1136/medethics-2016- 103395. 2 Weinstein BD. Dental ethics. Philadelphia: Lea and Febiger 1993. 3 Physicians for a National Health Program. Healthcare systems-Four Basic Models, http://pnhp.org/single-player- resources/health_care_systems_four_basic_models.php (accessed 8 Jun 2016). 4 Weir S. 2015. The welfare state is dead - what is rising from the grave?. http://opendemocracy.net/ourkingdom/stuart-weir/welfare-state-is- dead-%E2%80%93-what-is-rising-from-grave (accessed 7 Jun 2016). 5 Pearse N. 2015. Welfare debate marks opportunity to renew Beveridge's legacy. http://opendemocracy.net/ourkingdom/nick-pearse/welfare-debate- marks-opportunity-to-renew-beveridge%E2%80%99s-legacy (accessed 7 Jun 2016). 6. OECD. Country Note: How does health spending in the United Kingdom compare? 7 July 2015. OECD Heath Statistics http://www.oecd.org/health (accessed 7 Jun 2016). 7 Quaglio GL, Karapiperis T, Van Woensel L, et al. 2013. Austerity and Health in Europe. Health Policy 2013; 113: 13-19. 8 Thomas S, Burke S, Barry S. 2014. The Irish health-care system and austerity: sharing the pain, Lancet, May 3, 2014; 383: 1545-1546. 9 Suhrcke M, Stuckler D. 2012. Will the recession be bad for our health?: it depends. Soc Sci Med 2012; 74: 647-653. 10 Lynch, K. 'New managerialism' in education: the organisational form of neoliberalism, Open Democracy, 16 Sept 2014. https://opendemocracy.net/kathleen-lynch/'new-managerialism'-in-education- organisational-form-of-neoliberalism (accessed 7 Jun 2016).

Conflict of Interest:

None declared

A properly worded consent form must make risks transparent but if the person has not even been asked to participate, discrimination is too easily slipping in. Even giving the reason as duty of care can be mis/used to eliminate some people - but their participation may be valuable as well as ethical. There can be an unconscious bias to avoid difficulties for researchers but discrimination will miss opportunities for the unexpected to be revealed by the exclusion of risk. Intolerance of risk means whole groups may not benefit from research carried out and they subsequently may be treated incorrectly, that is in the same way as the findings conclude for others with low risk. Exeter University has carried out much ground breaking work to enable wider participation in research by the public including via self referral and genuine rather than tokenistic efforts to involve the wider community. It has been promoted in other parts of the country by now but how much the public is aware of it is questionable. (Patient and Public Involvement Exeter web site) Open selection does not always happen though as some projects still select participants via GPs acting as gatekeepers. For example COBRA. (On Exeter web site) Researchers will not always get it right and results can be skewed. It would be interesting to see a comparison of the same or other studies conducted both by self referral and via gatekeepers. One area which could do more to become transparent to the public is, although more loosely described as research , the issue of conferences and events which are held by researchers/practitioners/professionals to debate and share information with each other exclusively , any resulting write ups are also exclusive. Many are not open to the public either because admission is only for stated specialist groups or because the cost of admission is entirely prohibitive for those who are not funded. These events are using information given directly or indirectly by the public and paid for by citizens. On these grounds as well as it being ethically right to make debate inclusive to all citizens - events and conferences which have an impact on or interest to the public should be made open access.

Conflict of Interest:

None declared

As an active participant in the debate that took place in the province of Quebec concerning medical aid in dying (MAID), I would like to take the liberty of commenting on an article by Udo Shuklenk published recently in your journal: "Canada on course to introduce permissive assisted dying regime". In my view, some of the factual information given in this text needs more precision.

First of all, the chronology. In fact, the debate began in Quebec long before and on other bases than in the rest of Canada (ROC). When Gloria Taylor and Kay Carter's family decided to contest the Criminal Code prohibition in British Columbia (BC) in 2009 and 2010, the public debate was already going on in Quebec, where the drive to change was not a court action but a political decision. On December 4, 2009, the National Assembly created a special commission to discuss the issue of end-of-life care in public. When the BC Supreme Court rendered its decision in favour of the plaintiffs in June 2012, this commission had already completed its report, which was submitted on March 22, 2012. And when the Supreme Court of Canada (SC) released its decision in Carter in February 2015, Quebec had already adopted its Act Respecting End-of-Life Care. Adopted on June 5, 2014, the Act has been in force since December 2015. As to the report of the Royal Society of Canada's expert panel, of which the author was a member, it was submitted in November 2011.

So, this "high-profile report of an international expert panel", as the author puts it, may have had a great influence on the SC decision. And it is evident enough that the SC decision itself had a great influence in the debate. But it is a little difficult to follow the author when he concludes: "The other lesson, from Canada at least, is that what was required to drive the change that is now coming was court action." And it becomes almost impossible to follow him when he says, concerning the debate in Quebec: "At the last minute opponents of assisted dying succeeded in raising the access threshold from being a competent adult suffering an irreversibly low quality of life which that adult does not consider worth living by adding a further access criterion: the person must also be towards the end of their lives." I really don't know where this information can have come from. In fact, for many reasons that it would be interesting to discuss more seriously because they are not only contextual, the debate in Quebec was, from start to finish, limited to end-of-life care. This has nothing to do with the opponents' arguments, who were against any opening at all, all along.

I think it is important to be extremely clear about the facts because it might change the perspective on controversial issues such as access criteria or conscientious objection.

With respect to access criteria or scope, the author does not seem capable of even imagining that providing limited access to people near their natural death can be a defensible position. He explains that two committees addressed the issue in their reports since the election of a new parliament in Ottawa at the end of 2015: a provincial-federal expert panel and a parliamentary-senate special joint committee. "These two documents combined arguably constitute the Canadian consensus on this subject matter. Both conclude--in line with the SC decision--that terminal illness should not be an access threshold criterion." Arguably indeed. Why should that kind of overlapping consensus simply override the only one in Canada reached after a vast public discussion and enacted as law? Surely this is a moral and political question worth discussing.

With respect to conscientious objection, the author explains: "Doctors' lobby groups, such as the Canadian Medical Association and religious doctors' groups clearly overplayed their hand when they decided to take a hardline stance on the question of conscientious objection. They lobbied governments to be given the right to refuse to provide either assistance or transfer patients on to a professional who would provide the service." If that is true for doctors in the ROC, it is clearly false for doctors practicing in Quebec who have long been obliged to help the patient find another doctor in the event of conscientious objection. This obligation was reaffirmed in the Act Respecting End-of-Life Care. Besides, it is evident that conscientious objection is much less of a problem when a large part of the population, including doctors, has actively participated in creating the consensus, which has clearly been the case in Quebec. So, there are alternatives to simply taking away conscientious objection rights.

With that information in mind, it is not so easy to conclude that Canada is on course to introduce a permissive assisted dying regime. Maybe this will happen in the long run, but, for now, the fact is that in June 2016 the Parliament of Canada finally voted, despite the recommendations of the advisors they appointed, for a MAID regime somewhat less limited than the Act Respecting End-of-Life Care but much more restrictive than the author anticipated.

Michele Marchand, M.D., Ph.D.(Philosophy)

Conflict of Interest:

None declared

Earp and Moen demonstrate the absence of a relevant difference between the use of prostitutes by disabled people and by shy, ugly, libidinous, able-bodied people, and the impossibility of circumscribing the latter[1]. This is incorporated into a case for the full legalisation of prostitution based on: (a) the absence of a justification for its prohibition; and (b) the "needs" it meets. We posit that (b) misrepresents prostitution and then outline a response to (a).

Earp and Moen develop Thomsen's argument[2] as follows:

(1) Many or most persons have a sexuality that generates strong needs for sexual relations, and (2) Some disabled [or any] persons are partially or entirely incapable of satisfying this need except through the purchase of sexual services from a prostitute. (C) There is a prima facie case for legalising prostitution.

The notion that "the purchase of sexual services from a prostitute" is a response to "strong needs for sexual relations" is problematic. Evidence suggests that men who use prostitutes do not consider themselves to be satisfying such a "need". Punternet.com, a website where men rate their experiences with prostitutes, found that only 28% of punters[i] considered themselves unable to find "free sex"[3]. Similarly only 1 in 5 London punters "[c]an't get what he wants sexually or emotionally in his current relationship"[4]. Men use prostitutes not out of necessity but choice. Outside the simple framework Earp and Moen create, the purported "need for sexual relations" is not fulfilled by the use of a prostitute. This desire is subsidiary to the human drive for social intimacy, to which the mutual giving and receiving of sex contributes. As McKinnon states, "The consideration for sex is sex (and if there's some other consideration then it's something else)"[5]. The Crown Prosecution Service of England and Wales considers it appropriate that "prostitution is addressed as sexual exploitation"[6]. When 55% of men who use prostitutes believe that the majority of women in prostitution have been "lured, tricked or trafficked"[4], this confirms that the behaviour is usually a gratuitous act of conscious abuse.

Given the facts about prostitution, the Nordic model of legislation[5] mentioned by Thomsen[2] is a more appropriate way forward. Indeed, this model deals more effectively with the authors' presented concerns. Earp and Moen correctly point out that prohibition does not make women safer[1]. Criminalising women makes it harder for them to leave prostitution and find a safer way of living. In many settings they are vulnerable to police corruption and violence[5]. This must end. Concurrently, it is reasonable to focus on, and even consider punishing, punters. Just as Earp and Moen proposed using the law as a tool to change social attitudes, this model transfers the stigma away from prostituted women - recognising the complexity of their situation - and instead stigmatises male customers who recklessly participate in abuse. The combination of punter stigma and sanction is likely to reduce demand and in turn decrease trafficking[5]. Analysis of 150 countries found that the degree to which full legalisation expands punter demand far outstrips any increase in legal prostitutes. Countries with legalized prostitution have experienced greater human trafficking inflow[7].

Earp and Moen claim that people are usually granted autonomy regarding choice of work[1]. Trafficked women are evidently denied this, but autonomy can also be influenced and diminished by external factors commonly associated with prostitution such as adverse childhood experiences and grooming. Prospective cohort research shows that child sexual abuse victims are more likely to be prostituted in adulthood than victims of other abuse and neglect [8]. When Earp and Moen speculate "it is likely to be people who are already in very difficult situations who would find it worthwhile to sell sexual services"[1], perhaps that "very difficult situation" includes living with the long-term psychosocial consequences of sexual abuse and trauma. However, they are wrong to assert that reliving this confusing cycle is a positive act of autonomy; it is an act more redolent of a person who needs care, compassion and support to re -establish control over her life. The Nordic Model involves resourcing and training women to find other sources of income, thus expanding their financial autonomy[7]. The authors may not agree that women deserve active help to exit prostitution but, given the extent of trafficking and abuse in the sex industry, this ought to be a priority. Commitment to autonomy of choice of work would include education, training, and resourcing to ensure the choice of prostitution was truly free.

The so-called "need for sexual relations", disabled or otherwise, is penis- rather than person-centric and irrelevant: the use of a prostitute is a different category of act. The best response is to reduce demand and maximise the autonomy of prostitutes.

Footnotes

i. This is London slang for customer and a common term used to describe the men who use prostitutes.

References

1. Earp BD, Moen OM. Paying for sex??only for people with disabilities? J Med Ethics 2016. Published Online First: 5 Nov 2016. doi:10.1136/medethics-2015-103064

2. Thomsen FK. Prostitution, disability and prohibition. J Med Ethics 2015;41:451-9.

3. Myth: punters are lonely single men. Nordicmodelnow.org/myths- about-prostitution/myth-punters-are-lonely-single-men

4. Farley M, Bindel J, Golding JM. Men Who Buy Sex: Who They Buy and What They Know 2009. London: Eaves and San Francisco: Prostitution Research & Education.

5. McKinnon CA. Trafficking, prostitution, and inequality. Harvard Civil Rights Civil Liberties Law Review 2011;46(2):271-309.

6. Legal Guidance: Prostitution and exploitation of prostituted. Crown Prosecution Service. http://www.cps.gov.uk/legal/p_to_r/prostitution_and_exploitation_of_prostitution/#a15

7. Cho SY, Dreher A, Neumayer E. Does Legalized Prostitution Increase Human Trafficking? World Development 2013;41(1):67-82

8. Wisdom CS, Ames MA. Criminal consequences of childhood sexual victimization. Child Abuse & Neglect 1994;18(4):303-18

Conflict of Interest:

None declared