I would like to thank Professor Häyry for his complimentary remarks
on my
paper, and for his three (characteristically) incisive questions. In what
follows,
I will attempt to answer each of those questions in turn.
(i) Häyry asks how I can consistently maintain the conjunction of the
following
three propositions:
(a) taken together, the external and internal perspectives exhaust...
I would like to thank Professor Häyry for his complimentary remarks
on my
paper, and for his three (characteristically) incisive questions. In what
follows,
I will attempt to answer each of those questions in turn.
(i) Häyry asks how I can consistently maintain the conjunction of the
following
three propositions:
(a) taken together, the external and internal perspectives exhaust
the
standpoints available to a prospective parent in thinking about the lives
of
her possible future children;
(b) it is morally inapproriate for a prospective parent to take up the
external
perspective; but
(c) it is not obligatory for a prospective parent to take up the internal
perspective.
Häyry's thought here is that, if it is morally inappropriate for a
prospective
parent to take up the external perspective, and if the internal
perspective is
the only other available, then it must surely be obligatory for her to
take up
the internal. Häyry has clearly detected that I simultaneously feel both
tempted and reluctant to take the hard-line position that adoption of the
internal perspective is a strict duty for prospective parents! But while I
admit
that my intuitions pull me in two directions here, I am not convinced that
this
causes me to fudge the issue.
That is, the opposite of "morally inappropriate" does not seem to me
to be
"obligatory", but rather "morally appropriate". In saying that a
prospective
parent does something morally inappropriate in adoting the external
perspective, I am not suggesting that she is thereby contravening a duty.
Rather, I am saying that she is not, as it were, being the prospective
parent
she might be, since she is not taking up the perspective that is
appropriate
for her qua prospective parent. Now, doubtless it is trivially true that
we
should do what it is morally appropriate for us to do, but it seems to me
that
this claim makes use of a weaker sense of "should" than attaches to
statements of strict obligation. Importantly for my argument in the paper,
however, what does follow from the claim that the external perspective is
morally inappropriate for prospective parents, is that prospective parents
cannot be obliged to follow any principle (such as that of procreative
beneficence) that is rooted in that perspective.
(ii) As Häyry goes on to note, I state in my paper that the external
perspective
is the proper one for political decision makers to adopt, when choosing
policies that will affect which people are born, and the expected quality
of the
lives those people will lead (as in Parfit's conservation/depletion
example,
cited in my paper). Given this, Häyry asks what is to be done about the
apparent clash between the perspectives fitting for parents and for policy
makers, and between the actions that will result from the adoption of
those
perspectives. My answer is that political decision makers will be obliged
not
to interfere with decisions that ought to be the sole preserve of
prospective
parents. I take it that the choice of a conservation or a depletion policy
is not
such a decision, whereas whether to choose a better life embryo or a worse
life embryo is. Häyry's point does me the service of drawing my attention
to
the fact that I ought not to have said that "adoption of the external
perspective ... is obligatory for political decision makers ...", but
rather that it
is prima facie obligatory. I am grateful to him for this.
(iii) Towards the end of my paper, I introduce a principle of
acceptable
outlook (PAO), which I maintain ought to guide prospective parents'
decisions
about which children to produce, in place of Savulescu's principle of
procreative beneficence (PPB). PAO, I say, will take a form similar to "'I
will not
allow any child of mine to have a quality of life below L', where L is a
level of
acceptable outlook ... PAO will typically find expression in such
attitudes as 'I
do not want any child of mine to suffer unacceptably' ...". I also claim
that no
definite answer can be given to the question of where exactly L (the level
of
acceptable outlook) should be fixed, and rather imply that it may differ
from
prospective parent to prospective parent (although I do say that a life
not
worth living will fall below any plausible candidate for L).
Now, given this last point, Häyry asks what is stop a proponent of
PPB from
setting L at "the standard suggested by procreative beneficence", and
holding
that prospective parents either could or should hold a principle of the
form "I
do not want any child of mine to have a life that is worse than the best
life a
child of mine could have had". This, as Häyry notes, would involve the
collapse of the distinction between PAO and PPB.
But that such a collapse would occur ought to give us pause. That is,
if any
prospective parent employed PAO in this fashion, she would, in doing so,
be
making an external perspective judgement about the lives of her possible
future children. Such a judgement is, my paper argues, morally
inappropriate
for a prospective parent, and it is precisely this fact that prevents our
being
able legitimately to flesh out PAO in the way Häyry mentions.
Of course, it may be that a prospective parent locates L at a
standard that, so
to speak, just turns out to equal that of the best life a child of hers
could
have. This might seem a curiously high standard to set, but so long as it
is
not chosen just because it is the level of the best life a child of hers
could
have, it would involve no external perspective judgement, and so no
illegitimate
application of PAO.
Peter Herissone-Kelly[1] makes the case that it would be morally
inappropriate for prospective parents to select their children based on
comparative judgments about their life quality. This view is in stark
contradiction with the view, advanced by Julian Savulescu [2], that
parents have a moral obligation to select the best possible children they
can have.
Peter Herissone-Kelly[1] makes the case that it would be morally
inappropriate for prospective parents to select their children based on
comparative judgments about their life quality. This view is in stark
contradiction with the view, advanced by Julian Savulescu [2], that
parents have a moral obligation to select the best possible children they
can have.
Herissone-Kelly argues that future lives can be assessed from two
mutually exclusive viewpoints: the external and the internal. The external
perspective, assumed by Savulescu in his Principle of Procreative
Beneficence, is according to Herissone-Kelly (pp. 167-168), "obligatory
for political decision makers selecting social policies that will
indirectly affect both who will come into existence in the future, and the
quality of those future persons' lives." It would, however, be (p. 168),
"unfitting ... for prospective parents to take up the external
perspective", indeed, "it would be morally inappropriate for them to do
so."
The use of the internal perspective in parental decision making
leads, Herissone-Kelly maintains, to the rejection of the Principle of
Procreative Beneficence, and to the assumption of an alternative axiom,
the Principle of Acceptable Outlook. This stipulates that possible
children are not compared with one another – the fact that child A could
have a better life than child B is not a fitting (or at least not a
binding) parental reason for choosing A. It also stipulates that parents
are not obliged to have children whose life quality would be at a level
that the parents deem to be unacceptably low.
Herissone-Kelly's principle is in many respects intuitively more
acceptable than Savulescu's. It states that as long as all our potential
children would have a reasonably good life, we may choose any one of them.
(Savulescu would insist that the best must be selected.) It also allows us
not to have children at all, if none of our potential offspring can be
expected to have an acceptable life quality. (Savulescu's principle would
morally oblige us to have a child with a truly miserable life, if there
are no better options).
The claim is interesting and skilfully defended, and the author has
made a considerable contribution to the current discussion on the use of
technology in reproduction. I have three questions concerning the
Principle of Acceptable Outcome, its implications, and its applications.
(i) Herissone-Kelly hovers in the paper between the view that it is
prima facie obligatory for parents to adopt his principle and the view
that it is merely admirable and permissible for them to do so. He is
explicitly (p. 168) "inclined to say that it is not" obligatory, but he
also says that "it would be morally inappropriate" for the parents to take
up the external perspective.
My question is this. If the external and internal perspectives are
the only options available, and if it is morally inappropriate to assume
the external perspective, how can it not be obligatory to take up the
internal view? The logic of moral sentences seems to be that if one of
only two alternatives is wrong, then the one remaining is right in the
strong sense of being a moral duty.
(ii) If what I have said is correct, what are the social and
political implications? Herissone-Kelly states that political decision
makers have an obligation to take up the external view, and in the present
context this means that they should aim for the "best" future population
they can, probably by using all available genetic and medical technologies
in the choice of prospective citizens. The parents, on the other hand,
have an obligation to adopt the internal view, which implies that they
should resist at least some of the authorities' attempts to influence
their reproductive choices. How can this potential tension be handled?
(iii) In the internal assessment of the life quality of possible
children, Herissone-Kelly allows the parents to consider whether their
offspring would suffer unacceptably. He goes on to say that (p. 169) "what
counts as unacceptable suffering, or precisely where the level of
acceptable outlook ought to be fixed, are not questions to which any very
definite answer can be supplied."
If this is so, what prevents a proponent of Savulescu's principle
from arguing that the acceptable level should be set higher, to the
standard suggested by procreative beneficence? Parents could (or should?)
arguably have the attitude that "I do not want any child of mine to have a
life that is worse than the best life a child of mine could have had". In
this case, the difference between the principles would seem to evaporate.
References
[1] Herissone-Kelly P. Procreative beneficence and the prospective
parent. J Med Ethics 2006;32:166-169.
[2] Savulescu J. Procreative beneficence: why we should select the best
children. Bioethics 2001;15:413-426.
As a surgeon my attention was caught by the opening question "What
should we say to the man who has lost an arm in a farming accident", in
Savelescu, Foddy and Rogers' article on the clinical ethics of "What
should we say?" 1 Having read their article I believe the authors failed
to address the practicality of ethical difficulties in this and other
clinical scenarios.
As a surgeon my attention was caught by the opening question "What
should we say to the man who has lost an arm in a farming accident", in
Savelescu, Foddy and Rogers' article on the clinical ethics of "What
should we say?" 1 Having read their article I believe the authors failed
to address the practicality of ethical difficulties in this and other
clinical scenarios.
By introducing their own personal experiences as example, I think
that they immediately fell into the ethical trap which they were trying
to expose. That is the clinician viewing an illness and the ethics of
clinical practice in terms of their own, personal context as opposed to
the patient’s personal context
Furthermore, I believe the authors’ related negative experiences
have biased the article.
It is of course difficult to know what to say to a patient at times,
and as a clinician I have heard many of the quoted statements made by
family and physician, and indeed the patient themselves, as a means to
address and understand a set of circumstance, be it a broken arm or
cancer.
The primary goal of the physician who is unsure what to say following
trauma or any illness is very simple. One must restore control of the
situation to the patient. There are no “best treatments” in medicine. He
or she must be told what the problem is, and how it can be addressed.
Knowing what the treatments are, and the consequences of no treatment, the
individual is allowed to make an informed choice, choosing which
treatment is best for his set of circumstances. While knowledge of these
circumstance is informative, it should not prejudice the clinician.
The context of the patient’s diagnosis is vital to any relationship
with them. A soldier on the battlefield with a minor shrapnel wound to
face, it is likely that to be relieved to have survived, a Vogue® model
with a similar injury would more likely be devastated. The skill as a
physician is in recognising the patients own present fears, and future
aspirations, expectations, and worries. While we can restore control of
the immediate situation to a degree, we must educate patients of the
expected progress of an injury, or illness, including whether full
restoration of function is likely, the timeframe for recovery, and future
adverse possibilities. In so doing a patient experiences not complications
but consequences. What is a “gaping hole” in a calf may be viewed in
context as a healed wound. Albeit one which may require revision. In many
ways it is not how we say it but what we say.
Lance Armstrong was an athlete at 25 years of age when he developed
advanced cancer, Initially given a dismal chance of survival, even with
treatment, he nonetheless chose to undergo resection of brain metastasis,
chemotherapy; and subsequently has become one of the greatest athletes
alive. Having made dramatic recovery, and “rebuilding” his physique he
stated, "my ability to suffer a lot of pain and suffering helped me a
lot"2.
Happ was the Middle English word for chance, or fortune, from which
are derived words like happens, happenstance, hapless, but also happiness.
If more good things happen to us in life, than bad, then we may consider
ourselves happy 3. Clinical practice is similar. The patient who perceives
that good decisions have been made during treatment, and who knows to
expect possible adverse effects is more likely to be happy with their
treatment, even if the course of that treatment is not always smooth.
The perceived ability to have influence on one’s fate may restore
confidence and happiness to our patients.
In answer to the question posed by the authors; "What should we say?"
I believe that it is our duty as clinicians to establish a relationship
with the patient, determine what has happened, and then explain the nature
of what has happened to the patient, in terms that are clear and
understandable, with the advantages and disadvantages of any treatment.
Any comment or statement made before assessing the patient will ring
hollow.
When explaining to the patient following injury, a phrase I commonly
use is:
"You are unfortunate to have X injury, but fortunately we can offer
you Y".
I agree that illness may create a communication gap between patient
and clinician. It is the duty of a clinician to recognise such a gap and
ensure that the patient remains enabled in the decision making process.
Where there is difficulty in establishing such a clear relationship or
when the patient is incapable, through physical or mental illness then
ethical consideration must be as to who is best able to help the patient
in the decision making process. Simply establishing the competence of some
patients decision making ability is often incredibly difficult. In
particular when they present acutely with others whose opinion may be
biased. This is a very difficult area for the practicing clinician
involved in acute care. While I appreciate that theirs is an abstract
paper I believe the focus must ultimately be practical.
Absolute statements in general should be avoided. There will always
be patients who disprove the rule. For this reason I disagree completely
with their statement;
"A sick person will struggle to express the extent of their suffering
when we say, as was said to John "You are looking well"".
While at times a patient may correctly perceive the clinician who
says this to be completely dishonest, and disinterested in exploring real
concerns of the patient, for others, who have an established relationship
of trust with the clinician, this statement may restore true hope in the
future.
Returning to the scenario introduced by Savulescu et al, the patient
who has had an arm cut off in a farming accident, is unfortunate to have
had the accident, but fortunate to arrive in a timely fashion to a
microsurgical unit. Appropriately counselled, he may chose to have his arm
reattached and accept stiffness, numbness, scarring , risk of sepsis,
reduced function and need for future operations, or, may accept
disability , simply have the stump sutured, and return sooner to his work.
References
1. Savulescu J, Foddy B, Rogers. What should we say?
J.J Med Ethics. 2006 Jan;32(1):7-12.
2.Martin Cannellakis Director, The Science of Lance Armstrong,2005
Discovery Channel.
3.Lancaster J Pursuing Happiness, New Yorker. 2006 February 27;74(42):40,
78-82.
The case of an adolescent with terminal respiratory failure, sedated
and mechanically ventilated, raised the dilemma weather or not awaking him
to make him aware of his impending death and permit him to exercise
autonomous choices [1]. In the difficult task of weighing the various
ethical arguments for or against, the healthcare team ultimately agreed
with parents that it would be too distressing fo...
The case of an adolescent with terminal respiratory failure, sedated
and mechanically ventilated, raised the dilemma weather or not awaking him
to make him aware of his impending death and permit him to exercise
autonomous choices [1]. In the difficult task of weighing the various
ethical arguments for or against, the healthcare team ultimately agreed
with parents that it would be too distressing for the child to awake him
[1]. The commentary accompanying the paper [2] independently judged
benefits as “perhaps not strong enough to outweigh the possible burdens”.
Hence in this case non-maleficence, expressing the “objective” best
patient’s interest, as seen by caregivers and parents, prevailed over
patient’s autonomy [1,2].
Since the same questions and ethical concerns would arise in the case
of adult patients [2], I would refer to a very similar clinical situation
previously published [3], to propose some additional comment. An adult
woman underwent an emergency intubation and was sedated shortly before a
diagnosis of terminal lung cancer involving the trachea. The ethical
problem was again weather or not awaking her, in order to give her
information and allow autonomous decisions. Diverging positions were
discussed and finally she was not awoken.
Interestingly, the case was subsequently proposed to a sample of
healthcare professionals (mostly physicians and nurses), in order to know
the way the case was perceived and would be handled [4]. A strong
correlation was found between the preference expressed by participants for
themselves, if they were in the place of the patient, and what they would
do if in charge of the patient. These empirical data suggest that
subjective factors can heavily influence the recommended course of action.
It is not a surprising conclusion, since it is in keeping with the Golden
Rule: "Whatever you wish that men would do to you, do so to them"[5] .
But participants were almost equally divided between the two
alternatives, showing that personnel attitudes actually differ [4]. In
that case it seemed impossible to find an “objective” best patient
interest, defined by what a reasonable person would prefer in a defined
situation [4], because reasonable persons expressed opposite views.
As far as one acknowledges inter-subjective variability, the risk of
paternalistically projecting values and preferences on a person, that only
hypothetically shares them, is to be considered carefully. In the
adolescent case, parent’s choice was not “to risk any chance that their
son might be distressed” [1]. They knew the possible reactions of their
child and finally all the participants to a multidisciplinary meeting
agreed with them. There is no reason to draw different conclusions,
especially not being there at that moment. Similarly in the adult woman
case it was stated that, “there are limits to imposing suffering on
patients in order to grant them autonomy in decisionmaking” [3].
In general terms, one can object that “only patients themselves can
know exactly what those limits are” [3]. In weighing burdens and benefits,
subjectivity matters: something unbearable for one person may be
acceptable for another and something irrelevant for one person may be of
some interest for another. Accordingly, in the adult woman case, one
position supported the option to awake and inform the patient. Instead of
an all or nothing single action, the attempt was viewed as a series of
discrete steps. This appeared to be a useful approach, in order to
minimize harm: the sedation would be withdrawn and the patient asked if
she was able to tolerate, then if she wanted to know, if she wished to
participate in decisions or delegate others, etc.; sedation would readily
be re-induced if desired [3]. This way, the patient herself would have
weighed burdens and benefits, using her own values and current feelings.
Could the same approach have been considered in the child case as well?
The clinical situation discussed in these ethical cases is frequent,
as an European survey in 6 different countries found that 23-51% of deaths
were preceded by any end-of-life decision [6]. The ethical scrutiny of
such decisions is not yet a rule in clinical practice: in a significant
fraction of cases the evaluation formulated by physicians, beneficially
but subjectively, was de facto considered by them as coincident with the
“objective” best patient’s interest, either for incompetent or competent
patients, since these decisions were discussed neither with the patients
nor with relatives, nor with other caregivers [6]. The abovementioned
Golden Rule still appears to be more popular than the aphorism by G.B.
Shaw: “Do not do unto others as you would that they should do unto you.
Their tastes may not be the same”. As provocatively asked by B.S. Helger,
is beneficence for today and autonomy (maybe) for tomorrow ? [3]
Conflicts of interest: none.
References
1 Vince T, Petros A. Should children’s autonomy be respected by
telling them of their imminent death ? J Med Ethics 2006;32:21-23.
2 Godkin D. Should children’s autonomy be respected by telling them
of their imminent death ? J Med Ethics 2006;32:24-25.
3 Helger BS, Chevrolet JC. Beneficence today, or autonomy (maybe)
tomorrow? Hastings Cent Rep 2000; 30:18-19.
4 Helger BS, Chevrolet JC. Attitudes of heath care workers towards
waking a terminally ill patient in the intensive care unit for treatment
decisions. Intensive Care Med 2003;29:487-490.
5 Matthew 7:12.
6 van der Heide A, Deliens L, Faisst K, et al. End-of-life decision-
making in six European countries: descriptive study. Lancet 2003;361:345-350.
Schaller and Kessler (J Med Ethics 2006;32:65-69) offer an admirable
and most welcome account of the way in which these (regrettably common)
decisions should be made, with due regard for the ethical as well as the
clinical imperatives and free of pressure from those without direct
responsibility for their patients.
It is particularly pleasing to note their emphasis on the need for
observati...
Schaller and Kessler (J Med Ethics 2006;32:65-69) offer an admirable
and most welcome account of the way in which these (regrettably common)
decisions should be made, with due regard for the ethical as well as the
clinical imperatives and free of pressure from those without direct
responsibility for their patients.
It is particularly pleasing to note their emphasis on the need for
observation over adequate - sometimes prolonged - periods of time as the
necessary basis for a sufficiently robust working prognosis. Even then -
as they aver in reference to the two initially-unexpected survivals - it
is necessary "to refrain from making dogmatic statements which are
regarded as being beyond contradiction". Had that caveat been observed by
those who (from 1976 onwards in the UK) insisted that an invariably fatal
prognosis attached to the syndrome known as "brain stem death" - diagnosed
by simple bedside tests after only a few hours' of ventilator-dependent
coma - much trouble could have been avoided.
Why is it that despite having many of the same concerns about how
ethics may be included within undergraduate medical curricula, I write to
state my concerns about Cowley's formulation and conclusions?
I think my main problem is with an argument which starts from a
position of criticising 'universalising' but offers as a substitute, the
idealising of another universality - 'their own healthy i...
Why is it that despite having many of the same concerns about how
ethics may be included within undergraduate medical curricula, I write to
state my concerns about Cowley's formulation and conclusions?
I think my main problem is with an argument which starts from a
position of criticising 'universalising' but offers as a substitute, the
idealising of another universality - 'their own healthy intuitions and
vocabulary'. What is it that can assist in promoting an appreciation of
what might be a 'healthy', as opposed to an 'unhealthy', intuition? At the
risk of immediately undermining my argument by indulging in psychoanalytic
jargon derived from Freud (who for some reason was brought into the
argument for no reason other than to dismiss him, along with Marx),
idealisation of any form does not reflect the true value or merits of
something, but builds a part into the whole: maintaining this position
requires, as its counterpart, something else to denigrate and similarly
does not involve a proper valuation of that other thing. It does not act
ultimately in the service of better understanding.
Similarly, the use of ordinary language is something to be applauded,
particularly where it enhances understanding. In Manchester, 'Step 1' in
our '8-step PBL' process is 'clarify unfamiliar terminology'. I think this
should be accompanied by 'Step 1b', 'clarify apparently familiar
terminology'. It is not only the Americans and the British who may be
separated by a common language: unquestioned assumptions about a shared
understanding of meaning can be just as dangerous as spurious use of
technical jargon to give power to position or argument. My own experience
is that it is sometimes only through the use of the technical tools with
which I've become equipped that I arrive at the 'ordinary words' which
communicate best. This is in keeping with a part of Cowley's argument i.e.
the need to ensure that a full appreciation of process (of events and
experiences)in people's lives is part of what we learn and teach.
I wholeheartedly agree with Cowley about avoiding situations where
concepts inhibit rather than promote thinking. We all have plenty of
material relating to ethical dilemmas to work on from our lives, but are
we able to make of this material the tools to assist us not only in our
own personal lives but also in our professional lives? No one school of
thought can give us the answers to all problems, but they may help. The
use of technical concepts needs to be differentiated from their abuse.
Hence, part of what is required is the promotion of a learning environment
in which we can truly examine behaviour and values, if not without
prejudice, at least through seeking to minimise it. Examining whether we
are behaving reasonably and with good reasoning is a process for life.
Dismissing the use of carefully considered constructs, rather than
learning the limits of their use, is likely to be just as unhelpful as
believing that we cannot learn from life.
I read and reread this article, and was both very fascinated and
greatly disturbed by it. I wholeheartedly agree that nurses should make
every attempt to persuade a patient who is refusing a procedure they know
to be in the best interests of the patient. There are times when the
procedure being refused is absolutely necessary and must be done. It is my
belief that nurses need to attempt to discover "wh...
I read and reread this article, and was both very fascinated and
greatly disturbed by it. I wholeheartedly agree that nurses should make
every attempt to persuade a patient who is refusing a procedure they know
to be in the best interests of the patient. There are times when the
procedure being refused is absolutely necessary and must be done. It is my
belief that nurses need to attempt to discover "why" the patient is
refusing. I know, in my own case, that I would probably refuse having a
foley catheter inserted. Why? I just simply cannot handle even the
thought of this procedure, much less lying relaxed and actually having it
done! I would, however, agree to the catherization if I could be sedated
to where I would not be aware of it occurring. sometimes there are
interventions which could result in the consent of the patient, maybe
doing a procedure a little differently than is normal to accommodate the
patient. And how is it that a nurse can assure a patient that the
catherization will not hurt, as stated above in the article, if they
themselves have not experienced it?
While agreeing in the most part with the premise of the article, I was
also greatly disturbed by the action of the nurses in forcing non
compliant patients to have the procedure anyway. I was also completely
turned off by the attitude of "we know best" and the patient be damned.
No one, not even the most brilliant doctor or the best educated and caring
nurse know what is in my best interests better than ME. Courts all over
this country have upheld the right of the patient to refuse any and all
medical care if he so chooses. Has anyone ever brought assault and battery
charges against any of these nurses choosing to ignore this right? Nowhere
in the law is it stipulated that patients have the right to refuse
treatment, only if his nurse agrees with it. If any nurse ever forced a
procedure on me after I had explicitly refused, the only reason he or she
would be allowed back in my room would be to apologize. All the faith and
trust I ever had in the medical profession would be shattered and I would
never trust a nurse again.
In conclusion, I offer this suggestion. I understand that catheter
insertions are normally done without anaesthetics or painkillers. I
reiterate - normally. If the patient refuses this procedure and in
dialogue with them it is discovered that it is not the catherization
itself they are refusing, but are simply frightened by the pain and
discomfort it may cause. simply altering the manner in which the procedure
is done, sedating until peacefully asleep, may result in the patient
agreeing to have it done, rather than risk patient alienation by forcing
it upon them. I realize further that this is far from simple and that not
all patients can be anaesthetized, but it can be a starting point. my
personal feeling is that, if hospitalized, I would not refuse any
intervention that needs to be done - as long as provisions are made
to make it tolerable and every attempt is made to accommodate my wishes.
It is extraordinary that Rawlins and Dillon can open their paper with
the accusation that Harris has 'no understanding of the quality adjusted
life year'. I can only conclude that they did no background reading, other
than reading Harris's editorial (1), before they wrote their response to
him.
One would also think, from reading Rawlins and Dillon, that there was
no argument at all about QALYs,...
It is extraordinary that Rawlins and Dillon can open their paper with
the accusation that Harris has 'no understanding of the quality adjusted
life year'. I can only conclude that they did no background reading, other
than reading Harris's editorial (1), before they wrote their response to
him.
One would also think, from reading Rawlins and Dillon, that there was
no argument at all about QALYs, whereas it is actually one of the most
vigorous areas of debate within medical ethics.
I have some sympathies with Rawlins and Dillon when they suggest
Harris, and philosophers in general, live in a 'parallel - value and cost
free - universe', but Rawlins and Dillon seem to be living in a mono-value
universe: their own. To that extent, NICE shares a feature with many other
innovations of the present government.
Harris is right in his riposte (2) to Rawlins and Dillon to consider
the misrepresentation of the word 'excellence'. NICE was supposed to be
the Institute of Clinical Effectiveness but, supposedly, the politicians
insisted instead on excellence. My own view is that it should have been -
and still should be - the Institute of Clinical Expediency (3) and what we
urgently need is the 'engagement and debate' that Harris asks for, 'making
decisions which determine who will live and who will die, who will receive
medical treatment and who will not'. There seems little chance of that,
when the political response to individual cries for Herceptin in breast
cancer, for example, elicit only the bullying of Trusts by the Secretary
of State for Health.
References
1. Harris J. It's not NICE to discriminate. J Med Ethics 2005;31:373-
5.
2. Harris J. Nice and not so nice. J Med Ethics 2005;31:685-688.
3. Goodman NW. NICE and the new command structure: with what
competence and with what authority will evidence be selected and
interpreted for local clinical practice. Ch. 2 in: Miles A, Hampton JR,
Hurwitz B. NICE, CHI and the NHS reforms. Enabling excellence or imposing
control? London: Aesculapius Medical Press, 2000, pp. 33-50.
I truly don't understand why a competent person is a felon for
deciding to sell one of their own body parts to give potential life to
another person. The lack of donors (supply) is well documented. Yet, I
read on craigslist.org EVERY day in the job classifieds ad after ad for
sperm donors ($600) and egg donors ($1500). I honestly don't get the
difference. I know I cruised through quickly some of the a...
I truly don't understand why a competent person is a felon for
deciding to sell one of their own body parts to give potential life to
another person. The lack of donors (supply) is well documented. Yet, I
read on craigslist.org EVERY day in the job classifieds ad after ad for
sperm donors ($600) and egg donors ($1500). I honestly don't get the
difference. I know I cruised through quickly some of the article and one
of the salient points was what was considered "a body part that could be
parted with". This is all so subjective. ALL of these body tissues are
life giving. THAT is the point. There has never been controversy over
whether it's ok to pay for making babies, but yet we freak over paying to
SAVE a baby or person already alive.
Please let me know if anyone has any insight into this conundrum.
I did enjoy this article for it canvassed much of the disquiet I have
felt over the Four. The problem arises when the principles are
extrapolated to being rules, like changing a dirt road to a railway line –
the user is no longer permitted to leave the track. Regrettably much of
medicine has been taught in this way, the principle of evidence based
practice, which has always been present (its just that th...
I did enjoy this article for it canvassed much of the disquiet I have
felt over the Four. The problem arises when the principles are
extrapolated to being rules, like changing a dirt road to a railway line –
the user is no longer permitted to leave the track. Regrettably much of
medicine has been taught in this way, the principle of evidence based
practice, which has always been present (its just that the quality and
accessibility got better), has been converted into a set of absolute
rules; Learning physical examination becomes a set of lists of signs and
symptoms to be “found” in a “case”. The other aspect so neatly covered is
the “professionalisation” of Medical Ethics with the growth of jargon to
establish academic cred.
To define that there will always be people who cannot make a decision and
will defer to an “expert” is an acknowledgement of reality, and our
failure in basic education. That there will be circumstances where
Autonomy cannot apply, where Justice is irrelevant, were beneficence and
non maleficence are simply inappropriate is inevitable and our students
will need both the intellectual and emotional skills to cope is also a
truism.
So how do we find the best way of discussing ethics in clinical problem
solving? Surely it is not in having “Medical Ethics 101” in the
University course database, with grades, success and failure. Is it not
better to consider ethics as a topic heading for every clinical problem we
use in PBL just as we have signs, symptoms, pathophysiology, behaviour
etc.
Ethics is just one aspect of clinical medicine, and like medicine it is so
diverse and complex that only broad classifications can be used – it is
certainly not a field for absolutism.
Dear Editor,
I would like to thank Professor Häyry for his complimentary remarks on my paper, and for his three (characteristically) incisive questions. In what follows, I will attempt to answer each of those questions in turn.
(i) Häyry asks how I can consistently maintain the conjunction of the following three propositions:
(a) taken together, the external and internal perspectives exhaust...
Dear Editor,
Peter Herissone-Kelly[1] makes the case that it would be morally inappropriate for prospective parents to select their children based on comparative judgments about their life quality. This view is in stark contradiction with the view, advanced by Julian Savulescu [2], that parents have a moral obligation to select the best possible children they can have.
Herissone-Kelly argues that futu...
Dear Editor,
As a surgeon my attention was caught by the opening question "What should we say to the man who has lost an arm in a farming accident", in Savelescu, Foddy and Rogers' article on the clinical ethics of "What should we say?" 1 Having read their article I believe the authors failed to address the practicality of ethical difficulties in this and other clinical scenarios.
By introducing thei...
Dear Editor,
The case of an adolescent with terminal respiratory failure, sedated and mechanically ventilated, raised the dilemma weather or not awaking him to make him aware of his impending death and permit him to exercise autonomous choices [1]. In the difficult task of weighing the various ethical arguments for or against, the healthcare team ultimately agreed with parents that it would be too distressing fo...
Dear Editor,
Schaller and Kessler (J Med Ethics 2006;32:65-69) offer an admirable and most welcome account of the way in which these (regrettably common) decisions should be made, with due regard for the ethical as well as the clinical imperatives and free of pressure from those without direct responsibility for their patients.
It is particularly pleasing to note their emphasis on the need for observati...
Dear Editor,
Why is it that despite having many of the same concerns about how ethics may be included within undergraduate medical curricula, I write to state my concerns about Cowley's formulation and conclusions?
I think my main problem is with an argument which starts from a position of criticising 'universalising' but offers as a substitute, the idealising of another universality - 'their own healthy i...
Dear Editor,
I read and reread this article, and was both very fascinated and greatly disturbed by it. I wholeheartedly agree that nurses should make every attempt to persuade a patient who is refusing a procedure they know to be in the best interests of the patient. There are times when the procedure being refused is absolutely necessary and must be done. It is my belief that nurses need to attempt to discover "wh...
Dear Editor,
It is extraordinary that Rawlins and Dillon can open their paper with the accusation that Harris has 'no understanding of the quality adjusted life year'. I can only conclude that they did no background reading, other than reading Harris's editorial (1), before they wrote their response to him.
One would also think, from reading Rawlins and Dillon, that there was no argument at all about QALYs,...
Dear Editor,
I truly don't understand why a competent person is a felon for deciding to sell one of their own body parts to give potential life to another person. The lack of donors (supply) is well documented. Yet, I read on craigslist.org EVERY day in the job classifieds ad after ad for sperm donors ($600) and egg donors ($1500). I honestly don't get the difference. I know I cruised through quickly some of the a...
Dear Editor,
I did enjoy this article for it canvassed much of the disquiet I have felt over the Four. The problem arises when the principles are extrapolated to being rules, like changing a dirt road to a railway line – the user is no longer permitted to leave the track. Regrettably much of medicine has been taught in this way, the principle of evidence based practice, which has always been present (its just that th...
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