As somebody who has been lied to by doctors in the past, albeit not
about psychiatric drugs, this article makes my heart sink. Two weasel
phrases especially shriek out:
'The potential problem with placebos is that they may involve
deception.' The level of self deception in this statement is glaringly
obvious. Placebos involve deception. Parents and carers at times allow themselves to
lie to their children about medi...
As somebody who has been lied to by doctors in the past, albeit not
about psychiatric drugs, this article makes my heart sink. Two weasel
phrases especially shriek out:
'The potential problem with placebos is that they may involve
deception.' The level of self deception in this statement is glaringly
obvious. Placebos involve deception. Parents and carers at times allow themselves to
lie to their children about medicines, they openly acknowledge what they
are doing and take the responsibility for their action. But, if as time and
time again history shows that people lose trust in physicians who lie,
why advocate such a deception? The reason given, that drugs do not work, is
not an acceptable reason. Open compassionate mutual respect together with
appropriate psychological skills may. Some people will seek alternative
help themselves, they do not need to have their choices taken away by
tricks similar to those used by charlatans of past centuries. Study after
study has shown that the quality of relationship between practitioners and
individuals is key to non-drug help for depression, whether through
therapy or other support. The proposal in the paper treats people in a very
patronising manner. Drugs have side effects which must be explained. Would
there be further lies with regard to prescribing a placebo? Would it need
to have built in side effects as people are not as stupid as to think
there would be no side effects to drugs? Parents are in an ongoing
relationship with children and can judge how to treat them in a way it is
simple impossible in what is a very different professional client -
practitioner relationship.
'It is therefore possible there may be a limited unavoidable role for
deception in medicine.'
This statement is equally chilling. Who decides who is to be deceived?
Obviously the most uninformed members of the population will be easier to
dupe. It has overtones of the horrors of medical experiments and
treatments whereby certain populations have been deceived by the medical
profession. People would eventually find out and there will be another
unavoidable scandal and leak of trust. Finally what about the
psychological health of practitioners who prescribe treatments designed to
deceive?
In their recent piece, "Synthetic Biology and the Ethics of
Knowledge," Thomas Douglas and Julian Savulescu argued for an "ethics of
knowledge," in which bioethicists engage with the ethical issues
surrounding the pursuit and dissemination of scientific knowledge.1 Their
focus, as the title suggests, is the rapidly expanding field of synthetic
biology.
While I agree with the general claim made by Douglas and Sa...
In their recent piece, "Synthetic Biology and the Ethics of
Knowledge," Thomas Douglas and Julian Savulescu argued for an "ethics of
knowledge," in which bioethicists engage with the ethical issues
surrounding the pursuit and dissemination of scientific knowledge.1 Their
focus, as the title suggests, is the rapidly expanding field of synthetic
biology.
While I agree with the general claim made by Douglas and Savulescu, I
might suggest that they underestimate the nature of the field of synthetic
biology, and precisely what it might do to the life sciences in general.
In this, they undersell themselves in what precisely this emerging field
demands of the bioethics--and indeed the academic community--in general.
An ethics of knowledge, particularly of what research should or
should not occur for moral reasons, is so important because of the way in
which the life sciences is being radically deskilled. That is, the
science is not only becoming ubiquitous within the traditional academic
and research communities, but within a community of enthusiastic amateurs
who are only beginning to manifest their genius at synthetic biology.
Websites such as DIYBio,2 or the Personal Genome Project,3 are rapidly
breaking down the walls between the professional and the "expert amateur"
scientist.
Douglas and Savulescu noted in their initial thought experiment that:
[An old college friend has] discovered a new, cheap way to produce
synthetic viruses using out-of- date bench top DNA synthesisers that are
now ubiquitous, even in developing countries... [but] every major military
and terrorist group in the world has access to these obsolete
synthesisers. It would take only one malevolent agent and one such machine
to produce enough vaccine-resistant smallpox virions to devastate
humanity.
While the authors date this 2020, the truth is that 2020 is an
optimistic assessment. "Garage," "Open Source," or "DIY" Biologists have
already constructed a low-budget PCR thermocycler, the LavaAmp.4 While
they are still a ways away from the synthesis of life, we ought not to
underestimate the potential these groups possess to alter the way the life
sciences is pursued.
With this in mind, ethical analysis of the pursuit of research needs
to advance and engage not just with the professional, but with the amateur
(and in this sense, amateur is far from a pejorative term) community in
terms of an ethics of knowledge. This requires greater public engagement
by bioethicists and life scientists with the growing communities all over
the world who may one day become a significant player in synthetic
biology.
An ethics of knowledge must not only aim to encompass professional
guidance and ethics, but practical ethics for humanity at large. This is
no small feat. As Douglas and Savulescu argue, it is often--and
unconvincingly--argued that knowledge is separated from its use.
Challenging and providing an alternative to this accepted wisdom will
require not only serious academic endeavour, but positive and constructive
public engagement regarding the appropriate uses of knowledge, and how
best to avoid, mitigate or manage the harms that may result. Without
engagement with the relevant communities, we risk alienating them, which
may cause serious setbacks or even exacerbate the harms caused by the
misuse of synthetic biology.
Moreover, we need to seriously reexamine the ways in which the
advances in one area affect other areas of research. DIY biology may
someday come to pose a serious public health hazard, and the sooner we are
prepared for that eventuality, the better. As it is, the folks engaged
with DIY biology are already hard at work on these problems. But there is
always room for more engagement with the field. This in turn requires a
more sustained engagement by bioethicists with the field of public health,
a field which is still underdeveloped.
I would like to commend the authors on their well researched overview
of doctor-patient interactions across a gender divide for a Muslim
context. I would like to add two points to this discussion which I feel
were overlooked:
1) With the Muslim medical profession, there exists some disagreement
amongst Muslim physicians as to what the limits are when a male doctor
needs to examine a female patient.
I would like to commend the authors on their well researched overview
of doctor-patient interactions across a gender divide for a Muslim
context. I would like to add two points to this discussion which I feel
were overlooked:
1) With the Muslim medical profession, there exists some disagreement
amongst Muslim physicians as to what the limits are when a male doctor
needs to examine a female patient.
Some Muslim physicians feel the rules limiting physical contact
between genders should not be applied to a medical context. Those that
hold this view cite the example (not mentioned in this article) of female
Muslims treating wounded non-related Muslim males in the battles during
the life of the Prophet Mohammed (peace be upon him).
2) The authors mention the concept of necessity: it is necessary to allow what is
prohibited in certain cases. An example of this would be a pregnant female
patient having complications during delivery. If the case required
specialist skill beyond the ability of the female health care providers
available, all would recognise and accept the intervention of a male
obstetrician who had the necessary expertise. All Islamic jurists agree on
this.
However the subsequent question posed by this Islamic stance is how
would such expertise be produced in a male physician? It undoubtedly
requires prolonged exposure to normal and low-moderate complexity cases in
such a specialty. A male physician cannot get such experience except by
practicing in situations of non-necessity.
This creates a dilemma for the Islamic jurist which I have not yet
seen addressed amongst those scholars who state that female patients must
be seen by female doctors. In order to create a male physician with
expertise that can intervene in situations of necessity, such a physician
must have gained experience with female patients in situations of non-
necessity. So does this make it allowable for male physicians to examine
female patients for the purpose of training?
I feel that these Islamic differences of opinion are extremely
relevant to this discussion of cross gender interactions involving Muslim
patients.
To the authors of Muslim patients and cross-gender interactions in
medicine: an Islamic bioethical perspective
Thank you for a very clear and comprehensive explanation of the
Islamic bioethical perspective on cross-gender interactions in medicine.
It is of utmost importance that doctors should at all time take note of
the cultural and religious background of all patients and practice
accordingly. I refer to a...
To the authors of Muslim patients and cross-gender interactions in
medicine: an Islamic bioethical perspective
Thank you for a very clear and comprehensive explanation of the
Islamic bioethical perspective on cross-gender interactions in medicine.
It is of utmost importance that doctors should at all time take note of
the cultural and religious background of all patients and practice
accordingly. I refer to a very important paragraph in your article
"Muslims may be treated differently due to stereotyping or lack of
familiarity with their cultural practices and values". You end the
paragraph with the most important aspect of any interaction between people
from different cultural and religious background even if they are of the
same gender and that is "trust".
All doctors must be equipped with basic knowledge and skills. It is
expected of doctors to be able to diagnose and treat any patient
presenting with a complaint within his or her scope of practice. Students
should be encouraged to acquire these skills and become confident in
applying them in all situations. The one threat is that by assuming and
not enquiring whether a patient would object to being subjected to
adequate physical examination to come to a working diagnosis, doctors may
revert to defensive measures and do laboratory and radiological
examinations without even trying to examine patients. This may compromise
the quality of care and cause the impression of patients being
stereotyped. Thus the most important aspect is to determine what the view
of the patient is but also to communicate the need for certain physical
examination procedures to be done. We should not create the impression
that we can auscultate the heart or lungs through two layers of clothing
or palpate the abdomen without exposing in a respectful way obtaining the
consent from the patient. Patients do not know that these practices yield
no valuable information. As you mentioned it is often only needed to ask
and explain to find that patients who might have been reluctant to be
examined may actually willingly submit to physical examination. Young
students who come from the same Muslim background need to be guided and
need to acquire excellent communication skills to build rapport and gain
trust from patients to assist in the process of obtaining consent to
examine and confidently draw appropriate conclusions and management plans.
EAM Prinsloo
Department Family Medicine
Faculty of Medicine and Health Sciences
UAEU
I read Dr. Seale's article with interest, but am concerned that his
findings may not represent the actual activity of the medical profession,
whatever their beliefs.
The questionnaire asked doctors to state their religion, then how
religious they were. They were then asked to recall the last patient who
died and to answer questions about "ethically controversial decisions".
Isn't it possible (or...
I read Dr. Seale's article with interest, but am concerned that his
findings may not represent the actual activity of the medical profession,
whatever their beliefs.
The questionnaire asked doctors to state their religion, then how
religious they were. They were then asked to recall the last patient who
died and to answer questions about "ethically controversial decisions".
Isn't it possible (or even likely) that this may have altered the mindset,
or the recall of the doctors? In being asked to think about their
religion, and examine how religious they were, were the investigators not
biasing their results so that religion would play a greater role in the
doctors responses? Would someone who considered themselves "extremely
religious" be less likely to recall or record an activity which could be
considered in conflict with their religious teachings? It might be useful
to repeat the experiment on a group of doctors, without asking about their
religion, and see if the same spread of answers was achieved.
The above caveat taken into consideration, Seale's evidence suggests
those who were "very or extremely non-religious" were more likely to have
discussions, as well as being more likely to perform actions which might
ease their suffering and, by secondary intent, hasten death. I wonder
whether it was precisely because discussions were had that the increase in
sedation etc. occurred: were the non religious doctors simply carrying out
their patients' wishes? There is a significant body of evidence that
patients wish to have end of life issues, for example resuscitation,
discussed with them (1, 2) but despite this, doctors are still reticent in
initiating such conversations. As Dr.Seale suggests in his conclusion, we
should all be more mindful of the influences at play in deciding not only
which treatments to give, but whether or not we are respecting patient
autonomy.
Dr. Zoe Fritz
Bibliography
1. Morgan R, King D, Prajapati C, Rowe J. Views of elderly patients and
their relatives on cardiopulmonary resuscitation. BMJ 1994;308:1677-8.
2. Cotter PE, Simon M, Quinn C, O'Keeffe ST. Changing attitudes to
cardiopulmonary resuscitation in older people: a 15-year follow-up study.
Age Ageing 2009;38:200-5.
It is difficult to police the use of stored specimens across borders
and different jurisdictions. While many research participants may not
stand in immediate personal danger, it is obvious that many collaborating
partners are being exploited. When laboratory based studies are done on
these samples, the originating partners miss out on publications. If
one runs a simple survey on authorship of these publications, very few...
It is difficult to police the use of stored specimens across borders
and different jurisdictions. While many research participants may not
stand in immediate personal danger, it is obvious that many collaborating
partners are being exploited. When laboratory based studies are done on
these samples, the originating partners miss out on publications. If
one runs a simple survey on authorship of these publications, very few
names of African authors are found. Is this not a form of exploitation?
The other fear is community harm. Often times one comes across
genetic markers that may be used to alter fertility or be used by people
of diabolic minds to design germs that may be specific to certain
genetic subpopulations. This kind of covert studies may take place while
originators of sample sources have no control.
I suggest an international audit should inspect what has happened to sample sources stored across various labs to find out if investigators have stood by the MTA's.
I read with interest the findings from Professor Seale's study and
listened to the discussion with the author on Radio4's Today programme on
the 26 August 2010.
I commend the author's conclusions that "Greater acknowledgment of
the relationship of doctors' values with clinical decision-making is
advocated". The study opens up a wider debate about the relationship of
both doctors' and nurs...
I read with interest the findings from Professor Seale's study and
listened to the discussion with the author on Radio4's Today programme on
the 26 August 2010.
I commend the author's conclusions that "Greater acknowledgment of
the relationship of doctors' values with clinical decision-making is
advocated". The study opens up a wider debate about the relationship of
both doctors' and nurses' values with the whole process of care. The
Liverpool Care Pathway for the dying recommends that patients and their
families receive appropriate care, which includes their spiritual needs.
If the professionals' own values drive the quality of care provided to the
dying patient, then the findings of the study raise questions about the
extent to which the mismatch between the professionals' and the family's
spiritual beliefs and values impact on patient care.
Better engagement of doctors and nurses with the concerned family
from the outset should enable the professionals to examine their own
beliefs and values in light of the family's spiritual needs. This requires
a paradigm shift in the way we think, and a constant awareness of the
complex needs of people from different religious beliefs. If a doctor does
not believe in God, he or she needs to find a way to understand the needs
of those who do and provide appropriate care. Whatever our religious
beliefs, the term 'spirituality' is considered to encompass the general
human impulse to reach out towards those on their end of life journey, and
meeting the needs of the 'whole' person.
Although there is some empirical evidence on factors considered to be
important at the end of life by patients, family, physicians, and other
care providers (1), there is a dearth of research examining the impact of
differences in professionals' and patients' spiritual beliefs and values
on end of life care. Professor Seale's study provides a platform for such
future evaluations.
1. Steinhauser et al (2000)JAMA; 284:2476-2482
Dr Daksha Trivedi, Evidence Based Practice,Centre for Research in
Primary and Community Care, University of Hertfordshire, UK
Disclaimer: The views and opinions expressed are
those of the author and do not reflect those of the author's affiliated
institution.
I would first like to congratulate Dr. Seale for producing a thought-
provoking piece of research that has captured the imagination of the
nation's media. I would also like to point out an interesting discordance
that I have noted with regard to the findings of this important research,
which ought to stimulate further discussion.
Although religious doctors were significantly less likely tha...
I would first like to congratulate Dr. Seale for producing a thought-
provoking piece of research that has captured the imagination of the
nation's media. I would also like to point out an interesting discordance
that I have noted with regard to the findings of this important research,
which ought to stimulate further discussion.
Although religious doctors were significantly less likely than their
non-religious colleagues to provide continuous or deep sedation until
death or to provide treatment with at least some intent to shorten life,
when religious doctors did provide such treatment they were significantly
less likely to have discussed this with their patient.
This is the opposite of what would be expected if the religion-driven
values of the doctors were the key influence on the decision to provide or
withhold treatment with the potential to shorten life. If the religious
beliefs of some doctors may make them reluctant to choose such a treatment
option, in those instances in which they do choose that course of action,
we would perhaps expect them to have been more likely to have involved the
patient in the decision. Why, when these doctors do provide such
treatment, should they be less inclined to discuss this with their
patient? These findings warrant further exploration.
Given these findings, I strongly suspect the presence of an
undetected confounder. For example, perhaps in the cases where religious
doctors provided (or withheld) treatment with some intent to shorten life,
the distribution of reasons for doing so was different to that in non-
religious doctors who took the same decisions. Perhaps the religious
doctors only felt compelled to do so in cases when they felt the patient's
suffering was particularly intolerable, whereas the threshold may have
been slightly lower for non-religious doctors who have a more favourable
opinion of treatment options that may shorten life. Thus, in the context
of such extreme and apparently intolerable suffering, the doctors
providing potentially life-shortening treatment may have felt that it was
inappropriate (and even unethical) to delay treatment in order to engage
in a discussion about this treatment option with their patients.
Of course, this is speculation. However, this hypothesis, together
with other viable hypotheses, certainly warrant further investigation in
order to explore important confounding factors and resolve this apparent
discordance in the findings of this research.
RK Mohindra's recent paper criticises NICE's decision-making
regarding the use of antibiotic prophylaxis to prevent infective
endocarditis. He is also critical of our defence of NICE, but does not
actually engage with our argument, stating simply that he was "surprised"
to see a philosophical defence of something that should be decided by
evidence. We find it surprising that Mohindra believes that...
RK Mohindra's recent paper criticises NICE's decision-making
regarding the use of antibiotic prophylaxis to prevent infective
endocarditis. He is also critical of our defence of NICE, but does not
actually engage with our argument, stating simply that he was "surprised"
to see a philosophical defence of something that should be decided by
evidence. We find it surprising that Mohindra believes that logic should
play no part in assessments of evidence; this brief reply analyses this
and four other fundamental problems with his paper. In addition to this
first error, Mohindra is mistaken about the evidence being in equipoise in
his example case; his conclusion about cost-effectiveness does not follow;
he is wrong to suggest that NICE is engaged in a de facto clinical trial;
and is in error to suggest that anyone could ever win compensation because
they were not given prophylaxis.
Philosophy and logic
We argued in our paper that NICE's decision was logical and sensible,
given the lack of evidence for any effectiveness of antibiotic prophylaxis
(AP) in preventing infective endocarditis (IE), and that those who
disagreed were putting faith before logic and evidence.[1] In explaining
his reaction to our paper, Mohindra states that "The source of my surprise
was the fact that both philosophical and theological argument had been
brought to bear in order to persuade clinicians of the merits of this
particular piece of NICE guidance. Guidance that should have been driven
by the empirical data."[2] Here Mohindra suggests by implication that the
NICE guidance itself was based on "philosophical and theological argument"
rather than evidence, which does not follow from the fact that our paper
dealt in part with such arguments. More importantly, our paper did not use
theological argument: it pointed out that the attitudes towards evidence
displayed by many cardiologists are similar to those of some religious
people. If anything, our argument is more evidence-based than his own: we
criticised some cardiologists for faith in the face of evidence, and his
paper seems to be a further example of this. In addition, despite
criticising our paper, he offers no rebuttal of any of its key arguments.
It is also somewhat ironic that Mohindra criticises our use of philosophy
rather than evidence in a clinical journal when he claims to regard logic
and evidence as the crux of the matter. It shouldn't need saying, but
logic is philosophy, and the scientific method is a type of applied
philosophy. Criticising someone for using philosophical argument is the
same as criticising him for using logical argument.
Evidence and equipoise
Mohindra is certainly right to point out that there is not much
evidence regarding the benefits and harms of AP. He quotes the NICE
statement that "There is insufficient evidence to determine whether or not
antibiotic prophylaxis in those at risk of developing infective
endocarditis reduces the incidence of IE when given before a defined
interventional procedure (both dental and non-dental)."[3] From this
Mohindra concludes that "a fact neither formally proved nor formally
disproved lies at the heart of the NICE guidance." He goes on to argue
that this is different from a normal case of equipoise, where there is
approximately equal evidence both for and against an intervention; in the
case of AP for IE, there is virtually no evidence for or against, so this
is a case of what he calls "insufficient evidence clinical equipoise"
rather than the usual "competing evidence equipoise":
"There is evidence that carries adequate probative force both for and
against the proposition (competing evidence equipoise); or there is
insufficient evidence to support the determination of either the truth or
falsehood of the proposition (insufficient evidence equipoise)."
Unfortunately, this appears to be an attempt to create a false
distinction. What does "adequate" mean here? If the evidence both proves
and disproves the proposition, then there is insufficient evidence to
support the determination of either the truth or falsehood of the
proposition; the two supposedly different types of equipoise are actually
identical. Equipoise is simply the state of being in equilibrium, and
clinical equipoise is the term we use for the evidence base being in
equilibrium. This is true whether there is no evidence on either side or a
great deal, but the same amount, on each side. In fact, "insufficient" in
this context means that there is not enough evidence to decide one way or
the other, so cases of "competing evidence equipoise" are the same
because there is insufficient evidence on either side to make a decision.
Cost-effectiveness and resistance
Mohindra argues that we can make a decision based on a value
judgement in cases of "competing evidence equipoise" but that to do so in
cases of "insufficient evidence equipoise" is to make a value judgement
that by necessity cannot be based on any evidence of cost-effectiveness,
as there is no evidence concerning effectiveness. He does not explain why
the same is not true in cases of competing evidence equipoise, which again
suggests that this is a false distinction. Nonetheless, he states that:
"Two points emerge from this position. First in the absence of
adequate empirical evidence the use of other expert opinion as a
foundation for new expert opinion based guidance does not move the
evidential ball at all. Second, and critically, NICE cannot logically
reach a conclusion upon cost-effectiveness in the absence of adequate
evidence of effectiveness or ineffectiveness."
Regarding the first point, NICE never claimed to have produced new
evidence. They simply put an end to the practice of using an intervention
for which there is no evidence base. It is somewhat ironic that Mohindra
should criticise NICE for basing their guidance on expert opinion and
producing no new evidence when he seems to favour continuing to give
patients a treatment for which there is no evidence because of the faith-
based expert opinion of some cardiologists.
With regard to the second point, it is indeed true that a typical decision
about cost-effectiveness cannot be made in the absence of evidence of
effectiveness. But in the absence of evidence of effectiveness, there is
no reason whatsoever to even consider cost-effectiveness; it would be
irresponsible to spend money on treatment that is not supported by
evidence. Furthermore, as we pointed out in our original article, there is
also the cost of increased resistance to antibiotics and consequent harm
to patients, which Mohindra fails to consider.[4] If the evidence
regarding benefit to the patient is in equipoise, but the treatment costs
money and will contribute towards the development of antibiotic
resistance, the overall picture is that this is not a case of equipoise at
all.
Trials and tribulations
Mohindra argues that NICE should have concluded that more research is
needed into the use of AP to prevent IE. He also claims that NICE is
essentially running an unofficial trial: "the effect of the NICE guidance
is to institute a de facto population wide prospective cohort study to
test the null hypothesis that antibiotic prophylaxis does not reduce the
population wide incidence of IE". Is this true?
It is clearly not true. If anyone is guilty of conducting an
unethical trial, it is cardiologists who gave AP in the past or continue
to do so. As stated above and in our original article, NICE concluded that
AP should not be prescribed because there is no evidence for its efficacy.
Mohindra himself suggests that more research is needed because the
evidence is in equipoise. This means that a trial is necessary in order to
justify the use of AP for IE. Clinical trials test new interventions for
which there is no evidence base. But if the evidence is in equipoise, it
is giving prophylaxis that is the trial, not withholding it. If NICE had
allowed the widespread use of AP to continue, that would have been a
clinical trial by stealth, and that was what was happening before the new
guidance was issued: patients were being used as trial subjects because
the collective wisdom of cardiologists was that AP prevented IE. Such
faith-based experimentation in the face of the evidence is exactly what
our original paper targeted, and NICE actually put an end to "a de facto
clinical trial protocol outside the pre-existing legal regulatory
framework", as Mohindra calls it.
Compensation and consolation
Finally, Mohindra's point about compensation is deeply flawed. He
references Connaughton, who has suggested that "the NHS might adequately
compensate anyone whose health suffered as a consequence of the new
guidelines."[5] This whimsical wish could never be fulfilled. It would be
impossible to prove that an incidence of IE was caused by a failure to
administer AP in terms of causality, but also because there is no evidence
that AP prevents IE anyway. This argument would only work if there was
evidence of IE's efficacy, and Mohindra's use of the argument suggests he
has faith that AP does work despite the lack of evidence; in other words,
he is committing the very error that we highlighted in our original paper.
It is also irresponsible to suggest that patients could claim compensation
when they have no chance of doing so. Contrary to Mohindra's claim, this
view has no legal or ethical force.
Conclusion
We argued in our original paper that some cardiologists resemble the
people who accepted Pascal's Wager [6]. Just as someone might choose to
believe in God because of the prospective benefits and despite the lack of
evidence of His existence, so some cardiologists choose to believe in the
efficacy of AP, despite the lack of evidence that it works, in a modern
example of the so-called "no-lose" philosophy in medicine.[7] In his
attempt to discredit NICE's guidance on IE, Mohindra commits several
logical errors, and shows that his beliefs are based on faith rather than
evidence. Ironically, he argues that "absence of evidence does not imply
evidence of absence" to make the point that the lack of evidence does not
mean that AP is not effective against IE, seemingly unaware that this very
statement is frequently used as a theological argument for the existence
of God, just like Pascal's Wager. We seem to have come full circle. Both
logic and evidence indicate that NICE's guidance is quite correct.
Mohindra's suggestion that NICE is engaged in an illegal trial is
irresponsible, as is his suggestion that compensation could be claimed for
harm caused by omitting AP. Despite Mohindra's attempt to introduce a
false distinction, equipoise is equipoise, and there is not equilibrium in
this case.
References
1. Shaw D, Conway DI. Pascal's Wager, infective endocarditis and the "no-lose" philosophy in medicine. Heart 2010;96:15-18.
2. Mohindra RK. A case of insufficient evidence equipoise: the NICE guidance on antibiotic prophylaxis for the prevention of infective endocarditis. J Med Ethics doi:10.1136/jme.2010.036848 (online early).
3. National Institute for Health and Clinical Excellence. Clinical Guideline 64: prophylaxis against infective endocarditis. http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf (accessed 9 Aug 2010)
4. Lewis MA. Why we must reduce dental prescription of antibiotics: European Union Antibiotic Awareness Day. Br Dent J 2008;205:537-8.
5. Connaughton M. Commentary: Controversies in NICE guidance on infective endocarditis. BMJ 2008;336:771.
6. Pascal B. Pensees (no 233). http://www.gutenberg.org/files/18269/18269-h/18269-h.htm (accessed 9 Aug 2010)
7. Galbraith S. The "no lose" philosophy in medicine. J Med Ethics 1978;4:61-3.
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human rese...
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human research where some sensitive research projects are not reviewed by research ethics committees at all."
I agree that these are important problems. However, I would like to share some ideas emerging from my own view of these issues as applied to less developed countries. The thing to be seriously concerned about is the lack of standards. In many poor institutions in those countries, a gang based system is used to judge on research proposals. If it is a research proposed by the same group or by a friend, it is approved. If the project is proposed by an external group or by groups with which there is a conflict of interest, the project is managed differently managed. This problem of lack of standards can also be seen in other academic judgements such as nominations for local awards or professorship appointments. The standardization of international criteria for the acceptability and reliability of ethical regulation of research and for other form of academic judgements might be an answer.
References
1. E Gefenas, V Dranseika, A Cekanauskaite, K Hug, S Mezinska, E Peicius,
V Silis, A Soosaar, and M Strosberg. Non-equivalent stringency of ethical
review in the Baltic States: a sign of a systematic problem in Europe? J.
Med. Ethics 2010 36:435-439; doi
As somebody who has been lied to by doctors in the past, albeit not about psychiatric drugs, this article makes my heart sink. Two weasel phrases especially shriek out:
'The potential problem with placebos is that they may involve deception.' The level of self deception in this statement is glaringly obvious. Placebos involve deception. Parents and carers at times allow themselves to lie to their children about medi...
In their recent piece, "Synthetic Biology and the Ethics of Knowledge," Thomas Douglas and Julian Savulescu argued for an "ethics of knowledge," in which bioethicists engage with the ethical issues surrounding the pursuit and dissemination of scientific knowledge.1 Their focus, as the title suggests, is the rapidly expanding field of synthetic biology.
While I agree with the general claim made by Douglas and Sa...
I would like to commend the authors on their well researched overview of doctor-patient interactions across a gender divide for a Muslim context. I would like to add two points to this discussion which I feel were overlooked:
1) With the Muslim medical profession, there exists some disagreement amongst Muslim physicians as to what the limits are when a male doctor needs to examine a female patient.
So...
To the authors of Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective
Thank you for a very clear and comprehensive explanation of the Islamic bioethical perspective on cross-gender interactions in medicine. It is of utmost importance that doctors should at all time take note of the cultural and religious background of all patients and practice accordingly. I refer to a...
Dear Editor,
I read Dr. Seale's article with interest, but am concerned that his findings may not represent the actual activity of the medical profession, whatever their beliefs. The questionnaire asked doctors to state their religion, then how religious they were. They were then asked to recall the last patient who died and to answer questions about "ethically controversial decisions". Isn't it possible (or...
It is difficult to police the use of stored specimens across borders and different jurisdictions. While many research participants may not stand in immediate personal danger, it is obvious that many collaborating partners are being exploited. When laboratory based studies are done on these samples, the originating partners miss out on publications. If one runs a simple survey on authorship of these publications, very few...
Dear Editor,
I read with interest the findings from Professor Seale's study and listened to the discussion with the author on Radio4's Today programme on the 26 August 2010.
I commend the author's conclusions that "Greater acknowledgment of the relationship of doctors' values with clinical decision-making is advocated". The study opens up a wider debate about the relationship of both doctors' and nurs...
Dear Editor,
I would first like to congratulate Dr. Seale for producing a thought- provoking piece of research that has captured the imagination of the nation's media. I would also like to point out an interesting discordance that I have noted with regard to the findings of this important research, which ought to stimulate further discussion.
Although religious doctors were significantly less likely tha...
Introduction
RK Mohindra's recent paper criticises NICE's decision-making regarding the use of antibiotic prophylaxis to prevent infective endocarditis. He is also critical of our defence of NICE, but does not actually engage with our argument, stating simply that he was "surprised" to see a philosophical defence of something that should be decided by evidence. We find it surprising that Mohindra believes that...
Dear Editor
I read the recent report on the non-equivalent stringency of ethical review with a great interest [1]. Gefenas proposed that, for two identified problems, (1) there is an "asymmetry between rather strict regulations of clinical drug trials and relatively weaker regulations of other types of clinical biomedical research" and that (2) there are "gaps in ethical review in the area of non- biomedical human rese...
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