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Medical ethics

The Ethics of Private Payment for Health Care: The Example of Vaccination

30  July. This blog is an extended version of the post ‘Vaccines: All or Nothing’ (posted 29 July). 

A vaccine which would protect children from Meningitis B has been rejected by the Joint Committee on Vaccination and Immunisation (JCVI) as not cost effective, despite the fact the cost is not yet known.

The Department of Health’s director of immunization explained:

“This is a very difficult situation where we have a new vaccine against meningitis B but we lack important evidence. We need to know how well it will protect, how long it will protect and if it will stop the bacteria from spreading from person to person.

“We need to work with the scientific community and the manufacturer to find ways to resolve these uncertainties so that we can come to a clear answer.”

A call for more research is a standard answer to many dilemmas in healthcare, though perhaps one which is easy to ignore. As far as we know there are no current plans to ensure that this research takes place but the vaccine has already been found to be safe, and according to the BBC, “tests have suggested the vaccine is effective against 73% of the different strains of the disease”.

Resource allocation is an inevitable part of any health care system, and perhaps especially so in the NHS. Whilst we would like to provide all available treatments, prioritizing according to effectiveness and cost is necessary, though the exact method of calculating this (currently Quality Adjusted Life Years, or QALYs) is of course under intense debate and scrutiny.

In the meantime, children continue to suffer avoidable, lifelong disability due to infection with Meningitis B. I argue with Lach de Crespigny in a forthcoming paper on homebirth that actions (or failures to act) taken today which cause harm in the future are as wrong as if that harm were realized today. The plight of these children and adolescents should not be ignored.

Put simply, if you could prevent a child from getting brain damage, now or in the future, at little cost to you, you ought to perform that act.

One possible way forward would be to allow parents to pay for the vaccination of their child, at whatever price the company sets, just as holiday vaccinations can be provided by the NHS at a cost to the patient. Vaccinated children could be monitored and their data recorded. Not only would this generate the data that would establish how high up funding agendas this vaccine should be, but some individual children would be prevented from suffering this deadly and debilitating disease. To increase take up, the company would be under market pressure to keep the price as low as possible.

Read More »The Ethics of Private Payment for Health Care: The Example of Vaccination

I’ve warned you! But I shouldn’t have

Among close friends, or even within the family, the use of SSRI’s (selective serotonin reuptake inhibitors) can be a delicate topic, it may come with connotations of depression, suicidal behaviour, and can be emotionally marginalizing. A new scientific review may further entangle this already vexing situation, in the study (Isacsson, G. & Alhner, J. 2013)… Read More »I’ve warned you! But I shouldn’t have

How do you want to die?

How do you want to die? Quickly, painlessly, peacefully lying in your own bed?

Most people say that. But then, people seem to cling to their lives, even if that could mean a less peaceful end. When asked whether they would want physicians to perform certain interventions to prolong their lives like CPR (cardiopulmonary resuscitation) or mechanical ventilation (‘breathing machine’), people say ‘yes’.

Interestingly, a study discussed in a Radiolab podcast from earlier this year reveals that contrary to lay people, physicians do not want these life-saving interventions they perform on their patients performed on themselves.Read More »How do you want to die?

Killing by praying

Dale and Leilani Neumann are Pentecostal Christians. Their 11 year old daughter, Kara, fell ill. In fact she had (undiagnosed) diabetes. Her parents refused to obtain medical help. Instead they prayed.

‘Kara’s father testified that death was never on their minds.  He testified that he knew Kara was sick but was “never to the alarm of death,” and even after she died, her father thought that Jesus would bring Kara back from the dead, as he did with Lazarus.

The parents and friends testified that the parents took tangible steps to help Kara.  The mother tried to feed Kara soup and water with a syringe, but the liquid just dribbled out of Kara’s mouth.  The father tried to sit Kara up, but she was unable to hold herself up.  At some point, Kara involuntarily urinated on herself while lying unresponsive on the couch, so they carried her upstairs and gave her a quick sponge bath while she lay on the bathroom floor.

At one point, Kara’s maternal grandfather suggested by telephone that they give Kara Pedialyte, a nutritional supplement, in order to maintain the nutrients in her body.  The mother responded that giving Kara Pedialyte would be taking away the glory from God.  Kara’s mother had told another visiting friend that she believed that Kara was under “spiritual attack.”

Friends Althea and Randall Wormgoor testified that they arrived at the Neumanns’ home on Sunday at approximately 1:30 p.m.  The Wormgoors saw that Kara was extremely ill and nonresponsive.  Her eyes were partially open but they believed she needed immediate medical attention.  Randall Wormgoor pulled Kara’s father aside and told him that if it was his daughter, he would take her to the hospital.  The father responded that the idea had crossed his mind, and he had suggested it to his wife, but she believed Kara’s illness was a test of faith for their family and that the Lord would heal Kara….’ [1]

But the Lord did not. Or at least not physically. Kara died from diabetic ketoacidosis. The evidence was that, with conventional medical care, she would have lived. Read More »Killing by praying

Podcast: The Ethics of Infant Male Circumcision

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In this talk (audio- MP3 and video -youtube)  , Brian D. Earp argues that the non-therapeutic circumcision of infant males is unethical, whether it is performed for reasons of obtaining possible future health benefits, for reasons of cultural transmission, or for reasons of perceived religious obligation. He begins with the premise that it should be considered… Read More »Podcast: The Ethics of Infant Male Circumcision

‘Precarious (Bio)ethics: Research on Poisoning Patients in Sri Lanka’

On 9 May 2013, Salla Sariola, from ETHOX, gave a fascinating talk at the St Cross Ethics Seminar, based on work done collaboratively with Bob Simpson (Durham). The presentation focused on the large number of self-poisonings which have been taking place in Sri Lanka, often using lethal agricultural pesticides and herbicides unavailable in many developed countries. This presentation is now available as a podcast at the bottom right of the Oxford Uehiro Centre main webpage.Read More »‘Precarious (Bio)ethics: Research on Poisoning Patients in Sri Lanka’

Non-consensual testing after needlestick injury: A legal and ethical drama

By Charles Foster and Jonathan Herring

Scene 1: An Intensive Care Unit

Like many patients in ICU, X is incapacitous. He also needs a lot of care. Much of that care involves needles. Late at night, tired and harassed, Nurse Y is trying to give X an intravenous injection. As happens very commonly, she sticks herself with the needle.

Nurse Y is worried sick. Perhaps she will catch HIV, hepatitis, or some other serious blood-borne infection? She goes tearfully to the Consultant in charge.

‘Don’t worry’, he says. ‘We’ll start you on the regular post-exposure prophylaxis. But to be even safer, we’ll test some of X’s blood for the common infections. I doubt he’ll be positive, but if he is, we’ll start you straight away on the necessary treatment. We needn’t take any more blood: there are plenty of samples already available.’

A sample of blood is submitted for analysis. Read More »Non-consensual testing after needlestick injury: A legal and ethical drama

Forced Physical Exercise as an Intervention for Mental Disorders?

Studies have shown that regular physical activity has benefits for mental health: exercise can help people to recover from depression and anxiety disorders. However, not all people like exercise, and a mental disorder like depression can additionally decrease motivation for physical activity. So the disorder itself might inhibit behaviour that helps to overcome it.

We would assume that pressurising people is no solution here: several studies have shown that restricting freedom of choice or control increases stress in both humans and animals. However, new research tentatively indicates that controllability might play a smaller role than expected when it comes to exercise, and that even forced exercise might protect against depression and anxiety symptoms:

Read More »Forced Physical Exercise as an Intervention for Mental Disorders?

What happens when you die

I have just watched someone die. Just one person. But a whole ecosystem has been destroyed. Everyone’s roots wind round everyone else’s. Rip up one person, and everyone else is compromised, whether they know it or not. This is true, too, for everything that is done to anyone. Death just points up, unavoidably, what is always the case.

This is trite. But it finds little place in bioethical or medico-legal talk. There, a human is a discrete bio-economic unit, and there’s a convention that one can speak meaningfully about its elimination without real reference to other units.

In some medico-legal contexts this is perhaps inevitable. There have to be some limits on doctors’ liability. Hence some notion of the doctor-patient relationship is probably inescapable, and the notion requires an artificially atomistic model of a patient.

But ethics can and should do better.Read More »What happens when you die

“The Best Interests of the Family”: Parents v Baby?

There is much that is good to be said about Dominic Wilkinson’s new book Death or Disability? The ‘Carmentis Machine’ and decision-­making for critically ill children. My favourite part of the book is how Dominic confronts head on the issue of the best interests of the family in relation to care, and withdrawal of medical treatment,… Read More »“The Best Interests of the Family”: Parents v Baby?