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Politics

Should Junior Doctors Strike?

25 Jan, 16 | by Iain Brassington

Guest Post by Mark Toynbee, Adam Al-Diwani, Joe Clacey and Matthew Broome

[Editor’s note: Events in the real world have moved more quickly than David or I have; the facts of the junior doctors’ strike have moved on since the paper was published and this post submitted.  Still, the matters of principle remain. – IB]

A strike by junior doctors is planned for January 2016 following failure of the last-ditch ACAS (Advisory, Conciliation and Arbitration Service) mediated talks between the BMA and the Department of Health (via NHS Employers) – see media reports here, here, and here.  Industrial Action had previously been planned for December last year but was suspended at the last minute when both sides agreed to the now failed mediation.  The current regrettable position has resulted from over two years of formal negotiations between the BMA and NHS Employers regarding a new junior doctor contract.  The BMA went to its junior doctor members for a mandate for industrial action last autumn as the talks stalled and received an almost unprecedented mandate with 98% indicating they would be prepared to strike.

Subsequently, many well-known figures voiced their concerns about the ethical and practical implications of industrial action (here and here).  Strikes by doctors are not common, with only one example in the UK in the last generation, but far from unprecedented.  The overwhelming recent ballot result raises many interesting issues, foremost among them the ethical legitimacy of industrial action by doctors, specifically junior doctors.

The term ‘junior doctor’ is often misunderstood.  It applies to all doctors from graduation until completion of specialist training – over 50,000 individuals.  Their roles and responsibilities have evolved significantly over many years; their pay and hours have reduced whilst their debts, costs and responsibilities have increased.  The patient-doctor relationship has also changed with increased emphasis on patient involvement and the promotion of autonomy.

We have looked at arguments proposed during previous instances of doctor industrial action, often from this journal (see this, this, and this) and considered them in the current context.  Absolute ethical objections to doctor industrial action appear old-fashioned, especially when applied to junior doctors.  Concerns about harms caused by doctors withdrawing their labour also seem less sustainable in the light of recent evidence than perhaps would be expected.  Indeed, the ethical responsibilities of doctors may require them to take action if they believe patient care, or the well-being of their colleagues’, is being compromised.

So far there has been strong support for the junior doctors from the Consultant bodies of many Trusts, and the Royal Colleges.  The modern NHS asks more of its junior doctors than ever before, placing ever increasing responsibilities on their shoulders, with ever more challenging working conditions.  With industrial action by junior doctors now likely to go ahead, claims that it would be unethical appear to us to be increasingly hard to justify.

Read the paper here.

R-E-S-P-E-C-T

24 Dec, 15 | by Iain Brassington

Here’s an intriguing letter from one John Doherty, published in the BMJ yesterday:

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes, but such constructs are culture bound.

When I worked in outback Australia the patients called me “Mate,” which is what I called them.

They still wanted me to be in charge.

Intriguing enough for me to go and have a look at what this Kennedy person had written.  It’s available here, and the headline goes like this:

The Title “Doctor” in an Anachronism that Disrespects Patients

Oooooo-kay.  A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all.  (Don’t ask me why I detest that so; I don’t know.  It’s just one of those things that I will never be able to tolerate, a bit like quiche.)  But let’s see…  It’s not a long piece, but even so, I’ll settle for the edited highlights: more…

Pro-Lifers’ Arguments Might be their Greatest Gift to Pro-Choicers

19 Dec, 15 | by Iain Brassington

Abortion is always going to be a controversial topic.  For what it’s worth, I hold that there’s nothing wrong with it.  That’s me speaking from my habitual non-consequentialist position.  From a more utilitarian perspective, I’m willing to concede that, given the choice between world A, in which abortions happen, and world B, in which they don’t because noone gets pregnant without wanting it, and everyone is perfectly happy to continue with her pregnancy, A is worse.  But A is nevertheless a whole lot less bad than world C, in which women are compelled to continue with pregnancies they don’t want.  In other words, there’s no need or desire for abortion in super-happy-fluffy world, and super-happy-fluffy world is better than the real world – but we live in the real world, and having abortions available makes the real world better than it could be.

I’d like to think that I’m doughty enough to have my mind changed on this, though.  Should someone have a really good argument for the wrongness of abortion, or the overwhelming badness, I’d like to think that I could be persuaded – that I’d let the argument go wherever it takes me.  I think that that’s just intellectual honesty.  It’s just that I have yet to come across an argument that I find persuasive, and I don’t even know what such an argument would look like.

What I can say is that, while I find even the best pro-life arguments unpersuasive, some are worse than others, though.  There’s a guy who keeps posting to the Bioethics Facebook group with links to lamentably bad arguments.  And, of course, there’s the CMF.

On their blog, Philippa Taylor has been getting herself into a tizzy about the recent ruling that Northern Ireland’s very restrictive laws contravene human rights legislation, and suggests that there is a whole range of reasons why the law should not be changed there.

Let’s have a look… more…

Homeopathy, Blacklisting, and the Misuse of Choice

15 Nov, 15 | by Iain Brassington

It seems that homeopathy might at last be facing some serious opposition from within the NHS, with the prospect of its being blacklisted being considered.

There’s any number of people who’ll be entirely on board with that. Homeopathy doesn’t work.  Of course, a lot of medicines turn out not to work, or not to work well.  But the difference between homeopathy and unsuccessful drugs is that the latter are at least more likely to have a plausible mechanism – roughly, one of throwing molecules at other molecules, or coaxing the body to throw molecules at molecules.  Homeopathy doesn’t even have that.  It relies on water having a memory.

At the very best, it contributes nothing. But it does cost money – not much, but more than none, and in the end, the taxpayer has to pony up for it.  Money is being wasted every time the NHS pays for homeopathic treatment, and that looks to be unjust.  (It’s not the most unjust thing in the world, but that’s neither here nor there.  Wrongs are wrongs, even if harms might vary.)

It might even get in the way of effective treatments, if patients use it rather than them.  That might mean that they’re worse off than they could otherwise be.  At the outside, it might mean that they’re a danger to others – they might be spreading illness by dint of not getting treated properly for it.

To that extent, Simon Singh strikes me as being bang on the money: more…

Should Doctors Strike?

9 Nov, 15 | by bearp

 

Should doctors strike?

Is it ethical for doctors to go on strike, potentially putting their patients at risk of getting inadequate treatment?

As the BBC reports, ministers and junior doctors are currently “locked in a dispute.” One possible outcome of this disagreement is a physicians’ strike, which raises a number of tricky ethical questions. But before we get into those questions, it might be helpful to take a look at a quick sketch of what the problem is all about (from the BBC article):

Junior doctors’ leaders are objecting to the prospect of a new contract. The government has described the current arrangements as ‘outdated’ and ‘unfair,’ pointing out they were introduced in the 1990s. Ministers drew up plans to change the contract in 2012, but talks broke down last year. The government has indicated it will impose the new contract next year in England. The BMA has responded by initiating the industrial action process. …

The latest information provided by the government, which is the most detailed so far, includes an 11% rise in basic pay for doctors. But that comes at a price. Other elements of the pay package are being curbed.

The prospect of a strike appears to be firmly on the table: “Doctors can take strike action but only if it affects non-emergency care. The last time this happened was during [a] pensions dispute in 2012, but that was the first time such action had been taken for almost 40 years. Doctors still attend work – so they are ready for urgent and emergency cases.”

The Journal of Medical Ethics has tackled this issue before. Writing for the journal in 2013, John Park and Scott Murray gave an analysis of the 2012 “pensions dispute” just mentioned.

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. Almost all doctors will agree that we should always follow the law, but often the law is unclear or does not cover a particular case. Here we must appeal to ethical discussion.

The General Medical Council, in its key guidance document for practising doctors … claims that ‘Good doctors make the care of their patients their first concern.’ Is this true? And if so, how is this relevant to the issue of striking? One year on since the events, we carefully reflect and argue whether it was right for doctors to pursue strike action, and call for greater discussion of ethical issues such as the recent strikes, particularly among younger members of the profession.

In light of the current turmoil, the Journal of Medical Ethics welcomes submissions on the ethics of physicians striking, including papers which build on, critique, or respond to the work of Park and Murray. Their 2013 paper can be accessed here. As Associate Editor Dominic Wilkinson stated in an interview:

In their submissions, authors should focus on ethical questions and put their discussion in the context of ongoing international debate and existing literature. Possible questions include, for example: what is a fair level of remuneration for public sector healthcare workers, including doctors? Should all doctors be paid equally? Should antisocial hours be rewarded financially? In a financially constrained environment, should doctors’ pay go down in order to protect funding for health care provision?

Papers can be submitted to the Journal of Medical Ethics here. Author instructions are here.

The Journal of Medical Ethics remains the top-ranked journal in bioethics for 2015 according to Google Scholar Metrics, with an impact factor of 1.511 and an h5-index of 28. We look forward to seeing your submissions.

Check out the current issue by clicking here.

Stop What You’re Doing: This is Important.

14 Oct, 15 | by Iain Brassington

I’d not realised it, but the latest iteration of the erstwhile Medical Innovation Bill – colloquially known as the Saatchi Bill – is up for debate in the Commons on Friday.  This is it in its latest form: to all intents and purposes, though, it’s the same thing about which I’ve blogged before.

In a nutshell, the Bill does nothing except remove protections from patients who would (under the current law) be able to sue for negligence in the event that their doctor’s “innovative” treatment is ill-founded.

Much more articulate summaries of what’s wrong with the Bill can be found here and here, with academic commentary here (mirrored here on SSRN for those without insitutional access).  There have been amendments to the Bill that make the version to be discussed on Friday slightly different from that analysed – but they are only cosmetic; the important parts remain.

Ranged against the Bill are the Medical professional bodies, the personal injuries profession, patient bodies, and research charities.  In favour of the Bill are the Daily Telegraph, a few people in the Lords who should know better (Lord Woolf, Lady Butler-Sloss: this means you), and Commons MPs who – understandably – don’t want to be seen as the one who voted against the cure for cancer.

Gloriously, Christ Heaton-Harris, who introduced the Bill, did so only after winning the ballot for Private Members’ Bills.  In a nutshell, he was allotted Parliamentary time, and then began the process of wondering what to do with it – which suggests that even the Bill’s sponsor doesn’t have a burning commitment to the cause – or, at least, didn’t when he took it on.

Still, the Bill has the support of Government; as it stands, there’s a good chance that it’ll pass.

SO: Take a few minutes to look up your MP’s email address – you can do that by following this link – and drop him/ her a line to encourage them to vote against the Bill.

Do it.

Assisted Dying’s Conscience Claws

11 Sep, 15 | by Iain Brassington

Aaaaaaaand so the latest attempt to get assisted dying of some sort onto the statute books in the UK has bitten the dust.  I can’t say I’m surprised.  Watching the debate in the Commons – I didn’t watch it all, but I did watch a fair chunk of it – it was striking just how familiar the arguments produced by both sides were.  It’s hard to shake the feeling that, just as is the case with the journals, the public debate on assisted dying has become a war of attrition: noone has much new to say, and in the absence of that, it’s simply a matter of building up the numbers (or grinding down the opposition).  The Nos didn’t win today’s Parliamentary debate because of any dazzling insight; the Ayes didn’t lose it because their speakers were measurably less impressive than their opponents’.  If the law does change in the UK, I’d wager that it’ll be because of demographic brute force rather than intellectual fireworks.

(Every now and again I hear a rumour of someone having come up with a new approach to assisted dying debates… but every now and again I hear all kinds of rumours.  I live in hope/ fear: delete as applicable.)

Still, I think it’s worth spending a little time on one of the objections that’s been raised over the last couple of days to this Bill in particular; it’s an objection that was raised by Canon Peter Holliday, the Chief Executive of a hospice in Lichfield:

In an interview with the Church of England, Canon Holliday said: “If there is no possibility within the final legislation for hospices to opt out of being a part of what is effectively assisted suicide, then there is nervousness about where our funding might be found in the future. Would the public continue to support us and indeed would the NHS continue to give us grants under contract?”

Canon Holliday said the Assisted Dying Bill also contains no opt out for organisations opposed to assisted suicide in spite of high levels of opposition to a change in the law amongst palliative care doctors. Where hospices did permit assisted suicide the potential frictions amongst staff could be ‘enormous’ with possible difficulties in recruiting doctors willing to participate, he said.

“The National Health Service requires us, in our contracts, to comply with the requirements of the NHS. Now if the NHS is going to be required to offer assisted dying there is of course the possibility that it would require us or an organisation contracting with the NHS also to offer assisted dying. If we as an organisation were able, and at the moment under the terms of the bill there is no indication we would be able, but if we were able to say that assisted dying was not something that would happen on our premises, would that prejudice our funding from the NHS ?”

Is this worry well-founded? more…

Jeremy Hunt and Costs to the Taxpayer

2 Jul, 15 | by Iain Brassington

“Personal responsibility” is a strange phrase: while not as slippery as some, it can mean any number of things, and be put to use in any number of political contexts.  It was the title of the speech that the Health Secretary, Jeremy Hunt, gave yesterday.  In that, he spoke of three aspects to the concept.

First up, he talked about the need for personal responsibility for health – that while the NHS tops the leagues in a lot of respects, the UK as a whole is bad when it comes to “lifestyle illnesses”, particularly things derived from obesity and smoking.  I guess that telling us that that’s bad and we could look after ourselves better is something of a bromide; but slightly more jarring was the statement that

[t]hankfully people are starting to take more responsibility. Doctors report dramatic increases in the number of expert patients who Google their conditions and this can be challenging for doctors not used to being second-guessed. But it is to be warmly welcomed: the best person to manage a long-term condition is the person who has that long term condition. The best person to prevent a long term condition developing is not the doctor – it’s you.

This is worth noting for a few reasons: first, it’ll be interesting in the context of what I’m going to say in a couple of paragraphs’ time; but there’s a couple of other things worth noting.  While the final sentence may be fairly unobjectionable at first glance, the penultimate and antepenultimate ones seem much less obvious.  Management of long-term conditions may be best left to the patient in some cases; but in all?  That’s not nearly so obvious.  It’s particularly unlikely when Dr Google is the purported source of information.  Dr Google, after all, may send you to NHS Choices – but it may also send you to What Doctors Don’t Tell You*, or sites that are even more obviously written by and for what we may politely call aluminium milliners.  Sometimes, patients doing a bit of homework is a good thing.  But sometimes, they’ll just end up asking for colloidal silver therapy.  (What could possibly go wrong?)

I’ll come to the second theme in a moment; the third thing he talked about was taking responsibility for our families. more…

Prostitution, Harm, and Disability: Should Only People with Disabilities be Allowed to Pay for Sex?

17 Jun, 15 | by bearp

By Brian D. Earp

Introduction

Is prostitution harmful? And if it is harmful, should it be illegal to buy (or sell) sexual services? And if so, should there ever be any exceptions? What about for people with certain disabilities—say—who might find it difficult or even impossible to find a sexual partner if they weren’t allowed to exchange money for sex? Do people have a “right” to sexual fulfillment?

In a recent issue of the Journal of Medical Ethics, Frej Klem Thomsen[1] explores these and other controversial questions. His focus is on the issue of exceptions—specifically for those with certain disabilities. According to Thomsen, a person is “relevantly disabled” (for the sake of this discussion) if and only if:

(1) she has sexual needs, and desires to exercise her sexuality, and

(2) she has an anomalous physical or mental condition that, given her social circumstances, sufficiently limits her possibilities of exercising her sexuality, including fulfilling her sexual needs. (p. 455)

There is a lot to say here. First, in order to figure out the merits of making an exception to a general ban on prostitution (for people with disabilities or for anyone else), we have to start by deciding what to think about the advisability of such a ban in the first place. For, if we don’t think it’s a good idea to begin with (spoiler alert: this is my own view), then we can skip all the talk about making exemptions, and just argue against the ban.

But Thomsen doesn’t pursue that route. Instead, he wants to make a case for an exception. So, he has to try to convince his reader that a general prohibition makes at least some kind of moral and/or practical sense. How does he go about making this argument?

more…

Animal Liberation: Sacrificing the Good on the Altar of the Perfect?

24 Apr, 15 | by Iain Brassington

For my money, one of the best papers at the nonhuman animal ethics conference at Birmingham a couple of weeks ago was Steve Cooke’s.*  He was looking at the justifications for direct action in the name of disrupting research on animals, and presented the case – reasonably convincingly – that the main arguments against the permissibility of such direct action simply don’t work.  For him, there’s a decent analogy between rescuing animals from laboratories and rescuing drowning children from ponds: in both cases, if you can do so, you should, subject to the normal constraints about reasonable costs.  The question then becomes one of what is a reasonable cost.  He added to this that the mere illegality of such disruption mightn’t tip the balance away from action.  After all, if a law is unjust (he claims), it’s hard to see how that alone would make an all-else-being-equal permissible action impermissible.  What the law allows to be done to animals in labs is unjust, and so it doesn’t make much sense to say that breaking the law per se is wrong.

Now, I’m paraphrasing the argument, and ignoring a lot of background jurisprudential debate about obligations to follow the law.  (There are those who think that there’s a prima facie obligation to obey the law qua law; but I think that any reasonable version of that account will have a cutoff somewhere should the law be sufficiently unjust.)  But for my purposes, I don’t think that that matters.

It’s also worth noting that, at least formally, Cooke’s argument might be able to accommodate at least some animal research.  If you can claim that a given piece of research is, all things considered, justifiable, then direct action to disrupt it might not have the same moral backing.  Cooke thinks that little, if any, animal research is justified – but, again, that’s another, higher-order, argument.

One consideration in that further argument may be whether you think that there’s a duty to carry out (at least certain kinds of) research. more…

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