Paul Affleck , Julia Cons, and Simon E. Kolstoe.
De Marco et al have challenged the standard account of what makes a medical intervention invasive, stimulating a set of commentaries, including our own. Whilst we have enjoyed this correspondence, we still disagree on some fundamental points.
De Marco et al state it is not clear to them why including mental invasiveness in a definition of invasiveness “…must be rejected as mistaken, confused or practically irrelevant”. We would like to provide clarity. ‘Mental invasiveness’ is mistaken because it is only invasive if it is unwanted. Otherwise, all the information we receive via our senses is ‘invasive’ as the root word “invade” implies a movement from the external to the internal.
Interestingly, this is exactly the way the word invasive is used for medical interventions that are always considered invasive whenever there is an incision or insertion, regardless of whether the person sees it as unwanted. To be consistent with medical invasiveness De Marco et al would have to accept that all information received via the senses is invasive – rendering (as we contend) the use of the word redundant. Alternatively, they must accept that the term “mental invasiveness” only applies when harm is done, rendering their argument inconsistent as they also state: “It was not our intention to define invasiveness in terms of potential harm”. They cannot have it both ways. Either mental invasiveness refers to all sensory information, or they are defining mental invasiveness by whether the person suffers, or could suffer, the harm of mental distress.
To be charitable, and take this second definition as their meaning, De Marco et al cite McFarland et al’s commentary as evidence that ‘mental invasiveness’ is useful in the context of psychiatry. But we think this is also incorrect. What McFarland et al actually advocate is labelling medications (a physical intervention) as invasive, and although they call for “…a more comprehensive definition of mental invasiveness…”, they do not state “therapy-based alternatives” should be classified as invasive. If, for example, we describe both cognitive–behavioural therapy and antipsychotic medications as invasive it is not clear what we gain. The nature of delivery, be it via swallowing a pill or engaging in conversation, is largely irrelevant to McFarland et al’s aim of deciding on the best treatment.
However, it is true that oral medication is a challenge to the standard account of an invasive medical intervention since swallowing a pill or a liquid medication is a bodily insertion. If one wanted to expand the concept of medical invasiveness, it would be worth considering the concept of ingestion. While we accept that from an anatomical perspective the entire digestive track is separate from the circulatory, interstitial, and cellular components of the body, when considering the intuitive or plain use of the term for clear communication with patients, ingesting an item such as a telemetry pill can helpfully be described as invasive. Continuing this line of reasoning to its logical conclusion, the ingestion of any medication would count as invasive.
To be clear, we think including mental invasiveness in a definition of invasiveness is practically irrelevant because it does not aid communication professionally, and especially not with patients or research participants. As members of the Ministry of Defence Research Ethics Committee we often see applications that involve interviews or questionnaires on intensely personal or sensitive topics such as suicidal thoughts. We always advise applicants to make the potential for emotional distress clear in their participant information and to provide links to relevant support services. We do not see how this would be improved by calling such research mentally invasive, underpinned by an overarching account of invasiveness. For the avoidance of doubt, we do not think psychological interventions are necessarily less serious or harmful than physical interventions, we simply think they are different.
Authors: Paul Affleck , Julia Cons, and Simon E. Kolstoe
Affiliations:
PA: University of Leeds Faculty of Medicine and Health, Leeds, UK
JC: University of Nottingham, Nottingham, UK
SEK: School of Health and Care Professions, University of Portsmouth, Portsmouth, UK
Competing interests:
PA is a programme manager for the UK Colorectal Cancer Intelligence Hub, which is supported by Cancer Research UK (grant C23434/ A23706). He is also a Specialist Ethics Adviser and Co-Deputy Chair of the Interim Data Advisory Group at NHS England and a lay member of the Ministry of Defence Research Ethics Committee. JC is a Vice Chair of the Ministry of Defence Research Ethics Committee, an Independent Chair of NHS England’s Individual Funding Request Panel, a Commissioner on the Commission on Human Medicines and a Vice Chair of NHS England’s Specialised Commissioning Patient and Public Voice Assurance Group. SEK chairs research ethics committees for the UK’s Ministry of Defence, Health Research Authority and Health Security Agency. He receives income from consulting, writing, teaching, and lecturing in research ethics.