In the last few blog posts, we analyzed some of the ethical issues surrounding the beginning and end of an individual’s life. We also focused on the concept of decision-making and what happens when an individual cannot openly express their personal wishes. This week, I want to shift focus toward what happens when the wishes of the patient directly oppose the attending physician.

Module 5 of the Health Ethics, Law and Policy course presented at Queens University discusses the cases of two 11-year-old girls named JJ and Makayla. Their stories became highly publicized and provide an excellent case study for how to manage discrepancies between traditional and Western medicine.

JJ was a Mohawk girl diagnosed with acute lymphoblastic leukemia (ALL). ALL is the most common form of childhood cancer and with chemotherapy, JJ’s prognosis was assessed at 90-95%. The hospital’s pediatric oncologists are not collectively aware of any survivors without this treatment. A few days into JJ’s treatment, her mother withdrew consent with the intent to pursue traditional aboriginal medicine.

The pediatric oncologist disagreed with this decision and opted to file a report to the local children’s aid society, Brant Family and Children’s Services. When Children’s Aid chose not to intervene, the hospital filed an application. JJ’s doctor believed that the current situation violated subsection 37(2)e of the Child and Family Services Act:

“the child requires medical treatment to cure, prevent or alleviate physical harm or suffering and the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, the treatment.”

As often seen with legal issues that make headlines, both sides were in complete opposition with little common ground to compromise. On the one side, JJ’s mother believed she was making an informed decision about the medical care of her daughter. On the other, JJ’s doctor felt that her family was withholding lifesaving medicine.

This case was brought in front of The Honorable Justice GB Edward and can be read HERE. He dismissed the application on the grounds that it is legally within the rights of JJ’s SDM to pursue traditional medicine as outlined under section 35 of the Constitution Act:

“The existing aboriginal and treaty rights of the aboriginal peoples of Canada are hereby recognized and affirmed.”

The media’s focus on this case was exacerbated as the situation closely paralleled that of Makayla Sault. Similarly aged to JJ, Makayla was a young Ojibwe girl suffering from the same condition. She was being treated with chemotherapy at McMaster’s Children’s Hospital in Hamilton, ON. As the physical and emotional side effects worsened, she asked her parents to discontinue her treatment. Her mother supported her request and sought alternative traditional treatment. Her heartbreaking address to the public can be found on YouTube HERE.

Without previous media precedent, the plight of Makayla wasn’t received as easily as seen with JJ. The controversy surrounding the events are largely due to its presentation by mainstream media. The story being shared with the world caused Makayla’s family so much distress that they felt obligated to share their personal accounts of the events. Their side of the story as reported by CBC can be read HERE.

When disagreements happen, especially ones that are highly publicized, it is important to remember what the “truth” really is. While an objective truth does exist, it’s important to recognize that all individuals see that truth through their own paradigm. We approach situations with the knowledge of our unique experiences and personal biases. It’s quite common for two people to be looking at the same event, but “seeing” it remarkably different.

I believe that Makayla’s situation highlights the need to recognize our epistemological differences when approaching health-related issues. To better illustrate what I mean, we must consider the lenses that both sides are seeing the objective truth through.

Many physicians are extremely selfless and spend years pursuing medical degrees with the goal of helping others. As they commence their journey with the end in mind, they can develop consequentialist paradigms such as the theory of utilitarianism. Utilitarianism is a philosophical standpoint that suggests the morally best course of action is the one that yields the most happiness. Although this may share similarities with the risk-benefit analysis seen in bedside medicine, it is more appropriately applied to populations instead of individuals.

It’s also important to recognize that what may be happiness to one, may not be to another. This theme was seen when we discussed end-of-life care and is applicable to Makayla as well. Although the attending physicians may be focused on the end goal, it’s important to consider the amount of suffering that must be accomplished to achieve this.

Perhaps a deontological stance influenced by Immanuel Kant may be more appropriate. Kant suggested that people should never be treated as a means to an external end, but always respected as individuals with their own interests, values, and goals. Makayla and her family were suffering. Together, they made the decision to end Makayla’s treatment. I can only imagine how difficult a decision this must have been and am confident it’s not one they took lightly. It’s important to recognize that we will never be able to truly see the situation from their perspective.

As members of the Ojibwe community, Makayla’s family was part of a culture older than our country. This culture is full of traditions, values, and beliefs that ultimately influenced their decision. They opted to minimize Makayla’s suffering as they saw this as their version of happiness.

Even though the physicians at McMaster’s Children’s Hospital disagreed with the decision of Makayla’s family, I believe that all parties involved had good intentions in mind. As previously seen with the case of JJ, when conflicts arise regarding health care, it often falls on law and policy to resolve the situation. Unfortunately, Makayla passed away before her case had the opportunity to come to fruition.

The cases of JJ and Makayla provide an excellent case study for the requirement of health law and policy. I believe that Justice Edward made the best decision in advocating for the patient’s autonomy. In Canada, the Health Care Consent Act encourages autonomous decision-making as long as an individual is assessed as capable. Under subsection 4(1), capacity is defined as:

“A person is capable with respect to a treatment, admission to a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment, admission or personal assistance service, as the case may be, and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.”

JJ, Makayla, and their families experienced chemotherapy and its effects to an extent that gives them a more thorough understanding than most. The seriousness with which these decisions were made and the agreement between the pediatric patients and their respective SDM’s demonstrated that they were not made without consideration of the consequences. To me, this demonstrates that the patient (under their SDM) has sufficient capacity to choose their own medical treatment.

I believe it’s also important to recognize the stigma associated with traditional medicine. To those in favor of Western medicine, the alternative option elected by both girls and their families may seem like lower quality of care. It’s important to recognize that this treatment is extremely different and cannot directly be compared to a treatment like chemotherapy.

In conclusion, Justice Edward acted as a strong advocate for the individual rights of two young girls who could not adequately defend themselves. He recognized that the medical professionals may not have seen the situation from the patient’s paradigm and protected their rights to pursue traditional medicine as outlined in both the Constitution Act and the Health Care Consent Act. Moving forward, we should all strive to consider the reality of others and recognize that what might be best for us is not always best for them.

Michael

References

After last post’s focus on an ethical issue surrounding end-of-life care, this post we are examining the opposite end of an individual’s life. As one navigates the murky waters surrounding the topic of abortion, matters are further complicated when one considers the role of the father. Module 7 of Queen’s University’s Health Ethics, Law and Policy course provided excellent context in the form of the legal case between Jean Guy Tremblay and Chantal Daigle and a philosophical analysis by Philosophy Tube’s Olly.

Although Jean Guy Tremblay argued “yes” in the previously linked court case, I would disagree. From an ethical standpoint, this seems like the easier of the two questions to tackle. According to the Criminal Code of Canada, “a child becomes a human being within the meaning of this Act when it has completely proceeded, in a living state, from the body of its mother” (Government of Canada, 2021). Legal jargon aside, this means that a fetus is not considered a human being until after its birth. This simplifies the ethical issue as the only remaining individuals to consider are the father and the mother.

As discussed throughout the course and my previous blog post, Advance Directives, individuals who have demonstrated capacity have the right to make informed decisions about their own medical care (Ubel et al., 2018). As an abortion is a medical procedure that affects the health of the mother and not the father, the father should NOT have the right to prevent or compel a woman to undergo this treatment.

This question tends to spark a lot more debate than the first one. Before I present my stance on the issue, let me explain the compelling evidence for both sides. In 1996, Stephen Hales wrote an article titled “Abortion and Fathers’ Rights.” Here, he suggested that an expecting father should be able to relinquish all moral and financial responsibility through a written, legal process that would occur before birth (Hales, 1996). He justifies this stance by suggesting that men and women should have equal moral rights and duties and that because women have the opportunity to undergo an abortion, men should too.

More recently, Christine Overall released “Why Have Children?: The Ethical Debate.” She counters Hales’s argument by reminding the reader that an allowance of a financial abortion from the father would ultimately result in the child paying the penalty (Overall, 2012). Her conclusion is as far from Hales’s as realistically possible by suggesting that the father should always be liable, regardless of the circumstances. Olly, from the previously linked video on Philosophy Tube, ultimately agrees with her. He brings to light the irony that men could shed the “burden” of paying child support by fighting harder for women’s rights.

Like most ethical situations, this ethical dilemma exists on a spectrum. Although I am much closer to Overall’s view than Hales’s, I fall somewhere between the two. For starters, I agree with Overall that the individual who stands to suffer the most is the unborn child. Although progress is being made with each passing year, we are not yet at the point where women see all the same luxuries as men in terms of wealth and occupation. With that in mind, there are two main differences between my view and what Overall suggested in their book.

Firstly, I think the context of how the child was conceived matters. If any form of deception or dishonesty exists surrounding the circumstances under which the child was conceived, the father should be offered the ability to “opt out.” An example of this would be if a female lied about using contraception before engaging in sexual intercourse with a male. In this example, only the female would be privy to the true risks associated and therefore the father shouldn’t be held accountable for his actions.

Additionally, I think the financial situation of both the mother and father should be taken into consideration. While my limited understanding of economics prevents me from pinpointing an exact number, I think this is something that must be looked at. Consider the hypothetical example of an extremely wealthy businesswoman who becomes pregnant with the child of a construction worker struggling to make ends meet. If she chooses to raise the child independent of the father, is the limited amount of money he can contribute absolutely necessary to ensuring the child has a good upbringing?

In conclusion, I believe that prospective fathers do not have the right to prevent or compel a woman to have an abortion and, barring the sliver of the cases that meet the previously listed criteria, better be ready to deal with the consequences of their actions.

What do you think?

– Michael

Disclaimer: I am a male who doesn’t have children at present but would like to one day. I’m in a stable monogamous relationship and would contribute the necessary time and money to raise my child should the unexpected happen. I believe it is important for the reader to understand my paradigm to understand any biases included in my blog.

References

Government of Canada. (2021, February 24). Consolidated federal laws of canada, Criminal Code. Justice Laws Website. https://laws-lois.justice.gc.ca/eng/acts/c-46/?wbdisable=true

Hales, S. D. (1996). Abortion and Fathers’ Rights. In J. M. Humber & R. F. Almeder (Eds.), Reproduction, Technology, and Rights (pp. 5–26). Humana Press. https://doi.org/10.1007/978-1-59259-450-4_1

Overall, C. (2012). Why Have Children?: The Ethical Debate. The MIT Press.

Ubel, P. A., Scherr, K. A., & Fagerlin, A. (2018). Autonomy: What’s Shared Decision Making Have to Do With It? The American Journal of Bioethics : AJOB, 18(2), W11–W12. https://doi.org/10.1080/15265161.2017.1409844

Mr. Rasouli and His Family (1994)

Module 3 of Queen’s University’s BMED 373 course focuses on the ethical, legal, and policy issues related to end-of-life care. We were presented with the IDEA Ethical Decision-Making Framework and used it to discuss the Supreme Court case of Cuthbertson v Rasouli. Hassan Rasouli was a 59-year-old patient at Sunnybrook Health Sciences Centre who became comatose after bacterial meningitis spread throughout his brain. As Mr. Rasouli was initially admitted to undergo a routine surgery, he was never afforded the opportunity to directly express his wishes. According to Section 20 of the Ontario Health Care Consent Act (HCCA), Parichehr Salesel, the patient’s wife, was identified as the substitute decision-maker. Although Mrs. Salesel’s role as the substitute decision-maker was undisputed, Mr. Rasouli’s medical team did not agree with her decision to continue life-support.

Mr. Rasouli and His Family (2012)

Two of Mr. Rasouli’s physicians, Dr. Cuthbertson and Dr. Rubenfeld, believed that ending his current treatment in favour of palliative care was in the patient’s best interest. Matters were further complicated when Mozhgan Rasouli, the patient’s daughter, released a video pleading her father’s case. This leads us to the elephant in the room. When the opinions of a patient’s family and medical team are in direct conflict, what do we do? In order to answer this, we must first take a look at the cause of dispute within this case, the definition of treatment.

The Ontario Health Care Consent Act defines treatment as “anything that is done for a therapeutic, preventative, palliative, diagnostic, cosmetic or health-related purpose…”

The attending physicians argued that “life support that is not ‘medically indicated’ is not ‘treatment’” under the previously mentioned definition in the HCCA. While the Supreme Court addressed the ambiguity of the definition, they ultimately ruled that starting palliative care does constitute treatment. They further added that the removal of life support impacts patient autonomy and directly violates the underlying principles of the HCCA.

Personally, I agree with the decision made by the court. As Mr. Rasouli is unable to communicate, altering his treatment plan must be consented to by his substitute decision-maker. The HCCA is a lawful document that clearly outlines how the substitute decision-maker is selected and we must respect her ability to express the patient’s best interests.

The responsibilities of health advocacy are fourfold: (1) Patient needs, (2) Community needs, (3) Identifying social determinants of health, and (4) Health promotion. As such, there are two main facts that, if different, could result in me taking a different stance. Firstly, if Mr. Rasouli had personally expressed that he did not wish to be kept alive by life support, either through discourse with a physician or an advance care directive, I would argue that Mrs. Salesel’s stance no longer represents the best interests of the patient. Secondly, if Sunnybrook Health Sciences Centre had grossly limited resources such that the continuation of Mr. Rasouli’s treatment became detrimental to the larger community, I would be more inclined to side with the physicians. This would dramatically change the case and it’s impossible to speculate on the legal outcome of this hypothetical situation.

After identifying the facts in the IDEA Framework, we are encouraged to determine the ethical principles. The most glaring ethical dilemma in this case is that the removal of life sustaining treatment that is in line with the patient’s best interest (in this case expressed by his substitute decision-maker) largely violates the patient’s autonomy. Additionally, it is known by all that the discontinuation of Mr. Rasouli’s life support will directly cause his death. This situation reminded me of the Hippocratic Oath that one of my classmate’s quoted in an earlier discussion board and the doctor’s pledge to “keep patients from harm.” To me, engaging in an action that will bring about the death of a patient, knowing it is in violation of what they want, goes against this part of the oath. Lastly, the various news articles surrounding this case demonstrate the role culture plays in decisions surrounding end-of-life care. It is extremely important that physicians demonstrate cultural sensitivity and recognize the roles that our unique beliefs and experiences as humans bring to ethical situations.

When weighing the patient’s autonomy, role of physicians to keep patients from harm, and the cultural differences of the family, I would agree with the legal reasoning of this case. I believe that the decision of the Supreme Court is not only in line with the literal wording of the HCCA, but also it’s underlying theme of protecting patients’ rights to ownership of their own medical treatment.

– Michael

If this post interested you and you would like to better understand the case of Mr. Rasouli, please explore the following:

Hassan Rasouli Case: Top Court Upholds Right To Demand Life

Rasouli Case: Supreme Court Mulls Tough Questions On End Of Life Care

A Life Interrupted: Hassan Rasouli’s journey from an earache to a high-stakes battle over end-of-life decisions

The Supreme Court Decision In Rasouli

References

Cuthbertson v. Rasouli. (2013). SCC 53, [2013] 3 S.C.R. 341
https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/13290/index.do

Health Care Consent Act. (1996). Ontario. https://www.ontario.ca/laws/statute/96h02

Queen’s University. (2021). BMED 373 – Health Ethics, Law, and Policy

I recently began a course on Health Ethics, Law, and Policy at Queen’s University. In the first month of the course, we discussed decision-making towards the end of one’s life. We focused on the ethical issues surrounding this process stemming from the varying beliefs between different patients, their families, and healthcare professionals. To highlight this topic on a personal level, I completed an advanced directive for myself and my partner, Chloe. The template we used can be found at Speak Up Ontario.

Part 1

“What were my feelings when completing and then discussing the form?”

When trying to answer these questions, I felt slightly frustrated and confused. It was extremely difficult to articulate my generalized wishes for end-of-life care in a couple short sentences. There were so many passionate feelings stirring inside me and there was no way to explain my preferred outcome in every possible situation that might arise.

This was further complicated due to the nature of my work. Over the last decade, I have spent 7 years as an infantry soldier in the Canadian Army and 4 years as a Search and Rescue Technician in the Royal Canadian Air Force. The threat of death has been a real possibility throughout my entire career, and I had never put that much thought into “how I want to die.” This gave the eloquently worded questions a lot more weight as I began to imagine how real their answers might be.

How did Chloe react to the process? What questions or comments did she have?

Similar feelings were both expressed and amplified by Chloe when we attempted to complete the advance directive for her. She had an extremely hard time wrapping her head around several of the questions and I was often met with blank stares as she tried to find the words to express her intentions. She answered the questions using specific examples of her loved ones who died which made the process even more emotional. She asked me several times to explain the questions and her lack of understanding of how the healthcare system and medical interventions worked became apparent.

How did I respond to those comments?

Throughout our discussion, I aimed to calmly encourage her answers without ever putting words in her mouth. On my end it was a mixed bag on consoling the resurfaced grief for lost relatives and attempting to objectively explain the level of detail required by the questions. I tried to emulate the approach that I thought a doctor might take when having these conversations with their patients.

Do I think this experience was typical of discussions about end-of-life issues? Why?

Personally, I think this is an extremely typical example of conversations surrounding end-of-life issues. Most people, like Chloe, are not medical professionals and probably haven’t given much informed thought towards the idea of how they want to die. While they might have a vague understanding of some things they want, they might not have clearly defined, well articulated wishes. This can make conversations with relatives or physicians confusing, overwhelming, and even convoluted.

Part 2

What are the benefits and limitations of the form?

This form asks open-ended questions, allowing an individual to formulate their wishes void of medical terminology. It allows individuals to walk through some difficult questions in a stepwise manner. It is fairly exhaustive including an area for individuals to add any other information they feel might not have been captured by the questions. One of the limitations can come from the examples it gives. While the examples can further explain the questions, they can also guide the response of the individual. Sometimes it’s hard to truly explore your own thoughts and feelings when a specific prompt is provided. Another limitation is that it would be difficult for an individual without much medical knowledge (like Chloe) to complete on their own.

How understandable was the form to Chloe and I? How effective would the form be in different situations and for different people?

Although my education in the health sciences and my employment within the healthcare system allowed me to understand the form more easily, Chloe struggled to understand what some of the questions were asking her. I think the most effective use of a form like this would be its administration by a healthcare professional who could help clarify the questions. They would also be able to explain any in-depth medical procedures that the general population might not fully understand. Additionally, an informed individual might also be able to provide context to the questions or guide the individual down paths they may not initially consider relevant.

Does the framework of the form promote or confine free expression of preferences?

This semi-structured form has open-ended questions that promote free expression and allow the individual to discuss anything they deem relevant. The last section amplifies this by allowing individuals to include anything that they think may not have been captured by the previous questions. Although this form would be more easily completed with an understanding of the various medical procedures, it’s allowance for individuals to answer the questions in their own words encourages the autonomy outlined in the Health Care Consent Act. At the very least, it highlights the importance of having these conversations with a healthcare provider. This way, we can get back to doing the things we love with confidence that we will be taken care of in the way we deem best.

– Michael

References

Health Care Consent Act. (1996). Ontario. https://www.ontario.ca/laws/statute/96h02

Queen’s University. (2021). BMED 373 – Health Ethics, Law, and Policy

Speak Up. (2021). Advance Care Planning Workbook – Ontario Edition | Speak Up Ontario. https://www.advancecareplanning.ca/my-plan/

At What Cost

Humans have long been considered the biggest threat to themselves. This doesn’t just refer to physical conflict and the many wars fought over the last century, but also our ability to spread bacteria, viruses, parasites, and fungi. With a rapidly increasing population, infectious diseases are continuing to be a large problem worldwide. “As the first infectious disease to emerge as a new cause of human illness in the 21^st century, SARS underscores the growing importance of health issues in a globalized world” (Monaghan, 2004). Severe acute respiratory syndrome (more commonly known as SARS) is an atypical pneumonia caused by a virus that spread to over 8000 people across the globe when it surfaced in the early 2000’s. While SARS is not currently an immediate threat, it is worth discussing as the potential for resurging exists and it is a highly infectious disease.

While there is a lull in the havoc this disease causes, it is important to consider what actions should be taken if it resurfaces. Patients infected with SARS, as well as their families and others suspected to be at risk, should be quarantined. Beijing attempted this strategy when SARS originally surfaced by closing schools and forcibly locking both patients and healthcare workers in hospitals during the peak of the infections. While I believe that is an extremely inappropriate response, there are good arguments to be made in favour of quarantining individuals. First, it is important to understand that “isolation” refers to the separation of infected, symptomatic individuals, while “quarantine” refers to the separation of individuals who have been exposed to the infection, but are not yet ill. SARS has a four to six day incubation period. This means patients may have the disease for almost a week before they begin experiencing any symptoms. This, combined with the 10% mortality rate and spread via the droplet route, provide a strong case for quarantining individuals exposed to the deadly disease.

The two biggest counter arguments against quarantine are the potential cost, especially in a country that largely subsidizes medical treatment, and the ethical dilemma involving human rights. At first glance, it seems obvious that an extreme financial burden would be created by quarantining individuals just because they may have been exposed to an infectious disease like SARS. That being said, studies have already put this myth to rest. In a study presented in the Journal of Infection the “results indicate that quarantine is not only effective at containing newly emerging infectious diseases, but is also cost saving when compared to not implementing a widespread containment mechanism” (Gupta et al., 2005). A more compelling argument against quarantine is that it imposes on the right to freedom of movement. Is it acceptable for the government to place an asymptomatic individual in quarantine because a co-worker they have been working closely with or a family member has a confirmed infectious disease? After the AIDS epidemic in the 1980’s, the Siracusa principles were created to help determine when restriction to human rights can be justified. To summarize these principles, quarantine will be done in the best interest of the public, in accordance with the law, and without discrimination or unjustly restriction. It is worth considering that while quarantine may seem like a violation of the rights of the quarantined individual, letting them potentially spread a deadly disease they have been exposed to infringes on the rights of the rest of the population that they come into contact with. Sometimes small financial sacrifices or ensuring potentially infected individuals do something they may not want to must be done for the greater good.

All this information may initially be overwhelming, but lets look at what can be done in order to ensure our country doesn’t face another large scale SARS outbreak. First, there are many low-cost infection control changes that can be implemented. These can include the installation of Plexiglas shields at triage, increased hand sanitizer stations, and signage regarding respiratory hygiene and hand washing. These low cost implementations are not only beneficial for SARS, but for many other infectious diseases as well. Next, quarantine zones should be implemented for those exposed to the illness. This should be done in accordance with the Siracusa principles previously mentioned to minimize restriction on human rights. Lastly, financial support should continue to be given to those who require quarantine. As studies have already proven that quarantine is cheaper in the long-run, the government should have no issues in justifying the financial assistance of those requiring quarantine.

In conclusion, SARS is one of many extremely infectious diseases. Individuals suspected of being at risk should be quarantined for the greater good of quickly preventing the disease from the carnage it is capable of. This should be done in a way that makes sense financially and also minimizes restriction on human rights. Maybe the next time there is an outbreak of a deadly disease like SARS, the casualty count will be much lower.

To hear how Hong Kong has been changed, watch this video: Ten years on, the SARS outbreak that changed HK

RESCUE

Barbisch, D., Koenig, K.L., Shih, F.-Y., 2015. Is There a Case for Quarantine? Perspectives from SARS to Ebola. Disaster Medicine and Public Health Preparedness 9, 547–553. https://doi.org/10.1017/dmp.2015.38

Gupta, A.G., Moyer, C.A., Stern, D.T., 2005. The economic impact of quarantine: SARS in Toronto as a case study. Journal of Infection 50, 386–393. https://doi.org/10.1016/j.jinf.2004.08.006

Lander, F., er, 2014. Human rights and Ebola: the issue of quarantine | Global Health. Translational Global Health.

Martin, E., 2015. SARS, in: Concise Medical Dictionary. Oxford University Press.

Monaghan, K.J., 2004. SARS: DOWN BUT STILL A THREAT. National Academies Press (US).

SARS, questions and answers, 2003. Ontario. Ministry of Health and Long-Term Care.

Our Drugs Fix Everything

Picture this. It’s late at night and you’re stressed out. Maybe you’re having difficulty sleeping or maybe your sexual performance isn’t what it used to be. You turn on the television to pass some time and there it is. A commercial is showing you the answer to all your problems! Your situation is about to change for the better… or is it? Lunesta® and Viagra® are just a couple of examples of companies that practice direct-to-consumer advertising. More examples can be found HERE (sorry for the poor quality).

Direct-to-consumer pharmaceutical advertising (DTCPA) can be defined as “an effort… made by a pharmaceutical company to promote its prescription product directly to patients” (Ventola, 2011). This is commonly practiced in the United States of America and New Zealand, but is currently prohibited in Canada. This generates a problem for Canadians because American-made television and North American edition magazines, that are created in the USA with DTCPA, can both be consumed by the Canadian population. Further, in the examples given above, the companies attempting to sell their product are biased. They are selling you a product that directly affects your health, but as a business, their main goal is to make profit. How do you, the consumer, know which advertisements you can trust when trying to optimize your health. The controversies surrounding DTCPA make it an extremely important social issue.

Before we can make an informed decision on DTCPA, we must understand both sides of the debate. DTCPA drives up the price of prescription drugs as consumers become willing to spend more money for brand name drugs. This also results in in pharmaceutical companies putting large amounts of money into advertising that would otherwise go into research. Doctors have also been proven more likely to prescribe a drug when a patiently specifically requested it (“Direct-to-consumer Advertising,” 2011). Not only does this increase the likelihood of a patient receiving less suitable medication, but DTCPA also encourages healthy patients to think they would be better off with medication. Lastly, DTCPA generates a “focus on blockbuster and lifestyle drugs [that] excludes provision of information to traditionally ignored at-risk groups, such as pediatric patients, pregnant women, and orphan disease patients” (Liang and Mackey, 2011). At the end of the day, the pharmaceutical companies can make the most money by appealing to the masses, instead of catering to specific subpopulations.

If after that you’re thinking to yourself, “we need to protect ourselves against direct-to-consumer pharmaceutical advertising,” consider the following. “The number of regulatory actions taken by the FDA against companies marketing prescription drugs to consumers has fallen dramatically in recent years” (Donohue et al., 2007). Although many argue that this proves a fault with the FDA, it could also be suggestive of better compliance with pharmaceutical companies following FDA advertising regulations. Many individuals may not know that there is a problem or solution until viewing advertisements for different medications. DTCPA can spark important conversations between patients and clinicians or health care providers. This can result in a reduction of underdiagnosed and undertreated conditions as well as the encouragement of patient compliance (Ventola, 2011). Random surveys of the US public conducted in the late 90’s revealed that 20-25% of the respondents had seen advertisements for drugs they were currently taking. Of those, 33% said the ads made them more likely to take their medication (Mintzes, 2006). This means that DTCPA makes patients more likely to follow instructions given to them by a medical professional and it’s hard to interpret that in a negative light.

Personally, I am not in favour of direct-to-consumer pharmaceutical advertising. I strongly believe that important decisions, such as which medications a patient takes, should be made by a medical professional. I don’t like the idea of a doctor’s decision being swayed by a patient who specifically requests a drug. Doctors may feel that this will lead to better patient compliance, but it can actually result in the patient receiving less than premium care. Pharmaceutical companies are also less likely to state the risks while generating appealing advertisements. Vioxx (advertisement seen above) was withdrawn in 2004 after it was discovered to elevate the risk of heart attack and stroke (Tman, 2017). This drug used a celebrity figure (Dorothy Hamill) and a catchy slogan (“For everyday victories”), but undersold the risks of taking their drug. This advertisement encourages disease mongering as it suggests that the undiagnosed pain the consumer may be feeling can be cured with this “magic bullet” drug. As a result, the health of many individuals suffered based on these advertisements. At the end of the day, these pharmaceutical companies are businesses and their primary interest is not in patient well-being, but turning a strong profit. I am in support of Canada’s current decision to prohibit direct-to-consumer pharmaceutical advertisement and I hope this policy remains in place for the foreseeable future.

For an excellent video that further weighs the pros and cons on this issue, watch: How Americans got stuck with endless drug ads.

RESCUE

Direct-to-consumer Advertising: Canadian Federation of Nurses Unions Backgrounder [WWW Document], 2011. URL https://deslibris-ca.proxy.queensu.ca/ID/248608 (accessed 11.13.18).

Donohue, J.M., Cevasco, M., Rosenthal, M.B., 2007. A Decade of Direct-to-Consumer Advertising of Prescription Drugs. The New England Journal of Medicine; Boston 357, 673–81. http://dx.doi.org.proxy.queensu.ca/10.1056/NEJMsa070502

Liang, B.A., Mackey, T., 2011. Reforming direct-to-consumer advertising. Nature Biotechnology 29, 397–400. https://doi.org/10.1038/nbt.1865

Mintzes, B., 2006. Direct-to-Consumer Advertising of Prescription Drugs in Canada [WWW Document]. URL https://deslibris-ca.proxy.queensu.ca/ID/203599 (accessed 11.13.18).

Tman, Z., 2017. Here’s why direct-to-consumer drug ads need FDA oversight [WWW Document]. KevinMD.com. URL https://www.kevinmd.com/blog/2017/12/heres-direct-consumer-drug-ads-need-fda-oversight.html (accessed 11.13.18).

Ventola, C.L., 2011. Direct-to-Consumer Pharmaceutical Advertising. P T 36, 669–684.

Who I am

The sixth version of the International Classification of Diseases (ICD 6) was published in 1949 and deemed that mental disorders were in fact classified as diseases. This blanket statement encompasses all mental disorders, but are all mental disorders truly diseases? In this module we learned about “the disease concept,” and I plan on using this to identify one known mental disorder that should not be classified as a disease.

When I was a child, I was told that I had Attention Deficit Hyperactive Disorder (ADHD). This was the DIAGNOSIS given to me by a medical professional. Naming a disease allows them to group PATIENTS who suffer from similar ailments together. Until fairly recently, ADHD was considered a disorder affecting children that was outgrown by the end of adolescence and the beginning of adulthood. This is no longer the case as adults are not only exhibiting the same behaviors as when they were younger, but in fact being diagnosed over the age of 17. It has been diagnosed in roughly 3 times as many males as females giving it a more prevalent demographic. That being said, just because a condition has been given a name, and a group of people who it affects, doesn’t make it a disease.

A disease must have SYMPTOMS. In one Journal, symptoms of ADHD in adults include talkativeness, unable to make decisions, procrastinating, and being disorganized. This is a list of common personality traits, not an indication of a disease. Many people can have any or all of these personality traits without being considered as having ADHD just as many diagnosed individuals can have none of these. If I had heard only these symptoms, I might believe you are simply describing an extrovert or a teenager in their first year of university.

The problem with the proposed idea of ADHD is that there is no real test for it. As one Journal states, “ADHD is currently diagnosed by a diagnostic interview, mainly based on subjective reports from patients or teachers.” There is no concrete method of determining if an individual even has ADHD. If we can’t prove that they have it, maybe we can look at how they got it. The exact CAUSE of ADHD is unknown with speculations including genetics, behavioral, neurochemical, and even food. Without knowing how people develop ADHD there is no real way to prevent it.

If the test is subjective to determine if someone has ADHD and there is no way to prevent it, we should consider the OUTCOMES of those diagnosed (or misdiagnosed) with ADHD. Roughly 85% of the adult population who meet the criteria for ADHD go undiagnosed. They live their entire lives unaware that there may be a problem with them and are no worse for it in the context of their health. Some could argue that the previously mentioned symptoms of ADHD may not affect health, but may affect one’s ability to succeed in life. Diagnosed celebrities including comedian Howie Mandel, superstar Justin Timberlake, and Olympic record holder Michael Phelps would probably disagree.

Lastly, let’s consider the TREATMENT. While some believe ADHD symptoms can be treated with diet alone, the majority of the population look at using drugs in an aim to reduce symptoms. As we previously discussed, most of the symptoms are social traits and characteristics. Is being talkative necessarily a bad thing? This also brings up the ethical dilemma that changing an individual’s character traits can be seen as changing their personal identity.

When I was a younger, I was prescribed Ritalin to help manage my ADHD. Even though I was a child, my parents wanted to know how I felt about taking this medication. The doctor explained to me that Ritalin would “get rid of the excess noise and allow me to focus on the tasks at hand.” It was essentially explained to me that this drug would block some of my thoughts. Even at my early age, I was able to realize that there was no way for them to guarantee the thoughts being “blocked” wouldn’t be my best ides or my most creative inspirations. In my eyes, this is the way I am and how my brain operates. I am educated with a BSc in Math and Physics, I have friends and family that I love and whom love me, and I am completely infatuated with my work. There is no reason to believe that I am being negatively by the way that my brain is wired and potentially even benefit from it.

In conclusion, Attention Deficit Hyperactive Disorder is not in line with the Disease Concept, it does not necessarily have a negative impact on one’s quality of life, and therefore ADHD is not a disease.

For an interesting video on some of the science behind ADHD and how it can be beneficial watch: https://www.youtube.com/watch?v=n2EVEYmeSqg

RESCUE

Braganza, S.F., Galvez, M.P., Ozuah, P.O., 2006. When parents ask about diet therapy for ADHD: Part two. Contemporary Pediatrics 23, 47-.

Friedman, J., 2017. What is a disease? Rhode Island Medical Journal 100, 8–9.

Kyeong, S., Park, S., Cheon, K.-A., Jae-Jin, K., Dong-Ho, S., Kim, E., 2015. A New Approach to Investigate the Association between Brain Functional Connectivity and Disease Characteristics of Attention-Deficit/Hyperactivity Disorder: Topological Neuroimaging Data Analysis. PLoS One; San Francisco 10, e0137296. http://dx.doi.org.proxy.queensu.ca/10.1371/journal.pone.0137296

Shoot, B., 2011. The Stars Who Aligned ADHD with Success. ADDitude.

Valente, S., Kennedy, B.L., 2012. Recognizing and treating Adult ADHD: The Nurse Practitioner 37, 41–46. https://doi.org/10.1097/01.NPR.0000411105.20240.8c

Black and White

Is it ethical to use animals in scientific experiments? Is it ethical to use humans in scientific experiments? Are those two questions radically different? A lot of individuals would argue there is a large difference between those two questions. They might state that it is fair to use animals in scientific experiments, but debate that as humans we have are protected by rights. Animals should not be experimented on in any way that is considered morally wrong for a human.

Humans are part of the biological kingdom called Animalia. Most animals are made up of tissues with specialized functions, reproduce sexually, grow from sex cells to living, breathing creatures, and mature and grow through age. That sounds an awful lot like humans to me. Most animals are capable of feeling pleasure and pain, increasing their similarity to us and further shedding doubt on the idea of performing experimentation upon them. One might argue that as humans we are more intelligent beings and deserve to be ruling the world. Many animals like crows and dolphins have proved capable of using human-made tools and various monkeys have even learned to communicate with a human developed sign language.

Pause.

For those of you who know me, you may be a little confused. I am a medical professional and understand the much of the life-saving drugs and equipment I use on a daily basis has been tested on animals at some time or another. I fully support scientific experimentation on animals, within reason. My definition is a little grey, as most things in this world are not black and white. I believe that two criteria must be met in order to use animals for scientific experiments. Firstly, no unnecessary or unjust harm should be done to the animal in the experiment. Secondly, the experiment must be done with the intent to provide legitimate scientific advancement.

If you had asked me a week ago if I thought it was ethical to use animals in scientific experiment, I wouldn’t have hesitated in saying yes. Now, I’m not so sure. In writing this, I had been asked to consider the other side of the equation. At first, I didn’t even know how to begin writing about an opinion that I was so clearly against. Once I started writing it, I had to quickly reign myself in.

I listened to a TED Talk by Glenn Cohen called “Are There Non-Human Persons? Are There Non-Person Humans?” Glenn challenged me to think that there is a difference between a “person” and a “human.” He asks his audience what specific character traits they believe should qualify an individual to have rights. Most traits that come to mind are expressed by at least one species other than human. If we are to only qualify someone for rights based on their genetic makeup, we begin getting dangerously close to the ideals expressed by the controversial leaders of various genocides worldwide.

At the beginning of this module, I believed that it was ethical to use animals in scientific experiments. If I had written this blog then, I probably would have taken the stance that everything that can be done to save a human’s life should be. When reading about ancient anatomists dissecting animals to better understand the human body, I saw nothing wrong. I have since realized that this topic, like most controversial issues, isn’t exactly black and white.

One idea that I came across that has helped me find my place in the middle of these two extremes is the concept of the 3 R’s. The 3 R’s are a Replacement (methods which avoid the use of animals if possible), Reduction (strategies that will result in fewer animals being used), and Refinement (minimizing the pain and distress of any and all animals used). This concept makes a lot of sense to me. I still support the idea of animal experimentation because I have seen first hand how the resulting drugs and products can save human lives. After learning about the Nuremberg Code in this module, I believe that making guidelines and rules such as this for animals is a fair compromise to prevent excess cruelty.

This module has shown me a lot of opposing theories. We have seen the difference between teleology vs empiricism, vitalism vs mechanism, and speculation vs experimentation. Through these studies I have learned that the question of “Is it ethical to use animals in scientific explanation?” cannot be answered with a simple yes or no. Although I don’t believe any unjust harm should be applied to animals, the next time I find myself administering an antibiotic like penicillin at work, I am positive that I will be thankful for the experimentation process in place to save human lives.

RESCUE

Baldrick, P., 2010. Juvenile animal testing in drug development – Is it useful? Regulatory Toxicology and Pharmacology 57, 291–299. https://doi.org/10.1016/j.yrtph.2010.03.009

Danza, A., 2018. Five Surprisingly Intelligent Animals. The Epoch Times, New York ed.; New York (NY) B5.

Dewey, T., n.d. Animalia – Biology Encyclopedia – cells, body, function, process, organisms, organs, cycle, life, structure, types [WWW Document]. Biology Reference. URL http://www.biologyreference.com/A-Ar/Animalia.html (accessed 10.16.18).

Lestel, D., 2002. Human/animal communications, language, and evolution. Sign systems studies 201–212.

Russell, W.M.S., Burch, R.L., 1959. The principles of humane experimental technique. Methuen, London.

Not Really the End

“What happens when I die?” This is a question often wondered by people around the globe. Although there is no definite answer for what may happen to your conscious being, it is worth considering what will happen to your body.

Throughout history, the dissection of a human body has always been a controversial topic. For hundreds of years it was forbidden and, even when it was allowed, it was met with strict rules and stipulations by the governing bodies of the time. This was largely a result of human nature. As humans, we naturally fear what we don’t understand and before the rise of medical science, death and disease were quite scary. Even today, medical students themselves are unlikely to donate their bodies to science, citing religion and culture as reasons why (De Gama et al., 2018).

Not only are dissections used by medical professionals in some attempts to discover an unknown cause of death, more and more universities are allowing medical students to perform dissections with educational intent. “The medical and biological sciences are currently progressing more rapidly than at any other point in history. To properly approach and keep up with this medical evolution, health professionals require human material with which to conduct experiments and learn” (Park et al., 2011). As the future leaders in the medical community, it is important for today’s students to have a strong understanding of the human body. As discussed in The Body Donors, a documentary following two individuals who plan on donating their bodies to science, the ability for future medical professionals to practice some of the skill sets they will be called upon to use one day is extremely valuable. As someone who has undergone minor surgeries in the past, the experience and knowledge of the surgeon is extremely comforting.

After reading the above, it is probably easy to see that I view the act of donating your body to science as a noble pursuit. The obvious question that follows is, “Do I plan on donating my body to science?” As of this moment in time, no. Before the hypocritical accusations start flying, allow me to briefly justify. I am currently an organ donor and the two are mutually exclusive. As a healthy individual, I very strongly believe that if I were to unexpectedly die, a lot of lives can be saved via organ transplant. In my job as a SAR Tech, I am directly providing life saving treatment to the patients who come into my care. With that theme in mind, I think it would be amazing for me to be able to continue my work of directly saving the lives of others through my death.

That being said, I do not believe my answer will always be no. A couple years ago, my mother was diagnosed with cancer. Although I am an ideal candidate for organ donation, she is not. However, she is an ideal candidate for donating her body to science. Not only will this provide an opportunity for others to learn about the disease that is plaguing her body, it will also potentially save the lives of other in a more indirect approach. In How to donate your body to science, an article by The Star, a third-year medical student named Bernadett Kovacs explains how valuable a learning experience it is for medical students to be able to work on real bodies. In fact, working with cadavers is becoming such common practice amongst universities that privatized companies are starting to emerge to supply schools in need (Wingfield, 2018). If donating your body to science truly results in more competent doctors and surgeons, then it can be seen as indirectly saving lives. If down the road I am no longer an eligible candidate for organ donation, I will definitely allow my body to be used for scientific purposes.

I have always believed that giving back to society through death is a noble action. Whether it be organ donation or body donation, there is a real chance for people to do something for others when their body is no longer of use for them. Although this mod hasn’t directly influenced my personal decision on this topic, it has made me realize how important it is for medical students to be able to practice their craft while in school. For that reason, I plan to be more active about encouraging others to donate their body to science. I hope to be a medical student one day and would jump at the chance to work with as real of a training tool as there is. So the next time you ask yourself, “What happens when I die,” consider making a difference in the world by donating your body to science.

RESCUE

Branswell, H., 2008. How to donate your body to science | The Star [WWW Document]. The Star. URL https://www.thestar.com/life/health_wellness/2008/11/24/how_to_donate_your_body_to_science.html (accessed 10.2.18).

De Gama, B.Z., Bhengu, T.T., Satyapal, K.S., 2018. Attitudes of Undergraduate South African Students towards Body Donation. International Journal of Morphology 36, 130–134. https://doi.org/10.4067/S0717-95022018000100130

Park, J.-T., Jang, Y., Park, M.S., Pae, C., Park, J., Hu, K.-S., Park, J.-S., Han, S.-H., Koh, K.-S., Kim, H.-J., 2011. The trend of body donation for education based on Korean social and religious culture. Anatomical Sciences Education 4, 33–38. https://doi.org/10.1002/ase.198

Wingfield, H.A., 2018. Body donation today: A Critical Comparison of Two Current Practices, and Moving into the Future. Clinical Anatomy 31, 86–89. https://doi.org/10.1002/ca.23010