tag:theconversation.com,2011:/us/topics/hippocratic-oath-9763/articlesHippocratic Oath – The Conversation2019-11-11T19:00:57Ztag:theconversation.com,2011:article/1265802019-11-11T19:00:57Z2019-11-11T19:00:57ZAs NZ votes on euthanasia bill, here is a historical perspective on a ‘good death’<figure><img src="https://images.theconversation.com/files/300825/original/file-20191108-10935-w4iaqq.jpg?ixlib=rb-1.1.0&rect=70%2C149%2C5163%2C3201&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Critics of assisted suicide often raise moral objections while proponents focus on the trauma of terminally ill patients. But all arguments have a long history.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>This week New Zealand’s parliamentarians will vote on the third reading of the <a href="https://www.parliament.nz/en/pb/bills-and-laws/bills-proposed-laws/document/BILL_74307/end-of-life-choice-bill">End of Life Choice Bill</a>. </p>
<p>Much public discussion on the merits of euthanasia has centred around the role of the medical practitioner as healer. Some doctors and conscientious objectors worry that physician-assisted suicide will alter the <a href="https://www.rnz.co.nz/news/political/392774/seymour-unfazed-by-doctors-letter-against-end-of-life-choice-bill">relationship between doctors and their patients</a>. They argue it is unethical, often invoking the <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=20909">Hippocratic oath</a>. </p>
<p>The oldest code of medical ethics, the oath dates to around the fourth century BC and is still sworn by doctors today. It specifically <a href="https://www.jstor.org/stable/pdf/24624423.pdf?refreqid=excelsior%3Ace52758660d62b03cd7c96af548f9691&seq=1#page_scan_tab_contents">forbids physicians from administering lethal drugs</a>, among its other precepts.</p>
<p>Some critics of the bill present religious and moral objections against euthanasia, while proponents have focused on the trauma and pain of terminally ill patients and their families. All these arguments have a long history.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-places-where-its-legal-how-many-people-are-ending-their-lives-using-euthanasia-73755">In places where it's legal, how many people are ending their lives using euthanasia?</a>
</strong>
</em>
</p>
<hr>
<h2>The art of dying well</h2>
<p>Like the Hippocratic oath, euthanasia (in its literal meaning of “good death” in ancient Greek) <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953603005756">first appeared</a> around the fourth and third century BC. Ancient Roman emperors, at death’s door, were known to <a href="https://www.goodreads.com/book/show/37440902-of-the-advancement-and-proficience-of-learning">consume wine, drugs and other palliatives to ease their dying</a>. Good emperors were believed to deserve a dignified death, and often <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953603005756">staged them</a>. </p>
<p>In pre-modern Europe, <a href="http://www.helsinki.fi/collegium/journal/volumes/volume_18/Death%20and%20Dying%20in%20Medieval%20and%20Early%20Modern%20Europe.pdf">experiencing a good death</a> and intentionally shortening the agony of dying were separate matters. From 1400 on, there was a thriving trade in <a href="http://www.deathreference.com/A-Bi/Ars-Moriendi.html">advice books on the art of dying</a>. These instructed readers on how to prepare their souls for a “good death” and the Christian afterlife. </p>
<p>Prayers, rituals and information about what to expect offered practical guidance for attaining salvation. Christian theologians saw euthanasia as “<a href="https://books.google.co.nz/books?id=uYNbwVzdPm4C&printsec=frontcover&dq=Bartolomeo+Castelli,+Amaltheum+Castello-Brunonianum,+sive,+Lexicon+medicum&hl=en&sa=X&ved=0ahUKEwjfh_KcgdnlAhUOfH0KHeapA44Q6wEIOzAB#v=onepage&q=euthanasia&f=false">a blessed and peaceful death of the faithful</a>”. </p>
<p>Whether and how people sought to hasten or ameliorate death is less clear. Scholars only began considering the doctor’s role in enabling euthanasia in the late 16th century.</p>
<h2>Early ideas about assisted dying</h2>
<p>In 1605, English lawyer, statesman and natural philosopher <a href="https://www.biography.com/scholar/francis-bacon">Francis Bacon</a> wrote that the physician’s office extends to <a href="https://books.google.co.nz/books/about/Bacon.html?id=bslNAQAAMAAJ&printsec=frontcover&source=kp_read_button&redir_esc=y#v=onepage&q&f=false">matters of health as well as dying</a>. In his words, a physician ought “not only to restore health, but to mitigate dolours, and torments of Diseases”. If there was no hope of the patient’s recovery, everything should be done “to make a fair and easie passage out of life”.</p>
<p>Bacon called this “fair and easie passage” euthanasia. Importantly, he distinguished between “outward” euthanasia and the soul’s peaceful transition to the afterlife. While the latter remained the purview of the spiritual realm, Bacon placed the former within medicine’s province.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=594&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=594&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=594&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=747&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=747&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301052/original/file-20191111-194641-1v74pou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=747&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A devil and an angel weigh up a dying man’s soul. From Hieronymus Bosch: The seven deadly sins.</span>
<span class="attribution"><span class="source">from Wikimedia commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Until recently, historians believed active euthanasia did not exist in pre-modern Europe, but historian of medicine <a href="https://www.medizingeschichte.uni-wuerzburg.de/stolberg.html">Michael Stolberg</a> has <a href="https://www.springer.com/gp/book/9783319541778">challenged this notion</a>. </p>
<p>A physician in 1660s Antwerp, <a href="https://www.dbnl.org/tekst/bran038biog01_01/bran038biog01_01_0550.php">Michiel Boudewijns</a>, wondered whether doctors could help their terminal patients die. While moved by patients in agony, Boudewijns urged Christian doctors to observe the fifth commandment and the Hippocratic rule of “do no harm”. He cautioned his colleagues against undertaking risky procedures and acting on compassion to expedite death in hopeless cases. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-hypothetical-designs-can-help-us-think-through-our-conversations-about-euthanasia-125975">How hypothetical designs can help us think through our conversations about euthanasia</a>
</strong>
</em>
</p>
<hr>
<h2>A matter of trust</h2>
<p>Physicians also feared patients would lose trust in them if they knew they shortened dying patients’ lives. It was not until the late 17th century that facilitating dying sparked public debate among scholars. In 1678, Caspar Questel, a Silesian lawyer active in Saxony, wrote about assisted dying in the homes of ordinary people. </p>
<p>Methods to accelerate dying ranged from acts of faith and folklore to illegal actions. Questel had discovered that family members, nurses, nuns and other carers removed the pillow from under the head of the dying person. It was a widespread custom that was believed to quicken death. </p>
<p>Other forms of assistance included opening a window so the soul of the dying person would be encouraged to leave the body and meet God, placing lit candles around the gravely sick and placing the dying on the ground or putting them outdoors. More fatal actions involved suffocating the dying with a pillow or cutting their veins. Exercising empathy for the suffering of the dying was weighed against the risk of being charged for their premature deaths.</p>
<p>In present-day New Zealand, if this week’s vote is in favour of euthanasia, the option for assisted dying will still need to be ratified in <a href="https://www.rnz.co.nz/news/political/401616/key-vote-for-referendum-on-voluntary-euthanasia-looms">a referendum next year</a>. </p>
<p>Clearly, cultural customs, prevailing medical ethics and beliefs about death and the afterlife have evolved over time. Today discussions about euthanasia involve a wider range of participants than in pre-modern Europe. The distance between learned professionals and everyone else has narrowed. Civil rights, legal precedents and protections have given us a new language and ethics through which to understand fraught issues concerning our health, body and death.</p><img src="https://counter.theconversation.com/content/126580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Abou-Nemeh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The arguments in favour or against euthanasia have a long history, going back to the Hippocratic oath that doctors still swear today.Catherine Abou-Nemeh, Lecturer in Early Modern History, Te Herenga Waka — Victoria University of WellingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1222002019-08-22T05:23:47Z2019-08-22T05:23:47ZA Hippocratic Oath for data science? We’ll settle for a little more data literacy<figure><img src="https://images.theconversation.com/files/289019/original/file-20190822-170906-15pj7l.jpg?ixlib=rb-1.1.0&rect=11%2C0%2C3982%2C2670&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bias in, bias out: many algorithms have inherent design problems.</span> <span class="attribution"><span class="source">Vintage Tone/Shutterstock</span></span></figcaption></figure><blockquote>
<p>I swear by Hypatia, by Lovelace, by Turing, by Fisher (and/or Bayes), and by all the statisticians and data scientists, making them my witnesses, that I will carry out, according to my ability and judgement, this oath and this indenture.</p>
</blockquote>
<p>Could this be the first line of a “Hippocratic Oath” for mathematicians and data scientists? Hannah Fry, Associate Professor in the mathematics of cities at University College London, <a href="https://www.theguardian.com/science/2019/aug/16/mathematicians-need-doctor-style-hippocratic-oath-says-academic-hannah-fry">argues that mathematicians and data scientists need such an oath</a>, just like medical doctors who <a href="https://www.britannica.com/topic/Hippocratic-oath">swear</a> to act only in their patients’ best interests. </p>
<p>“In medicine, you learn about ethics from day one. In mathematics, it’s a bolt-on at best. It has to be there from day one and at the forefront of your mind in every step you take,” Fry argued.</p>
<p>But is a tech version of the Hippocratic Oath really required? In medicine, these oaths vary between institutions, and have evolved greatly in the nearly 2,500 years of their history. Indeed, there is some debate around whether the oath <a href="https://www.bmj.com/content/355/bmj.i6629">remains relevant to practising doctors</a>, particularly as it is the law, rather than a set of ancient Greek principles, by which they must ultimately abide.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-code-of-ethics-in-it-just-lip-service-or-something-with-bite-32807">A code of ethics in IT: just lip service or something with bite?</a>
</strong>
</em>
</p>
<hr>
<p>How has data science reached the point at which an ethical pledge is deemed necessary? There are certainly numerous examples of algorithms doing harm – <a href="https://www.theatlantic.com/ideas/archive/2019/06/should-we-be-afraid-of-ai-in-the-criminal-justice-system/592084/">criminal sentencing algorithms</a>, for instance, have been shown to <a href="https://www.technologyreview.com/s/612775/algorithms-criminal-justice-ai/">disproportionately recommend that low-income and minority people are sent to jail</a>.</p>
<p>Similar crises have led to proposals for ethical pledges before. In the aftermath of the 2008 global financial crisis, a <a href="https://ssrn.com/abstract=1324878">manifesto</a> by financial engineers Emanuel Derman and Paul Wilmott beseeched economic modellers to swear not to “give the people who use my model false comfort about its accuracy. Instead, I will make explicit its assumptions and oversights.”</p>
<p>Just as prejudices can be learned as a child, the biases of these algorithms are a result of their training. A common feature of these algorithms is the use of black-box (often proprietary) algorithms, many of which are trained using statistically biased data. </p>
<p>In the case of criminal justice, the algorithm’s unjust outcome stems from the fact that historically, minorities are overrepresented in prison populations (most likely as a result of long-held human biases). This bias is therefore replicated and likely exacerbated by the algorithm. </p>
<p>Machine learning algorithms are trained on data, and can only be expected to produce predictions that are limited to those data. Bias in, bias out.</p>
<h2>Promises, promises</h2>
<p>Would taking an ethical pledge have helped the designers of these algorithms? Perhaps, but greater awareness of statistical biases might have been enough. Issues of unbiased representation in sampling have long been a cornerstone of statistics, and training in these topics may have led the designers to step back and question the validity of their predictions. </p>
<p>Fry herself has <a href="https://www.theregister.co.uk/2017/03/20/dr_hannah_fry_even_in_the_nhs_we_need_to_beware_of_algorithms_behind_closed_doors/">commented on this issue in the past</a>, saying it’s necessary for people to be “paying attention to how biases you have in data can end up feeding through to the analyses you’re doing”.</p>
<p>But while issues of unbiased representation are not new in statistics, the growing use of high-powered algorithms in contentious areas make “data literacy” more relevant than ever. </p>
<p>Part of the issue is the ease with which machine learning algorithms can be applied, making data literacy no longer particular to mathematical and computer scientists, but to the public at large. Widespread basic statistical and data literacy would aid awareness of the issues with statistical biases, and are a first step towards guarding against inappropriate use of algorithms.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/algorithms-are-everywhere-but-what-will-it-take-for-us-to-trust-them-118830">Algorithms are everywhere but what will it take for us to trust them?</a>
</strong>
</em>
</p>
<hr>
<p>Nobody is perfect, and while improved data literacy will help, unintended biases can still be overlooked. Algorithms might also have errors. One easy (to describe) way to guard against such issues is to make them publicly available. Such open source code can allow joint responsibility for bias and error checking. </p>
<p>Efforts of this sort are beginning to emerge, for example the <a href="https://webtap.princeton.edu">Web Transparency and Accountability Project</a> at Princeton University. Of course, many proprietary algorithms are commercial in confidence, which makes transparency difficult. Regulatory frameworks are hence likely to become important and necessary in this area. But a precondition is for practitioners, politicians, lawyers, and others to understand the issues around the widespread applicability of models, and their inherent statistical biases.</p>
<p>Ethics is undoubtedly important, and in a perfect world would form part of any education. But university degrees are finite. We argue that data and statistical literacy is an even more pressing concern, and could help guard against the appearance of more “unethical algorithms” in the future.</p><img src="https://counter.theconversation.com/content/122200/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lewis Mitchell works for the University of Adelaide, and is an Associate Investigator in the ARC Centre of Excellence for Mathematical and Statistical Frontiers (ACEMS). He receives funding from the Centre for Invasive Species Solutions, and has previously received funding from Data to Decisions CRC.</span></em></p><p class="fine-print"><em><span>Joshua Ross works for the University of Adelaide and is an Associate Investigator in the ARC Centre of Excellence for Mathematical and Statistical Frontiers (ACEMS). He receives funding from ARC, NHMRC, Centre for Invasive Species Solutions, DST Group and US-DoD. </span></em></p>Mathematician Hannah Fry has called for tech and data scientists to make an ethical pledge, as medical doctors do. But the same result might be delivered by simply asking people to mind their bias.Lewis Mitchell, Senior Lecturer in Applied Mathematics, University of AdelaideJoshua Ross, Professor of Applied Mathematics, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1210212019-08-15T11:14:39Z2019-08-15T11:14:39ZShouldn’t there be a law against reckless opioid sales? Turns out, there is<figure><img src="https://images.theconversation.com/files/287749/original/file-20190812-71936-1tevb1e.jpg?ixlib=rb-1.1.0&rect=901%2C6%2C3399%2C2050&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protests and lawsuits against opioid manufacturers are growing more common, but drug distributors are also facing scrutiny.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Lawsuit-Massachusetts/7b91e013eb9943c9ba37dbc261b36d8b/5/0">AP Photo/Charles Krupa</a></span></figcaption></figure><p>The massive scale of prescription opioid shipments as the ongoing overdose epidemic unfolded has started to come into focus.</p>
<p>Drug companies shipped <a href="https://www.washingtonpost.com/investigations/76-billion-opioid-pills-newly-released-federal-data-unmasks-the-epidemic/2019/07/16/5f29fd62-a73e-11e9-86dd-d7f0e60391e9_story.html">76 billion opioid pain pills</a> to U.S. health care professionals, hospitals and pharmacies between 2006 and 2012, according to data <a href="https://www.washingtonpost.com/investigations/76-billion-opioid-pills-newly-released-federal-data-unmasks-the-epidemic/2019/07/16/5f29fd62-a73e-11e9-86dd-d7f0e60391e9_story.html">The Washington Post</a> and the <a href="https://www.wvgazettemail.com/newly-released-federal-data-unmasks-epidemic-that-led-to-billion/article_4c672920-756f-5cd1-8c4e-6d17951cafa1.html">Charleston Gazette-Mail’s owner</a> acquired by <a href="https://assets.documentcloud.org/documents/6163333/19a0133p-06.pdf">suing the government</a>. </p>
<p>Hundreds of pills per person were delivered to rural areas like <a href="https://www.washingtonpost.com/national/a-remote-virginia-valley-has-been-flooded-by-prescription-opioids/2019/07/18/387bb074-a8ca-11e9-9214-246e594de5d5_story.html">Wise County, Kentucky</a>, and the town of <a href="https://www.pharmacist.com/article/remote-virginia-valley-has-been-flooded-prescription-opioids">Norton, Virginia</a>. Meanwhile, the number of <a href="https://overdosemappingtool.norc.org/">fatal overdoses</a> involving all kinds of prescription opioids soared across all of <a href="https://www.medpagetoday.com/neurology/opioids/78170">Appalachia and other hotspots</a> as the national death toll climbed from 3,442 in 1999 to <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">17,029 in 2017</a>.</p>
<p>In addition, a federal court in Cleveland has released scores of <a href="https://www.reuters.com/investigates/special-report/usa-courts-secrecy-judges/">previously sealed documents</a>. The <a href="https://www.washingtonpost.com/graphics/2019/investigations/opioid-drug-company-documents/">corporate memos and legal depositions</a> suggest that drug company executives, pharmacists and others involved at every level of the prescription opioid trade failed to heed troubling signs that the industry was facilitating drug abuse.</p>
<p>As a health law professor who studies the <a href="https://ssrn.com/abstract=3237663">relationship between the U.S. health care system and opioid overdoses</a>, I have <a href="https://ssrn.com/abstract=3308838">researched</a> the epidemic’s causes. In particular, I have researched the likely <a href="https://twihl.podbean.com/e/158-opioid-litigation-update-guest-jennifer-oliva/">liability of drugmakers and pharmaceutical distributors</a> in the multiple pending and resolved <a href="https://www.baltimoresun.com/health/bs-hs-more-lawsuits-filed-over-opioid-crisis-20190722-rskg6ulgb5hujmz7ms4o4vvcvm-story.html">federal</a> and <a href="https://www.npr.org/sections/health-shots/2019/07/16/741960008/pain-meds-as-public-nuisance-oklahoma-tests-a-legal-strategy-for-opioid-addictio">state</a> lawsuits filed against all of the industry’s key players.</p>
<p>One thing that I’ve often wondered about is why no law on the books could slow what now appears to have been the reckless oversupply of opioids by companies in the health care business. </p>
<p><iframe id="n19t1" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/n19t1/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>A duty to report</h2>
<p>Well, there is, as it turns out.</p>
<p>The <a href="https://www.law.cornell.edu/uscode/text/21/chapter-13/subchapter-I">Controlled Substances Act</a> creates what experts call a “<a href="https://www.deadiversion.usdoj.gov/pubs/manuals/pract/section1.htm">closed system</a>.” That is, the federal government has designed a way to <a href="https://www.everycrsreport.com/reports/R45164.html">track every controlled substance</a> – medications with the potential for abuse or dependence, including opioids – from factory to pharmacy counter and hospital bed. Manufacturers, distribution companies, health care professionals, pharmacies, hospitals and others who buy, sell and dispense these drugs must be registered with the Drug Enforcement Agency.</p>
<p>The roughly <a href="https://www.dea.gov/press-releases/2018/02/14/dea-creates-new-resource-help-distributors-avoid-oversupplying-opioids">1.73 million people and companies</a> registered with the DEA must maintain precise records and report their interactions with all controlled substances.</p>
<p>The Controlled Substances Act categorizes drugs into different “<a href="https://www.deadiversion.usdoj.gov/21cfr/21usc/811.htm">schedules</a>” that determine the degree of regulatory oversight and the responsibilities required of anyone handling them. The government has designated opioids such as Oxycodone and hydrocodone as “<a href="https://www.dea.gov/drug-scheduling">Schedule II</a>” drugs, the most dangerous category that can be prescribed.</p>
<p>Manufacturers and distributors of Schedule II drugs must file reports about the opioids that pass though their hands using the government’s <a href="https://www.deadiversion.usdoj.gov/arcos/index.html">Automated Reports and Consolidated Orders System</a>, or ARCOS. These reports generate data that track the numbers of drugs shipped or sold and their destinations, at county and pharmacy levels.</p>
<p>A <a href="https://www.deadiversion.usdoj.gov/21cfr/cfr/1301/1301_74.htm">DEA rule</a> issued back in 1971 also requires all registrants to design systems for reporting “suspicious orders” – meaning, among other things, purchases and deliveries that are unusually big or frequent.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/287753/original/file-20190812-71917-lygxgv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Several high-ranking executives from prescription drug distributors and wholesalers testified about their roles in the opioid addiction epidemic before Congress in 2018.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Opioids/673d1ee4fce8438ca2b1f2568aa553d9/7/0">AP Photo/Alex Brandon</a></span>
</figcaption>
</figure>
<h2>Inadequate oversight</h2>
<p>The federal government gave <a href="https://www.nytimes.com/2018/03/05/health/opioid-crisis-judge-lawsuits.html">the court in Cleveland</a> reams of ARCOS data in February 2018. However, U.S. District Judge Dan A. Polster, who is presiding over the landmark opioid litigation that pools some 2,000 separate lawsuits, <a href="https://www.ohnd.uscourts.gov/sites/ohnd/files/MDL2804-167.pdf">refused to let the press and the public</a> see that information until <a href="https://assets.documentcloud.org/documents/6163333/19a0133p-06.pdf">an appeals court</a> ordered its release.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=422&fit=crop&dpr=1 600w, https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=422&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=422&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/287750/original/file-20190812-71897-1uiua8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">U.S. District Judge Dan A. Polster is overseeing landmark opioid litigation in Cleveland.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Lawsuits/95258a7da15f4f2780766f19f027b553/1/0">AP Photo/Tony Dejak</a></span>
</figcaption>
</figure>
<p>The unsealed documents and data reveal the DEA possessed massive amounts of information about the oversupply of prescription opioids while the overdose epidemic was mushrooming. The newly released court exhibits also suggest that some opioid manufacturers and distributors repeatedly failed to report suspicious orders as required by law.</p>
<p>Congress had already suspected that corporate oversight was lacking.</p>
<p>The <a href="https://republicans-energycommerce.house.gov/wp-content/uploads/2018/12/Opioid-Distribution-Report-FinalREV.pdf">House Energy and Commerce Committee</a>, for example, issued a report in 2018 that was highly critical of the DEA’s oversight of opioid distribution in West Virginia. The DEA, according to the report, was aware of wide-scale diversion and suspicious shipments as early as 2005 and even began an initiative to educate distributors about their obligations regarding suspicious orders.</p>
<p>In 2011, <a href="https://www.dea.gov/sites/default/files/pr/speeches-testimony/2012-2009/110524_testimony.pdf">then-DEA administrator Michele Leonhart</a> testified before a Senate judiciary subcommittee that the agency was increasing its investigations of doctors and pharmacists who illegally diverted controlled substances. What I believe the DEA missed was that the manufacturers and distributors of opioids had gone rogue.</p>
<p>In a recent filing in the consolidated Cleveland case, <a href="http://www.opioidsnegotiationclass.info/Home/FAQ#faq2">local governments</a> like Coos County, New Hampshire, and the city of Chicago allege that the corporate defendants’ “<a href="https://www.washingtonpost.com/investigations/newly-unsealed-exhibits-in-opioid-case-reveal-inner-workings-of-the-drug-industry/2019/07/23/acf3bf64-abe5-11e9-8e77-03b30bc29f64_story.html?">failure to identify suspicious orders was their business model</a>.” </p>
<p>The <a href="https://www.washingtonpost.com/investigations/newly-unsealed-exhibits-in-opioid-case-reveal-inner-workings-of-the-drug-industry/2019/07/23/acf3bf64-abe5-11e9-8e77-03b30bc29f64_story.html">unsealed documents</a> suggest a pattern. Manufacturers and distributors either had deficient systems for monitoring of suspicious orders, simply ignored them or went out of their way to call them something else. For example, rather than acknowledging that enormous or extraordinarily frequent orders were “suspicious,” employees and executives would describe these transactions as “peculiar” or “unusual.”</p>
<p>The newly available documents indicate that when DEA investigators did find evidence that distributors were not reporting suspicious shipments, the authorities reached settlements instead of moving forward with prosecutions. As a result, distributors paid civil penalties rather than facing more serious criminal charges. Therefore, with <a href="https://www.deachronicles.com/2017/07/dea-prevails-over-masters-pharmaceutical-inc/#more-1886">few exceptions</a>, distributors who had failed to report suspicious shipments were able to stay in business. </p>
<p>And although the number of shipments continued to rise beyond 2012 – the end of the period covered by the newly available data and documents – the <a href="https://www.washingtonpost.com/investigations/the-dea-slowed-enforcement-while-the-opioid-epidemic-grew-out-of-control/2016/10/22/aea2bf8e-7f71-11e6-8d13-d7c704ef9fd9_story.html">number of enforcement actions actually fell</a> in 2013.</p>
<p>It wasn’t until 2017 that the DEA seemed to pay serious attention to the role of manufacturers and distributors in the opioid overdose epidemic. That year, it reached a <a href="https://www.dea.gov/press-releases/2017/07/11/mallinckrodt-agrees-pay-35-million-settlement">US$35 million settlement with Mallinckrodt</a>, one of the largest oxycodone manufacturers, for failing to detect and report suspicious orders. The settlement also obliged Mallinckrodt to monitor downstream distribution, as the DEA said for the first time that the obligation to “know your customer” includes knowing “your customer’s customer.”</p>
<h2>Stepping up enforcement</h2>
<p>I see a new <a href="https://www.congress.gov/bill/115th-congress/house-bill/6/text#H8909942BDF304C42AA654FCEAD3C0AA8">federal law</a> President Donald Trump signed in 2018 as a step in the right direction. It tightens up the definition of “suspicious activity,” clarifies reporting obligations and requires the DEA to establish a centralized database for all reports of suspicious prescription drug orders.</p>
<p>The federal government also seems to be taking a more aggressive stance against opioid distributors. For instance, it filed felony charges against the distributor <a href="https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney-and-dea-announce-charges-against-rochester-drug-co-operative-and">Rochester Drug Co-Operative</a> and two of its former executives in April 2019. The government alleges that the company intentionally failed to report suspicious orders and looked the other way amid signs that opioids were being shipped for illicit purposes.</p>
<p>In July 2019, the government announced charges against <a href="https://www.justice.gov/usao-sdoh/pr/pharmaceutical-distributor-executives-pharmacists-charged-unlawfully-distributing">Miami-Luken</a>, another distributor, and two of its former executives for allegedly failing to report suspicious orders and conspiring with two pharmacists to illegally distribute millions of prescription opioid painkillers.</p>
<p>It does look like lawmakers have strengthened the Controlled Substances Act and that the government is making strides on enforcement. However, it remains unclear why it took them so long to use the powers they already had to stop reckless shipments.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=thanksforreading">Thanks for reading! We can send you The Conversation’s stories every day in an informative email. Sign up today.</a></em> ]</p><img src="https://counter.theconversation.com/content/121021/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicolas Paul Terry receives funding from The Indiana University Addictions Grand Challenge <a href="https://addictions.iu.edu/">https://addictions.iu.edu/</a> </span></em></p>Previously secret documents and data make it clear that many companies engaged in the distribution of prescription painkillers either skirted or ignored their legal obligations for years.Nicolas Paul Terry, Professor of Law, IUPUILicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/862882018-01-29T11:28:15Z2018-01-29T11:28:15ZHow should we decide what to do?<figure><img src="https://images.theconversation.com/files/203552/original/file-20180126-100908-oli6m8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How many times do we wonder, 'what's the right thing to do'?</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File%3AHelping_the_homeless.jpg">Ed Yourdon from New York City, USA (Helping the homeless Uploaded by Gary Dee, via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Most of us are faced with ethical decisions on a regular basis. Some are relatively minor – perhaps your cousin makes a new recipe and it really doesn’t taste good, and you have to decide whether to tell the truth or a little white lie so as not to hurt her feelings. </p>
<p>Others are weightier – should you blow the whistle when you discover that your co-worker is behaving in ways that could jeopardize everyone at your workplace? Should you forego a relaxing vacation and instead donate the money to a worthy cause? </p>
<p>For thousands of years, philosophers have debated how to answer ethical questions, large and small. There are a few approaches that have withstood the test of time. </p>
<h2>Doing the most good</h2>
<p>One approach, which we often use in our day-to-day lives even if we aren’t aware that it is a type of ethical deliberation, is to figure out what the consequences of our actions might be and then determine if one course of action or another will lead to better outcomes. In the policy context, this is often referred to as a <a href="https://books.google.com/books?hl=en&lr=&id=Ftd7AgMtIGcC&oi=fnd&pg=PA179&dq=moral+cost+benefit+analysis&ots=w4quICsxdO&sig=1PRVTUzSmn9DtZECklqedr5Qifk#v=onepage&q=moral%20cost%20benefit%20analysis&f=false">cost-benefit</a> analysis. </p>
<p>“Consequentialism,” an ethical system, suggests that the right thing to do is the action that will bring about the best consequences for all those affected by the action. “Best consequences” are usually thought of as those that bring about the <a href="https://plato.stanford.edu/entries/utilitarianism-history/">most happiness</a> over suffering. </p>
<p><a href="https://books.google.com/books?hl=en&lr=&id=Ftd7AgMtIGcC&oi=fnd&pg=PA179&dq=moral+cost+benefit+analysis&ots=w4quICsxdO&sig=1PRVTUzSmn9DtZECklqedr5Qifk#v=onepage&q=moral%20cost%20benefit%20analysis&f=false">Utilitarianism</a> is the primary version of this ethical system. Its most noted living defender, philosopher <a href="http://www.petersinger.info/">Peter Singer</a>, has made compelling arguments about how we should decide what to do. He argues that when we can do something to <a href="https://www.thelifeyoucansave.org/resources/peter-singers-girl-in-the-pond">promote the well-being of others</a>, whether they are near or far, human or nonhuman, at relatively little cost to ourselves, that is what we should do. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203472/original/file-20180125-100915-v3c25f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Should an individual forego a vacation to help fight global poverty?</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/fmsc/14098532037/in/photolist-ntQEoz-adBUmm-nU6nNC-byRMeq-saG7GS-cGutkY-bzB5bp-7FbmsU-of2eK2-ow58Pe-of2ibf-MapB9i-ow8UBh-nvNmP-oYGaFd-nTC1uu-rRAVVZ-nSR9GX-7DgrJB-dNxmKq-97cWE-6QhcP2-d4LsQ-JBSYuy-U9C1NH-pQboEj-2kQTf1-cRQ8WE-aHVb9T-5HRRDN-5HRNmW-qD9wxR-9qptrF-orKtTd-dNxnoY-bnKaMk-9ySro8-8DBEhm-DqKK7-NAGXk-amXYF4-jjDszm-4EpDnX-vkzs6-7orLfT-7cUQZM-2a1CKW-p3N37j-dmTVaD-hweB8h">Feed My Starving Children (FMSC)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>For example, across the globe <a href="https://www.dosomething.org/us/facts/11-facts-about-global-poverty">children are suffering and dying</a> from easily preventable diseases. Their lives could be saved if those of us in wealthier countries gave just a little bit of our wealth to organizations fighting global poverty. </p>
<p>Perhaps people could go on less expensive vacations or bring lunch from home rather than eating out and then donate the money saved to help those in need. The suffering that could be prevented would greatly outweigh the slight loss of happiness that such luxuries provide. </p>
<h2>Following the rules</h2>
<p>But why stop at giving up a fancy vacation? Why not forego all travel for pleasure? Surely that could do much more good. In fact, why not forego having children or donate one of our <a href="https://www.nytimes.com/2015/10/11/books/review/strangers-drowning-by-larissa-macfarquhar.html">kidneys to someone in need</a>? </p>
<p>When I raise these possibilities with my students, they often complain that this is going too far. So I push the examples to an extreme to try to get clearer about what is wrong: </p>
<p>Imagine a person in a hospital recovering from knee surgery whose organs happen to match three people who just were rushed into the emergency room after a car accident. The three people need a heart, a lung and a liver. </p>
<p>Imagine further that the person recovering hears the family members of those in the accident crying, and the person asks the doctor to take his heart, lung and liver to save the three people. A doctor wouldn’t do that – it is unethical to kill one person to save three people. But why? It would bring greater happiness.</p>
<p>Doctors take a Hippocratic oath to do no harm, so that is one reason why they wouldn’t do this even if asked. The Hippocratic oath can be seen as part of another system of ethics, one that locates the ethical thing to do in doing one’s duty or acting according to good principles. The Hippocratic oath is one such principle. </p>
<p>Doctors follow this rule, not for the sake of following a rule, but because this rule, like the <a href="http://www.iep.utm.edu/goldrule/">Golden Rule</a>. “Do unto others as you would have them do unto you” protects and promotes important values. Values we might promote include respecting people for themselves, not their body parts, and treating others and their projects as worthy.</p>
<h2>Empathetic care</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=803&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=803&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=803&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1009&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1009&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203471/original/file-20180125-100915-1hhn2qx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1009&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Aristotle.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File%3AAristotle_Altemps_Inv8575.jpg">After Lysippos via Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>There is another ethical approach, one that I have been <a href="https://lanternbooks.presswarehouse.com/books/BookDetail.aspx?productID=438993">developing</a>, that comes out of a tradition in ethics that doesn’t focus only on outcomes or on duties, but rather on being a good person and promoting <a href="http://voidnetwork.gr/wp-content/uploads/2016/10/The-Ethics-of-Care-Personal-Political-and-Global-by-Virginia-Held.pdf">caring</a> relationships. </p>
<p>Many philosophers, going back to Aristotle, have argued that <a href="https://books.google.com/books?id=YqzABgAAQBAJ&printsec=frontcover&dq=Routledge+companion+to+virtue+ethics&hl=en&sa=X&ved=0ahUKEwixp5zUlPPXAhVic98KHdDHCrEQ6AEIKDAA#v=onepage&q=Routledge%20companion%20to%20virtue%20ethics&f=false">virtue</a> can be our guide. When figuring out what to do, we might want to ask how our actions reflect back on ourselves and the relationships we value. </p>
<p>There are many different ideas about exactly what counts as virtuous. But it’s hard to deny that being a compassionate, respectful, empathetic person, who takes responsibility for her relationships and works to make them better, would count. Honing these skills and acting on them can be a guiding ethos for our choices, actions, and making our way in the world. </p>
<p>If we strive to be better people in caring relationships, doing the right thing, even when difficult, can have unexpected rewards.</p>
<p><em>Editor’s note: This piece is the start of our series on ethical questions arising from everyday life. We would welcome your suggestions. Please email us at <a href="mailto:ethical.questions@theconversation.com">ethical.questions@theconversation.com</a>.</em></p><img src="https://counter.theconversation.com/content/86288/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lori Gruen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A scholar suggests a few approaches that have withstood the test of time.Lori Gruen, William Griffin Professor of Philosophy, Wesleyan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875702018-01-08T03:57:04Z2018-01-08T03:57:04ZHow does assisting with suicide affect physicians?<figure><img src="https://images.theconversation.com/files/200845/original/file-20180104-26169-16fulj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-syringe-doctors-hands-on-patients-398371651?src=zApkQ3soziZScBtoFq1Sig-1-1">Art_Photo via www. Shutterstock.com</a></span></figcaption></figure><p>When my mother was in her final months, suffering from a heart failure and other problems, she called me to her bedside with a pained expression. She took my hand and asked plaintively, “How do I get out of this mess?” </p>
<p>As a physician, I dreaded the question that might follow: Would I help her end her life by prescribing a lethal drug?</p>
<p>Fortunately for me, my mother tolerated her final weeks at home, with the help of hospice nurses and occasional palliative medication. She never raised the thorny question of what is variously termed “medical aid in dying” or <a href="https://www.medscape.com/viewarticle/885866#vp_2">“physician-assisted suicide.”</a> </p>
<p>As a son and family member who has witnessed the difficult final days of parents and loved ones, I can understand why support for MAID/PAS is <a href="http://news.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx">growing</a> among the general public. But as a physician and medical ethicist, I believe that MAID/PAS flies in the face of a 2,000-year imperative of Hippocratic medicine: “Do no harm to the patient.”</p>
<p>Studies point out that even many doctors who actually participate in MAID/PAS remain uneasy or <a href="https://jamanetwork.com/journals/jama/article-abstract/187854%5D">“conflicted”</a> about it. In this piece, I explore their ambivalence.</p>
<h2>Assisted suicides</h2>
<p>In discussing end-of-life issues, both the general public and physicians themselves need to distinguish three different approaches.</p>
<p>MAID/PAS involves a physician’s providing the patient with a prescription of a lethal drug that the patient could take anytime to end life. In contrast, active euthanasia or <a href="http://www.bbc.co.uk/ethics/euthanasia/overview/introduction.shtml">“mercy killing”</a> involves causing the death of a person, typically through a lethal injection given by a physician. Finally, the term “passive euthanasia” refers to hastening the death of a terminally ill person by removing some vital form of support. An example would be disconnecting a respirator.</p>
<h2>Increasing international acceptance</h2>
<p>In the U.S. some form of legislatively approved MAID/PAS (but not active euthanasia) is <a href="https://euthanasia.procon.org/view.resource.php?resourceID=000132">legal</a> in five states and the District of Columbia. In my home state – following a passionate debate – the Massachusetts Medical Society recently decided to <a href="http://www.masslive.com/news/index.ssf/2017/12/mass_medical_society_rescinds.html">rescind its long-held opposition</a> to the practice. MMS has taken a position of <a href="http://www.masslive.com/news/index.ssf/2017/12/mass_medical_society_rescinds.html">“neutral engagement,”</a> which it claims will allow it to “serve as a medical and scientific resource … that will support shared decision making between terminally ill patients and their trusted physicians.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=437&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=437&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=437&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=549&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=549&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200846/original/file-20180104-26163-fz1u4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=549&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Physician-assisted suicide is finding more acceptance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-doctor-giving-helping-hands-elderly-262436840">Ocskay Bence</a></span>
</figcaption>
</figure>
<p>In a few countries, MAID/PAS has grown increasingly common. In Canada, for example, MAID/PAS was <a href="http://www.npr.org/sections/thetwo-way/2016/06/18/482599089/canada-legalizes-physician-assisted-dying">legalized in 2016</a>. In Belgium and the Netherlands, both <a href="https://www.washingtonpost.com/opinions/europes-morality-crisis-euthanizing-the-mentally-ill/2016/10/19/c75faaca-961c-11e6-bc79-af1cd3d2984b_story.html?utm_term=.94c68af85b89">active euthanasia and physician-assisted suicide </a> are permitted by law, even for patients whose illnesses may be treatable, as with major depression; and whose informed consent may be compromised, as in Alzheimer’s disease. In the Netherlands, a proposed <a href="http://thefederalist.com/2017/06/30/netherlands-considers-euthanasia-healthy/">“Completed Life Bill”</a> would allow any persons age 75 or over who decide their life is “complete” to be euthanized – even if the person is otherwise healthy. </p>
<h2>U.S. physician response</h2>
<p>Among U.S. physicians, MAID/PAS remains controversial, but national data point to its increasing acceptance. A report published in December 2016 found 57 percent of <a href="http://www.healthleadersmedia.com/physician-leaders/poll-many-doctors-have-wished-patient-had-right-die">doctors agreed that physician-assisted death</a> should be
available to the terminally ill – <a href="http://www.healthleadersmedia.com/physician-leaders/poll-many-doctors-have-wished-patient-had-right-die">up from 54 percent in 2014 and 46 percent</a> in 2010. </p>
<p>Perhaps this trend is not surprising. After all, what sort of physician would want to deny dying patients the option of ending their suffering and avoiding an agonizing, painful death? </p>
<p>But this question is misleading. Most persons requesting PAS are not actively experiencing extreme suffering or inadequate pain control. Data from the Washington and Oregon PAS programs show that <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1213398">most patients choose PAS</a> because they fear loss of dignity and control over their own lives.</p>
<h2>Some physicians feel conflicted</h2>
<p>Physicians who carry out assisted suicide have a wide variety of emotional and psychological responses. In a structured, in-depth <a href="https://jamanetwork.com/journals/jama/article-abstract/187854">telephone interview survey</a> of 38 U.S. oncologists who reported participating in euthanasia or PAS, more than half of the physicians received “comfort” from having carried out euthanasia or PAS. </p>
<p>“Comfort” was not explicitly defined, but, for example, these physicians felt that they had helped patients end their lives in the way the patients wished. However, nearly a quarter of the physicians regretted their actions. Another 16 percent reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.</p>
<p>For example, one physician felt so “burned out” that he moved from the city in which he was practicing to a small town. </p>
<p>Other data support the observation that MAID/PAS can be emotionally disturbing to the physician. </p>
<p><a href="http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/radiation-medicine/about/faculty-staff/kenneth-stevens.cfm">Kenneth R. Stevens Jr.</a>, an emeritus professor at Oregon Health and Science University, reported that for some physicians in Oregon, <a href="http://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782?needAccess=true">participation in PAS was very stressful</a>. For example, in 1998, the first year of Oregon’s “Death with Dignity Act,” 14 physicians wrote prescriptions for lethal medications for the 15 patients who died from physician-assisted suicide.</p>
<p>The state’s annual 1998 report observed that:</p>
<blockquote>
<p>“For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, ‘It was an excruciating thing to do … it made me rethink life’s priorities,’ ‘This was really hard on me, especially being there when he took the pills,’ and ‘This had a tremendous emotional impact.’”</p>
</blockquote>
<p>Similarly, reactions among European doctors suggest that PAS and euthanasia <a href="http://www.tandfonline.com/doi/abs/10.1080/20508549.2006.11877782">often provoke strong negative feelings</a>. </p>
<h2>Why the discomfort?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=447&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=447&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200848/original/file-20180104-26166-i5b9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=447&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Feeling conflicted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/geriatric-nurse-holding-hands-senior-man-329394167?src=zApkQ3soziZScBtoFq1Sig-1-4">Robert Kneschke</a></span>
</figcaption>
</figure>
<p>As a physician and medical ethicist, I am opposed to any form of physician assistance with a patient’s suicide. Furthermore, I believe that the term “medical aid in dying” allows physicians to avoid the harsh truth that they are helping patients kill themselves. This is also the view of the very influential <a href="http://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper">American College of Physicians</a>. </p>
<p>I believe that the ambivalence and discomfort experienced by a substantial percentage of PAS-participating physicians is directly connected to the Hippocratic Oath – arguably, the most important foundational document in medical ethics. <a href="http://www.greekmedicine.net/whos_who/The_Hippocratic_Oath.html">The Oath clearly states</a>: </p>
<blockquote>
<p>“I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” </p>
</blockquote>
<p>In 5th century BC Greece, Hippocrates was something of a revolutionary in this respect. As the classicist and medical historian, <a href="https://academic.oup.com/jhmas/article-abstract/XXI/2/173/699618?redirectedFrom=PDF">Ludwig Edelstein</a> has <a href="https://books.google.com/books?id=ehQgAQAAMAAJ&focus=searchwithinvolume&q=hippocrates">pointed out</a> some non-Hippocratic physicians probably did provide poisons to their dying patients, in order to spare them protracted suffering. Hippocrates opposed this practice, though he did not believe that terminally ill patients should be exposed to unnecessary and futile medical treatment.</p>
<p>Palliative care specialist <a href="http://irabyock.org/about-ira-byock/">Ira Byock</a> has <a href="https://www.pbs.org/wgbh/frontline/article/the-shadow-side-of-assisted-suicide/">observed</a> that:</p>
<blockquote>
<p>“From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was – and is – a necessary protection so that the power of medicine is not used against vulnerable people.” </p>
</blockquote>
<p>Indeed, when patients nearing the end of life express fears of losing control, or being deprived of dignity, <a href="https://jamanetwork.com/journals/jama/article-abstract/2482333">compassionate and supportive counseling</a> is called for
– not assistance in committing suicide.</p>
<p>To be sure, comprehensive palliative care, including home hospice nursing, should be provided to the subset of terminally ill patients who require pain relief. But as physician and ethicist <a href="https://www.aei.org/scholar/leon-r-kass/">Leon Kass</a> has <a href="https://www.firstthings.com/article/1996/08/dehumanization-triumphant">put it</a>:</p>
<blockquote>
<p>“We must care for the dying, not make them dead.”</p>
</blockquote><img src="https://counter.theconversation.com/content/87570/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald W. Pies does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Massachusetts Medical Society recently reversed its long-held opposition to physician-assisted suicide. A psychiatrist notes many physicians are painfully conflicted about participating.Ronald W. Pies, Emeritus Professor of Psychiatry, Lecturer on Bioethics & Humanities at SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/761542017-04-20T05:17:12Z2017-04-20T05:17:12ZA doctor’s sexual advances towards a patient are never ok, even if ‘consensual’<figure><img src="https://images.theconversation.com/files/166017/original/file-20170420-2423-1ub7602.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's important patients know what is appropriate and what isn't.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>In a recent <a href="https://nhpopc.gov.au/wp-content/uploads/Chaperone-review-report-WEB.pdf">independent review</a>, I recommended chaperones no longer be used as an interim protective measure to keep patients safe while allegations of sexual misconduct by a doctor are investigated. </p>
<p>The review was commissioned by the Medical Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA), <a href="http://www.smh.com.au/national/health/sex-abuse-doctor-andrew-churchyard-allowed-to-keep-working-by-cabrini-hospital-20160729-gqgl4k.html">following media reports</a> that a Melbourne neurologist was facing criminal charges for sexually assaulting a patient. </p>
<p>Dr Andrew Churchyard was allowed to keep practising after the alleged sex abuse. But this was subject to a condition on his registration that an approved chaperone be present for all consultations with male patients.</p>
<p>The Medical Board of Australia and AHPRA have accepted my recommendations that the current system of using chaperones is outdated and paternalistic. In future cases where a doctor is accused of sexual misconduct, and interim protection is considered necessary, restrictions may be imposed after an assessment of the allegations by a specialist board committee. </p>
<p>They will include prohibitions on contact with patients of a specified gender, prohibitions on any patient contact, or suspension from practice. </p>
<p>Sadly, cases of sexual misconduct are likely to continue. It’s important patients know the warning signs and where to seek help if they suspect their doctor is behaving inappropriately.</p>
<h2>Ethical boundaries</h2>
<p>The <a href="https://books.google.com.au/books?id=cZC-W0JlNBMC&pg=PA64&lpg=PA64&dq=abstain+from+all+intentional+wrong-doing+and+harm,+especially+from+abusing+the+bodies+of+man+or+woman+hippocratic+oath&source=bl&ots=_yzf2K3Gvq&sig=5L69JwrqQOXLO6eoJOAvVBj7yYI&hl=en&sa=X&ved=0ahUKEwi4-Nau77HTAhVBo5QKHbrhC2QQ6AEIOzAF#v=onepage&q=abstain%20from%20all%20intentional%20wrong-doing%20and%20harm%2C%20especially%20from%20abusing%20the%20bodies%20of%20man%20or%20woman%20hippocratic%20oath&f=false">Hippocratic Oath states</a> that in their professional lives, doctors will:</p>
<blockquote>
<p>abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman. </p>
</blockquote>
<p>The oath frames sexual contact with patients as a type of intentional harm that is forbidden. Much has changed in medical practice since the days of the ancient Greeks, but Hippocrates’ clear-eyed prohibition on sexual contact with patients, and categorisation of such conduct as a form of abuse, remains apt. </p>
<p>It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact. </p>
<p>International <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228872/7015.pdf">studies indicate</a> that the prevalence of sexual boundary violations by health practitioners may be as high as 6 to 7%. A <a href="http://www.worldcat.org/title/crossing-the-boundaries-the-report-of-the-committee-on-physician-sexual-misconduct-prepared-for-the-college-of-physicians-and-surgeons-of-british-columbia/oclc/839388109?referer=di&ht=edition">Canadian survey</a> of 8,000 members of the public in 1992 found that 4.1% of respondents (4.7% of women, 1.3% of men) reported touching of a private body part by their doctor “for what seemed to be sexual reasons”. </p>
<p>During my review, I heard first-hand accounts of the harm sexual contact from their doctor causes patients. The harrowing stories from abused patients and their families confirm what the literature says. </p>
<p>Patients who are sexually exploited by their doctor <a href="http://www.professionalstandards.org.uk/docs/default-source/publications/policy-advice/clear-sexual-boundaries-guidance-for-fitness-to-practise-panels-2008.pdf?sfvrsn=6">suffer from major depressive disorders</a>, suicidal and self-destructive behaviour, and relationship problems. They <a href="https://books.google.com.au/books/about/Sexual_Exploitation_in_Professional_Rela.html?id=hAzAZ2V57D4C&redir_esc=y">experience feelings of shame</a>, guilt, isolation, poor self-esteem and denial. They may also delay seeking medical help.</p>
<p>Their trust in their doctor, and in the consultation room as a safe place to share problems and seek advice, is shattered.</p>
<h2>Consensual relationships?</h2>
<p>The impact on patients who have been indecently assaulted – by being subjected to unnecessary and inappropriate clinical examinations – has much in common with the effects of sexual abuse on victims in other, non-clinical contexts. </p>
<p>But patients who engage in “consensual” sexual relations with their doctor also suffer harm. Issues of vulnerability, transference and breach of trust are <a href="http://www.rcpsych.ac.uk/usefulresources/publications/books/rcpp/9781904671374.aspx">well recognised</a> for current patients. Yet even former patients may be harmed by entering a sexual relationship with their former doctor. </p>
<p>Critics of a “zero tolerance” approach to doctor-patient contact suggest notions of vulnerable patients being exploited by their doctor are old-fashioned. They argue that a mature, consenting adult <a href="http://www.hdc.org.nz/decisions--case-notes/commissioner's-decisions/2004/03hdc11070">should be free</a> to enter a consensual sexual relationship with their doctor, once the doctor-patient relationship has ended. Such views are misguided.</p>
<p>It is one thing to accept that a doctor may later become romantically involved with a patient after fleeting professional contact. But if the doctor-patient relationship has endured for some time, and has involved confidential disclosures and advice, any subsequent sexual relationship risks harm to the patient, and damaging professional consequences for the doctor.</p>
<h2>Warning signs</h2>
<p>It may be very difficult to discern whether an examination of the genitalia is warranted. For all the rhetoric about empowered patients, when we are unwell and consulting a doctor (especially someone new) for diagnosis and treatment, it can feel awkward to ask whether it is really necessary to disrobe for a full examination. </p>
<p>During my review, <a href="https://nhpopc.gov.au/wp-content/uploads/Chaperone-review-report-WEB.pdf">one patient recalled</a> seeing a specialist about his severe migraines. He thought a full body examination was unusual, but said: “How was I meant to know what was normal?” </p>
<p>Ideally, patients will know that it’s always ok to ask why an examination or procedure is necessary, to request to have a support person present, and to raise any concerns with a practice manager after a consultation. </p>
<p>Patients concerned that their doctor may have acted improperly can contact support services such as <a href="http://www.casahouse.com.au/">CASA House in Victoria</a>, which provides information and counselling to victims of sexual assault.</p>
<p>Patients should be alert to signs that their doctor’s interest is more than professional. Scheduling appointments for the end of the day, asking personal questions unrelated to the presenting problem, and providing their mobile number may all be warning signs. </p>
<p>Doctors should always be willing to question their own motives and, if in doubt, to seek advice from a professional mentor.</p>
<p>Sexual advances or sexual assault by doctors causes significant harm. A strict “zero tolerance” approach protects patients and doctors.</p><img src="https://counter.theconversation.com/content/76154/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ron Paterson received funding from AHPRA (the Australian Health Practitioner Regulation Agency) for researching and writing a report entitled 'Independent review of the use of chaperones to protect patients in Australia' (2017). He is employed as a Professor of Law at the University of Auckland.</span></em></p>It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact.Ron Paterson, Professor of Health Law and Policy, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/653792016-09-16T14:11:21Z2016-09-16T14:11:21ZDecriminalise use of medical marijuana and legalise small-scale cultivation<figure><img src="https://images.theconversation.com/files/137917/original/image-20160915-30587-ra9vou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-313419206/stock-photo-doctor-writing-on-prescription-blank-and-bottle-with-medical-cannabis-on-table-close-up.html?src=FRihLsDfa00bCAddJUnI4g-1-9">Africa Studio/Shutterstock.com</a></span></figcaption></figure><p>A large number of people in Britain are committing crime to alleviate pain and suffering. They do this by growing cannabis for medicinal use. But cannabis cultivation is a <a href="http://www.legislation.gov.uk/ukpga/1971/38/contents">criminal offence</a> that can carry a substantial <a href="https://www.sentencingcouncil.org.uk/offences/item/production-of-a-controlled-drug-cultivation-of-cannabis-plant/">prison sentence</a>, even in these circumstances. Some sick people grow cannabis for themselves, but often growers provide cannabis for others – which means committing the more serious offence of <a href="http://www.sentencingcouncil.org.uk/offences/item/supplying-or-offering-to-supply-a-controlled-drug-possession-of-a-controlled-drug-with-intent-to-supply-it-to-another/">drug supply</a>. The law labels these people as drug dealers, despite their altruistic motivations.</p>
<p>This all runs counter to common-sense understandings of criminals as people who commit crime for personal gain or to inflict pain and suffering on others. It also runs counter to beliefs about providing healthcare: that medicines should be available to those who need them. And this is why a <a href="http://www.publications.parliament.uk/pa/cm/cmallparty/register/drug-policy-reform.htm">group of MPs working on drug policy reform</a> has <a href="https://drive.google.com/file/d/0B0c_8hkDJu0DRnBfdGRDRXBROUU/view">called for a change in the law</a> to allow for cannabis to be prescribed by doctors, and even to allow patients to grow a limited number of plants themselves.</p>
<p>I’ve been researching <a href="https://www.google.co.uk/imgres?imgurl=http://t3.gstatic.com/images%3Fq%3Dtbn:ANd9GcQlmK4Mizp5oVctdhtuVRxPS9TRtcBhtMlPZkH-NRU8RGWW-_BP&imgrefurl=http://books.google.com/books/about/Weed_Need_and_Greed.html%3Fid%3DsyZMbwAACAAJ%26source%3Dkp_cover&h=822&w=520&tbnid=T4PrzmnV2ioWsM:&tbnh=160&tbnw=100&docid=FJbRW7h7xmS60M&itg=1&usg=__ycR8LM-4CpuMXj_4gMEflX8qSks=">cannabis cultivation in the UK</a> for more than 15 years, and have spoken to a lot of people who grow cannabis for medical reasons. In some of these cases medical experts also supported their use of cannabis even though there is no legal recognition of the medicinal use of the plant <a href="http://www.release.org.uk/law/uks-law-medical-cannabis">under UK law</a>. This places not just the patients, but their doctors, in a moral dilemma. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137918/original/image-20160915-30611-1268x3x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People can be jailed, despite their altruistic motivation.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-400289620/stock-photo-trafalgar-square-london-uk-2nd-april-2016-editorial-giant-size-monopoly-board-game-built-in-the-middle-of-trafalgar-square-london-to-celebrate-the-history-of-video-games-in-london.html?src=3dqrQQlcWtReab5EmlZCNQ-1-19">John Gomez/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The Hippocratic oath that doctors take means they are supposed to do anything in their power to help patients, but to advise patients to use this drug means encouraging them to break the law and could be construed as incitement to commit a crime.</p>
<p>Despite the legal position, there is <a href="https://drive.google.com/file/d/0B0c_8hkDJu0DUDZMUzhoY1RqMG8/view">strong evidence</a> that cannabis is beneficial for a range of conditions. Even when there is no direct medical benefit in the form of alleviating symptoms or curing an illness, cannabis can be beneficial. As the wife of one terminal cancer patient told me, smoking cannabis meant “the difference between dying of cancer, and living with cancer”. I helped her find a supply of locally grown cannabis, which arguably makes me a criminal too. But who can really stand by and watch someone, especially a loved one, suffer? Isn’t it the law itself, rather than breaking it, that is wrong in these circumstances?</p>
<h2>Legalise small-scale cultivation</h2>
<p>Medical cannabis growers don’t like the fact that they have to break the law to get the medicine that they need, but they see little choice when the alternative is unbearable pain, or suffering the side effects of conventional medicines. They often comment on the irony of having to become drug dealers themselves to avoid the need to buy their medicine from drug dealers.</p>
<p>Not all people who grow cannabis do so for medical reasons, as I also found in my research. Some are in it simply to make money. And legalising cannabis for medical use may provide cover for some non-medical users and profit-motivated dealers. But complete prohibition leaves too much of the market in the hands of organised crime (a lesson we should have learned from the US experiment in alcohol prohibition in the 1920s), and forces desperate or compassionate growers to break the law. Legalisation of small-scale cultivation would not only benefit those who suffer from a range of illnesses, it would also <a href="http://www.itv.com/news/2013-10-14/exposure-britains-booming-cannabis-business/">undermine the links</a> between cannabis growing and other, more serious, types of crime.</p>
<p>The work of the <a href="http://worldwideweed.nl/">Global Cannabis Cultivation Research Consortium</a> – which aims to get a better understanding of domestic cannabis cultivation – shows that people all over the world turn to growing cannabis as a source of medicine. The difference, in an increasing number of countries, is that access to therapeutic medicine is now legal in some form or another.</p><img src="https://counter.theconversation.com/content/65379/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Potter receives funding from The British Academy/Leverhulme Trust. </span></em></p>There is strong evidence that cannabis is useful for treating a range of conditions. Legalising small-scale cultivation is a start to helping those in need.Gary Potter, Senior Lecturer in Criminology, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/244982014-04-04T12:43:30Z2014-04-04T12:43:30Z‘Confidentiality’ is wrongly used to block carers from helping loved ones<figure><img src="https://images.theconversation.com/files/45636/original/tpbm6xfq-1396604751.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bureaucratic button.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/llauren/42440652/sizes/l">llauren</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Imagine your partner experiences extreme mood swings: you’ve seen them at their lowest, you’ve seen them at their highest, you’ve seen them when they are well. You’ve “monitored” their mood, checked they’ve taken their medication, that they eat well, sleep enough. You’ve taken them to hospital and looked after them after discharge. You’ve done the lot. You’re their carer when they are unwell, their partner when alright, their confidant, significant other, next of kin, better half. You’re there day and night.</p>
<p>You start noticing that they are getting ill again. You are scared about yourself, afraid about what is due to come. You contact the health services to let them know and ask for help. They respond: “I am afraid we cannot speak to you without the written consent of your partner. It’s confidential.” </p>
<p>Over 2,500 years ago, Hippocrates referred to “confidentiality” as “all that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.” This today forms part of the Hippocratic Oath taken by medical doctors and in most countries it is a legal right governed by various parliamentary acts and codes of practice that define <a href="http://www.dhsspsni.gov.uk/gmgr-annexe-c8">professional relationships</a> with patients <a href="http://www.legislation.gov.uk/ukpga/1998/29/section/59">and data protection</a>. </p>
<p>Confidentiality has evidently lasted a long time and for good reasons. But carers of people with mental health problems do not always experience it positively.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/aO0AIWkcVfQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">One mum speaks up.</span></figcaption>
</figure>
<p>Conversely, some people with mental health problems often want their carers to be involved when they are well, but object to any involvement when unwell. This makes things difficult for health professionals, who feel the pressure when it comes to deciding what they can and can’t share with carers and when. In effect, they often avoid carers and refuse to talk to them because they are afraid of breaking confidentiality. As one told us during a <a href="http://www.lancaster.ac.uk/shm/research/spectrum/research/queensberry/queensberry.php">recent project of ours</a>:</p>
<blockquote>
<p>We hide behind the confidentiality thing sometimes because it’s complicated … If someone wants to talk to you, you’re worried about confidentiality; you then have to end the conversation.</p>
</blockquote>
<p>But rather than employing confidentiality as a black and white concept that can work against care, appropriate information should be shared with carers on a need-to-know basis. Appropriate information is often relevant to the nature of the person’s experiences, how to care, and how to prepare. </p>
<p>In effect, sharing information with carers is not governed by an all or nothing rule – there is always something that can and often should be shared. There are <a href="http://www.rethink.org/resources/s/sharing-mental-health-information-with-carers">different types of information</a> such as general information, personal and/or personal and sensitive. </p>
<p>General information includes information in the public domain on mental health problems, available treatments or resource directories for local services. Personal is about specific information relating to the care of the service user such as diagnosis, medication types or content of their care plan, and personal sensitive is information that is of a highly personal nature such as HIV status, history of sexual and emotional abuse or views on relationships with family members.</p>
<p>While based on this distinction it seems rather straight forward what health professionals should share or not, it is far from it. When a carer asks a question that requires disclosure of <a href="http://www.rethink.org/resources/s/sharing-mental-health-information-with-carers">personal sensitive</a> information, health professionals need to be able to think, explore and decide what can be shared – <a href="http://bjp.rcpsych.org/content/190/2/148.full.pdf">and also what to do</a> when the person experiencing mental health problems refuses sharing with carers. Is it possible that by not sharing, carers or other vulnerable adults or children may be exposed to risk? And would sharing be relevant on this particular occasion with this particular individual? In fact, in certain cases health professionals that fail to share even personal sensitive information, <a href="https://www.gov.uk/government/policies/helping-carers-to-stay-healthy">may go against</a> carers’ rights, for example if illicit drugs have been used in the presence of minors. </p>
<h2>Changes over time</h2>
<p>Consent changes over time and health professionals should keep an ongoing conversation with service users about what to share and what not to share and with whom, and this should be documented in the form of <a href="https://www.rethink.org/living-with-mental-illness/rights-restrictions/advance-statements-planning-for-the-future">advance statements</a>.</p>
<p>With more people currently being treated in the community, the system heavily depends on carers. There is no dilemma then as to whether carers should be involved or not. It is about how to ensure that they are involved in the most effective ways by endorsing confidentiality and not perceiving it as something that gets in the way. Engaging with the complexity of information sharing in such contexts is difficult, but this shouldn’t block relatives from being involved unless safeguarding issues towards the service user suggest otherwise.</p>
<p>And as most carers often complain: there is nothing confidential about listening to what they have to say.</p><img src="https://counter.theconversation.com/content/24498/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Gerasimos Chatzidamianos does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Imagine your partner experiences extreme mood swings: you’ve seen them at their lowest, you’ve seen them at their highest, you’ve seen them when they are well. You’ve “monitored” their mood, checked they’ve…Dr Gerasimos Chatzidamianos, Senior Research Associate, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.