Ethics

In reply

Jeffrey Braithwaite · Robyn Clay-Williams · Natalie Taylor

To the Editor: In their recent article, Shulruf and colleagues1 concluded that prior academic achievement constituted the most effective means of predicting timely graduation. This outcome measure overlooks a more important graduate attribute: professionalism — the values and skills that the profession and society expects of doctors. This attribute is identifiable at admission, and it is possible to test for and select for this.2 When considering the desired outcome of satisfactory performance at junior medical officer level, the authors state that the “outcome of subsequent workplace performance, while important, is moderated by influences beyond the undergraduate environment”.1 This statement contradicts extensive literature suggesting otherwise. An erosion of vicarious empathy during medical education programs is well documented and is evident across other health care professions.3 Medical school education fails to consistently foster the development of advanced moral reasoning in medical students, with particular problems developing during the period of clinical immersion, when the influence of the “hidden curriculum” becomes evident to students.3 The above have been linked to the experience of burnout in students, which can manifest as professionalism lapses in both pre-clinical and clinical rotations.4 Papadakis and colleagues5 suggested that disciplinary action by a medical board was strongly associated with prior unprofessional behaviour in medical school. Most complaints against doctors are due to conduct, not competence. Many organisations have developed guidelines to ensure medical students adhere to professional standards. Academic and intellectual qualities alone cannot predict the ideal candidate for admission to medical school, and facets of professionalism such as moral orientation, resilience and self-control are acknowledged to contribute to one’s efficacy as a doctor. Furthermore, prioritising timely completion may promote students not seeking help, perpetuating poor performance in an effort to ensure timely completion. This perpetuates a workplace culture where people do not feel able to seek help, with significant repercussions as seen in the recent suicides of young doctors. Timely completion may indeed be predicted by prior academic success; however, attitudinal and behavioural factors are highly relevant at selection and throughout subsequent careers. An overemphasis on prior academic achievements may de-emphasise student characteristics associated with the development of professionalism.

Mark H Arnold · Jennifer Smith-Merry · Andrew S Lane

To the Editor:Emanuel1 enjoins readers to focus on the data concerning euthanasia and physician-assisted suicide (PAS), and to aim at improving the care of dying patients, but advances straw arguments on the basis of three claims in the end-of-life debates that are disputed by neither advocates nor opponents of assisted dying. From the fact that euthanasia and PAS are rarely requested and rarely cause death, Emanuel argues that legalising them will not help solve the problem of inadequate symptom management or improve palliative care. But he adduces no evidence that supporters of legalisation make this claim. Describing legalisation as “really a sideshow in end-of-life care — championed by the few for the few” minimises the plight of those who would avail themselves of euthanasia and PAS, and is belied by the consistent majority support in Western communities for legalisation.2 Pain is recognised, by both advocates and opponents of legalisation, to not be the primary reason why people seek euthanasia and PAS. To claim that the real motivators of requests for assistance (eg, depression, loss of control and loss of dignity) “are not relieved by increasing the dose of morphine, but by antidepressants and therapy”, perpetuates the myth that medicine can, and should, always provide therapeutic answers to such personal dilemmas.3 Emanuel describes requests for euthanasia and PAS as amounting to “traditional suicide condoned and assisted by the medical community”, on the grounds that they are motivated by psychological factors. This statement begs the question about the ethical and legal propriety of euthanasia and PAS by equating PAS with other categories of suicide, without adequate analysis. No one would be surprised at the data supporting Emanuel’s claim that all medical procedures have problems and complications, and that euthanasia and PAS are no exceptions. But to conclude from this that “the common view of euthanasia and PAS as quick, flawless, and painless ways to die is unrealistic” introduces an alleged “common view” that is also unsupported. These are all examples that seem to advance evidence-based arguments in support of a particular ethical and policy position, but one that has been decided ahead of the evidence.

Malcolm H Parker

In reply

Ezekiel Emanuel

To the Editor:While vaccine refusal is but one contributor among several to failures of vaccine-preventable disease control, as stated by Beard and colleagues,1 there are important ethical aspects of vaccine refusal. Intentionally opting out of vaccination imposes risks on others, and policies allowing some to opt out weigh their freedom to do so against the rights of others not to be harmed by vaccine-preventable diseases.2 In particular, people who cannot be safely vaccinated (eg, infants) or maintain immunity (eg, the immunosuppressed) are at increased risk of severe disease — including death — and depend on the immunity of others.2 It is true that herd immunity has no “magic threshold”:1 even with high population vaccination levels, severe harm may be caused when just one unvaccinated person has contact with an infectious person and then a vulnerable person. The death of an immunosuppressed woman from measles pneumonitis in the state of Washington, United States, in 2015 is a case in point.3 Tighter legislation on universal vaccination does not unfairly target vaccine refusal. Indeed, Victorian No Jab, No Play legislation has a general objective: “to increase immunisation rates for young children,”4 which applies equally to people who have unintentionally failed to vaccinate and those who intentionally opt out due to hesitancy or refusal. Policy should make vaccination the norm and aim for the highest possible coverage. Moreover, while we should revise financial penalties if they unfairly burden poor families (while the wealthy may pay to opt out), policy should, in some way, recognise that conscientious objection to vaccination has consequences for others.5 Measles outbreaks are correlated with vaccine refusal6 and lead to significant social costs, which Australia may avoid if high levels of vaccination are maintained. Though the true epidemiology is certainly more complex, if measles vaccination leads to immunity in 99% of vaccine recipients, and 95% of people are vaccinated,1 the population level of immunity would be 94.05%. Threshold concepts have limitations, but whether this is “comfortably exceeding” 94%,1 or perilously close to recurrent measles outbreaks — which impose avoidable risks of harm on others — is a matter for debate.

Euzebiusz Jamrozik

In reply

Frank H Beard · Julie Leask · Peter B McIntyre

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

To the Editor:Advance care planning (ACP) promotes conversations about future health care, in case a person should lose capacity for decision making. Advance care directives (ACDs) provide written documentation of these conversations. Yet, although the Australian Medical Association advocates ACP within routine clinical practice,1 ACD completion rates remain low.2 While recognising numerous barriers to ACP, including patient, practitioner and health care system factors,3 a dedicated ACP Medicare Benefits Schedule (MBS) item number was mentioned in a number of general discussions at the 2016 Advance Care Planning Australia national conference (Melbourne, 15–17 November) as a potential incentive to increase the use of ACDs in primary care. In general, we support this recommendation. Health economics tells us that where there is a shortage of a specific service, as could be argued for ACP, the supply of this service will increase under fee-for-service payment.4 Patients are less knowledgeable about prices, services and associated benefit than providers; however, the existence of an agency relationship5 (where the patient assigns decisional authority on the basis that they have less information) between general practitioners and patients would facilitate ACDs from which patients are most likely to benefit. On the other hand, there is some risk that financial incentives will motivate GPs to do more than is optimal or desired, especially if the service is priced above standard consultation fees. There is also an opportunity cost; if GPs are providing more ACP services they will have less time to provide other primary care services. However, the risk of financial incentives may be mitigated by the non-financial barriers to ACP (fear or reluctance of patients, insufficient GP skills or organisational factors). Therefore, in designing policies to increase uptake, especially where financial incentives are the driver, a multifaceted approach should be considered. Service reimbursement mechanisms and potential barriers should also be balanced against maintenance of ACP values such as patient autonomy and informed decision making. As a starting point, a two-tiered MBS item number could be beneficial, the first item billable for initiation of ACP and the second used for revisitation of ACDs after a given time period (eg, annual review). Subsequent review of policy responses, including patient and medical practitioner input, will be needed to ensure appropriate directions surrounding MBS billing. Further accompanying strategies may be required to address non-financial barriers to ACP uptake.

Amanda Pereira-Salgado · Jennifer J Watts