The harm principle, personal identity and identity-relative paternalism.

Is it ethical for doctors or courts to prevent patients from making choices that will cause significant harm to themselves in the future? According to an important liberal principle the only justification for infringing the liberty of an individual is to prevent harm to others; harm to the self does not suffice.In this paper, I explore Derek Parfit's arguments that blur the sharp line between harm to self and others. I analyse cases of treatment refusal by capacitous patients and describe different forms of paternalism arising from a reductionist view of personal identity. I outline an Identity Relative Paternalistic Intervention Principle for determining when we should disallow refusal of treatment where the harm will be accrued by a future self, and consider objections including vagueness and non-identity.Identity relative paternalism does not always justify intervention to prevent harm to future selves. However, there is a stronger ethical case for doing so than is often recognised.

Between paternalism and illegality: a longitudinal analysis of the role and condition of manual scavengers in India.

Manual scavengers, or 'Safai Karamcharis', as they are known in India, are sanitation workers who manually clean human waste for a living and face considerable occupational health risks. They are subject to deep-seated, caste-based stigma associated with their perceived 'caste impurity' and lack of cleanliness, which result both in consistently dangerous substandard working conditions and lack of social mobility, with women facing greater hardships. The COVID-19 pandemic has further exacerbated their plight. Despite the considerable efforts of social advocates, organised movements and government institutions, reforms and criminalisation have produced mixed results and campaigners remain divided on whether banning manual scavenging is an effective solution. This article reviews the history of attempts to address scavenging in India. Starting in the colonial period and ending with the current government's Swachh Bharat Mission, it highlights how attempts to deal with scavenging via quick-fix solutions like legal bans criminalising their employment, infrastructure upgrades or paternalistic interventions have either failed to resolve issues or exacerbated scavengers' situation by pushing long-standing problems out of view. It argues that meaningful progress depends on abandoning top-down modes of decision-making, addressing the underlying sociocultural and infrastructural factors that perpetuate the ill health and social conditions of manual scavengers, collecting data on the true extent of scavenging, and investing in and providing political agency to communities themselves.

Imaging, Paternalism and the Worried Patient: Rethinking Our Approach.

The Covid pandemic has taught many lessons, including the importance of mental health. The value of the radiologist in holistic patient care may be underestimated and underresearched. Barriers to the acceptance of imaging as an important component in reassurance may be rooted in old ideas minimizing the importance of mental health.

Physician outreach during a pandemic: shared or collective responsibility?

In 'Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?' Strous and Karni note that the revised physician's pledge in the World Medical Association Declaration of Geneva obligates individual physicians to share medical knowledge, which they interpret to mean a requirement to share knowledge publicly and through outreach. In the context of the COVID-19 pandemic, Strous and Karni defend a form of medical paternalism insofar as the individual physician must reach out to communities who may not want, or know to seek out, medical advice, for reasons of public health and health equity. Strous and Karni offer a novel defence of why physicians ought to intervene even in insular communities, and they offer suggestions for how this could be done in culturally sensitive ways. Yet their view rests on an unfounded interpretation of the Geneva Declaration language. More problematically, their paper confuses shared and collective responsibility, misattributing the scope of individual physician obligations in potentially harmful ways. In response, this reply delineates between shared and collective responsibility, and suggests that to defend the obligation of medical outreach Strous and Karni propose, it is better conceptualised as a collective responsibility of the medical profession, rather than a shared responsibility of individual physicians. This interpretation rejects paternalism on the part of individual providers in favour of a more sensitive and collaborative practice of knowledge sharing between physicians and communities, and in the service of collective responsibility.

Resuscitating Patient Rights during the Pandemic: COVID-19 and the Risk of Resurgent Paternalism.

The COVID-19 Pandemic a stress test for clinical medicine and medical ethics, with a confluence over questions of the proportionality of resuscitation. Drawing upon his experience as a clinical ethicist during the surge in New York City during the Spring of 2020, the author considers how attitudes regarding resuscitation have evolved since the inception of do-not-resuscitate (DNR) orders decades ago. Sharing a personal narrative about a DNR quandry he encountered as a medical intern, the author considers the balance of patient rights versus clinical discretion, warning about the risk of resurgent physician paternalism dressed up in the guise of a public health crisis.

'We have become prisoners of our own age': from a continuing care retirement community to a total institution in the midst of the COVID-19 outbreak.

BACKGROUND AND OBJECTIVES: during the coronavirus disease 2019 pandemic in Israel, people residing in continuing care retirement communities (CCRC) found themselves under strict instructions to self-isolate, imposed by the CCRC managements before, during and after the nationwide lockdown. The present study explored the personal experiences of CCRC residents during the lockdown. RESEARCH DESIGN AND METHODS: in-depth interviews were conducted with 24 CCRC residents from 13 different CCRCs. Authors performed a thematic analysis of interview transcripts, using constant comparisons and contrasts. RESULTS: three major themes were identified: (i) 'Us vs. them: Others are worse off'. Older residents engaged in constant attempts to compare their situation to that of others. The overall message behind these downward comparisons was that the situation is not so bad, as others are in a worse predicament; (ii) 'Us vs. them: Power imbalance'. This comparison emphasised the unbalanced power-relations between older adults and the staff and management in the setting and (iii) 'We have become prisoners of our own age'. Interviewees described strong emotions of despair, depression and anger, which were intensified when the rest of society returned back to a new routine, whilst they were still under lockdown. DISCUSSION AND IMPLICATIONS: the measures imposed on residents by managements of CCRCs during the lockdown, and the emotional responses of distress among some of the residents, revealed that CCRCs have components of total institutions, not normally evident. This underscores the hidden emotional costs of the lockdown among those whose autonomy was compromised.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

Six Propositions against Ageism in the COVID-19 Pandemic.

The risk of developing severe illness from COVID-19 and of dying from it increases with age. This statistical association has led to numerous highly problematic policy suggestions and comments revealing underlying ageist attitudes and promoting age discrimination. Such attitudes are based on negative stereotypes on the health and functioning of older adults. As a result, the lives of older people are disvalued, including in possible triage situations and in the potential limitation of some measures against the spread of the pandemic to older adults. These outcomes are unjustified and unethical. We develop six propositions against the ageism underlying these suggestions to spur a more adequate response to the current pandemic in which the needs and dignity of older people are respected.