Carwyn Hooper

Adding insult to injury: the healthcare brain drain

Recent reports published by the United Nations and the World Health Organization suggest that the brain drain of healthcare professionals from the developing to the developed world is decimating the provision of healthcare in poor countries. The migration of these key workers is driven by a combination of economic inequalities and the recruitment policies of governments in the rich world. This article assesses the impact of the healthcare brain drain and argues that wealthy countries have a moral obligation to reduce the flow of healthcare workers from the developing to the developed world.

Is there a case for mandating influenza vaccination in healthcare workers

Ten years ago, Virginia Mason Medical Center became the first major American healthcare employer to implement a mandatory vaccination scheme for influenza [1]. Since then, other healthcare organisations, especially in the USA, have followed suit [2]. The UK’s General Medical Council has stated that doctors “should be immunised against common serious communicable diseases (unless otherwise contraindicated)” – though stopping short of advocating a mandate [3]. The recent popularity of mandatory schemes partly reflects growing anxiety about the emergence of novel influenza strains, e.g. H1N1, and the widespread harm they can cause, and partly by the significantly higher vaccination rates achieved by mandatory schemes over voluntary ones [4]. In this editorial we discuss the nature of influenza, the effectiveness and safety of influenza vaccines, the rationale for vaccinating healthcare professionals, the effectiveness of voluntary and mandatory vaccination schemes and, finally, the ethical arguments for (and against) the latter. We do not single out any individual group of staff but suggest that this issue is of major relevance to anaesthetists and intensivists through their exposure to, and treatment of, high-risk groups.

Liberty or death; don't tread on me

Many jurisdictions require cyclists to wear bicycle helmets. The UK is currently not one of these. However, an increasing number of interest groups, including the British Medical Association, want to change the status quo. They argue that mandatory cycle helmet laws will reduce the incidence of head injuries and that this will be both good for cyclists (because they will suffer fewer head injuries) and good for society (because the burden of having to treat cyclists suffering from head injuries will be reduced). In this paper we argue against this position. We suggest that cycle helmets may not be especially effective in reducing head injuries and we suggest that the imposition of such a restrictive law would violate peoples freedom and reduce their autonomy. We also argue that those who accept such a restrictive law would be committed to supporting further legislation which would force many other groups – including pedestrians – to take fewer risks with their health. We conclude that cycle helmet legislation should not be enacted in the UK unless, perhaps, it is restricted to children.

Ancillary care duties: the demands of justice

Ancillary care is care that research participants need that is not essential to make the research safe or scientifically valid and is not needed to remedy injuries that eventuate as a result of the research project itself. Ancillary care duties have recently been defended on the grounds of beneficence, entrustment, utility and consent. Justice has also been mentioned as a possible basis of ancillary care duties, but little attention has been paid to this approach. In this paper, the author seeks to rectify this omission by arguing that ancillary care duties can be based on a principle of justice as rectification.

Ethical implications of HIV self-testing

In April 2015, the first legally approved HIV self-testing kit went on sale in the UK—except Northern Ireland where they remain illegal. These tests allow individuals to test their HIV status and read the result in the privacy of their own home, much like a home pregnancy test. This paper explores the ethical implications of HIV self-testing. We conclude that there are no strong ethical objections to self-testing being made widely available in the UK. Pretest counselling for an HIV test is not an ethical necessity, and self-testing has the potential to increase early diagnosis of HIV infection and thus improve prognosis and reduce ongoing transmission. Self-testing kits might also empower people and promote autonomy by allowing people to dictate the terms on which they test their HIV status. We accept that there are some potential areas of concern. These include the possibility of user error with the tests, and the concern that individuals may not present to health services following a reactive result. False negatives have the potential to cause harm if the ‘window period’ is not understood, and false positives might produce psychological distress. There is, however, little evidence to suggest that self-testing kits will cause widespread harm, and we argue that the only way to properly evaluate whether they do cause significant harm is to carefully evaluate their use, now that they are available on the market.

Ethics virtual patients: a new pedagogical tool for educators?

Virtual patient (VP) cases are interactive computer simulations of real life scenarios that have been used in medical education for over a decade. They are popular with students and staff alike and have been shown to improve knowledge retention, clinical reasoning and decision-making skills. Ethics virtual patient (EVP) cases are interactive computer simulations of real life scenarios which have a substantive ethical component. They can also contain significant legal and professionalism components. EVP cases have only recently been used in medical education, but there is growing evidence to suggest that medical students find them interesting, engaging and helpful. This paper will provide a brief overview of the way in which EVP cases have been used at St Georges, University of London and explore the pedagogical rationale for using these cases to teach ethics, law and professionalism to medical students.

Placebo controlled trials

Researchers assessed the efficacy of varenicline (a licensed cigarette smoking cessation aid) in helping users of smokeless tobacco to quit. A double blind placebo controlled parallel group randomised controlled trial study design was used. The intervention was varenicline 1 mg twice daily. Treatment was delivered for 12 weeks, with 14 weeks’ follow-up afterwards. Participants were aged 18 years or more. They were also users of smokeless tobacco who wished to quit and had no abstinence period longer than three months during the year before recruitment. In total, 431 participants were recruited and randomised to varenicline (n=213) or placebo (n=218). All participants were offered brief behavioural support or counselling at the discretion of the investigators.1 The primary endpoint was continuous abstinence for four weeks at the end of treatment (weeks 9-12) confirmed by cotinine concentration. A significantly higher rate of abstinence was reported in the varenicline group compared with placebo (59% v 39%; relative risk 1.6, 95% confidence interval 1.32 to 1.87; P<0.001). Which of the following statements, if any, are true? Statement b is true, whereas a , c , and d are false. Smokeless tobacco is often used by smokers trying to quit because it is considered less harmful than …

Reply to Hidalgo's ‘The active recruitment of health workers: a defence’ article

Hidalgo offers a novel and interesting defence of the active recruitment of health workers by organisations based in the developed world.1 His conclusions are highly controversial and run directly counter to those drawn by a large number of bioethicists, empirical researchers and national and international organisations interested in the issue of health worker migration. The debate about the effects of the migration of healthcare professionals began in earnest in the 1970s. During this decade a number of researchers argued that migration flows from the developing to the developed world were detrimental to poorer countries and suggested that policies ought to be put in place to both retard the flow of migration and compensate countries for the negative effects of any ongoing migration.2 However, some researchers have recently argued that the migration of healthcare workers has many positive effects.3 This is because migration encourages human capital investment, leads to large scale flows of remittances back to source countries, encourages the transfer of knowledge, innovations and best practice, and improves trade relations. Clemens even argues that the net effects of migration are positive—which implies that the so called …

Should psychiatrists ‘Google’ their patients?

Since its beginnings in the 1980s the internet has come to shape our everyday lives, but doctors still seem rather afraid of it. This anxiety may be explained by the fact that researchers and regulatory bodies focus less on the way that the internet can be used to enhance clinical work and more on the potential and perceived risks that this technology poses in terms of boundary violations and accidental breaches of confidentiality. Some aspects of the internets impact on medicine have been better researched than others, for example, whether email communication, social media and teleconferencing psychotherapy could be used to improve the delivery of care. However, few authors have considered the specific issue of searching online for information about patients and much of the guidance published by regulatory organisations eludes this issue. In this article we provide clinical examples where the question ‘should I Google the patient?’ may arise and present questions for future research.

Placebos and sham treatments.

The effectiveness of topical chloramphenicol in preventing wound infection after minor dermatological surgery was evaluated. A randomised placebo controlled superiority trial was performed.1 Participants were patients with high risk sutured wounds who had undergone minor surgery. The intervention was a single application of topical chloramphenicol ointment to the sutured wound immediately after suturing. Chloramphenicol ointment is an antibiotic indicated for the treatment of bacterial conjunctivitis, but it is often used as prophylaxis for, or treatment of, wound infection, although little evidence exists for its effectiveness. The control treatment was placebo ointment, which consisted of a mixture of soft white and liquid paraffin with no known anti-infective properties. In total, 972 patients were recruited and randomised to topical chloramphenicol ointment (n=488) or placebo (n=484). All participants were instructed to follow standard management, keeping their wound dry and covered for 24 hours after surgery. The primary outcome was infection on the agreed day of removal of sutures or sooner if the patient re-presented with a perceived infection. The percentage of participants with an infection in the topical chloramphenicol group was significantly lower than in the placebo group (6.6% v 11.0%; difference −4.4%, 95% confidence interval −7.9% to −0.8%; P=0.010). Although the application of a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery produced a statistically significant reduction in the infection rate, the researchers concluded that the reduction …