Decision-Making Capacity to Refuse Treatment at the End of Life: The Need for Recognizing Real-World Practices
Round 1
Reviewer 1 Report
In principle this is a valid paper. While I appreciate it is a ‘Communication’ I feel it needs work to make it publishable.
Overall, I feel the authors need to take a more considered tone to their comments. A number of them are quite derogatory and seem unnecessarily inflammatory. This is a complex topic and debate is welcome. The authors make a number for valid points but these need to be clearer and set out with more logical flow for the reader. I think the paper would benefit from a wider and more detailed debate, beyond the critique of this one paper. This would strengthen the authors’ arguments and provide support from their rebuttal. At this time a considerable part of the paper is quoting the case study and approach provide by the paper being discussed. A number of the sections are very short and provide little other than a comment that the authors are not satisfied with the previous publications comments, I am not sure how useful this is for the reader. This is especially prominent in section 4.
Suggest need something in the title that indicate this is a critique of others work rather than empirical research or a review.
There are typos throughout. The Navin et al. paper is available and should be referenced fully. It was published in 2021
Mark Christopher Navin, Abram L. Brummett & Jason Adam Wasserman (2021) Three Kinds of Decision-Making Capacity for Refusing Medical Interventions, The American Journal of Bioethics, DOI: 10.1080/15265161.2021.1941423
Author Response
Reply to Rev 1 Comments and Suggestions for Authors
In principle this is a valid paper. While I appreciate it is a ‘Communication’ I feel it needs work to make it publishable.
Thank you for your comments. We have made a significant revision.
Overall, I feel the authors need to take a more considered tone to their comments. A number of them are quite derogatory and seem unnecessarily inflammatory. This is a complex topic and debate is welcome. The authors make a number for valid points but these need to be clearer and set out with more logical flow for the reader. I think the paper would benefit from a wider and more detailed debate, beyond the critique of this one paper. This would strengthen the authors’ arguments and provide support from their rebuttal.
Yes, we have totally change the strategy, and softened the tone. Our aim of this paper is not to criticize Navin’s paper. We selected it as an example since it is published in AJOB, first class journal.
We have searched quickly the PubMed and Philosophers’ index, and categories of papers into four types. 1) Written mainly from the perspective of ethicists or philosophers; 2) Written mainly from a clinical perspective; 3) Written mainly from the perspectives of other fields such as law; 4) Written mainly by interdisciplinary expert authors such as clinicians and ethicists.
Category 4 looks better, though we point out risks of category 4 approach.
Our conclusion is two-fold. First, discussions in this field should be based on the real-world practice. If this is not the case, proposals may be armchair theory, which is not needed in clinical settings. Second, interdisciplinary researchers should not stick to their position too firmly but should listen to the others. If this is not done, proposals made will just be paternalistic or philosophically biases to one position. Therefore, when philosophical collaboration is applied to the topic of clinical bioethics, it is necessary to thoroughly examine different positions and to carry out careful discussions with consideration for the medical care settings. The researchers also have to know what is really needed for trustful patient-doctor relationships. By making such efforts, clinical bioethics will contribute to the well-being of patients.
At this time a considerable part of the paper is quoting the case study and approach provide by the paper being discussed. A number of the sections are very short and provide little other than a comment that the authors are not satisfied with the previous publications comments, I am not sure how useful this is for the reader. This is especially prominent in section 4.
We did our best. We have also added 14 more references.
Suggest need something in the title that indicate this is a critique of others work rather than empirical research or a review.
As our purpose of this paper is not criticize one paper, rather point out risks researchers sometimes fall into, we leave the title as it is. We are ready to change the title if you still desire.
There are typos throughout. The Navin et al. paper is available and should be referenced fully. It was published in 2021
Mark Christopher Navin, Abram L. Brummett & Jason Adam Wasserman (2021) Three Kinds of Decision-Making Capacity for Refusing Medical Interventions, The American Journal of Bioethics, DOI: 10.1080/15265161.2021.1941423
Thank you. All corrected.
Once again, thank you for reading our manuscript in detail. English proof reading is done (Certification attached). I hope this is now acceptable for publication.
Author Response File: 
Author Response.docx
Reviewer 2 Report
I come at this review being an intensive care specialist and agree with the statements by the authors that the paper lacks clinical reality. The patient has a terminal condition - dementia, the commonest cause of death in the elderly. It is not accurate to use the word 'diagnosis' in the context of this case report. The patient has many so-called co-morbidities or chronic health problems the sum of which add up to a clinical condition which has no specific 'diagnostic' category about from terms such as frailty. It is not correct to assume this woman will leave hospital alive. That involves examining the individual challenges separately eg renal failure = can be cured by dialysis. Nor does it consider the person's practical situation of being on permanent dialysis even if she did survive. It is highly unlikely in view of the difficulty getting a simple NG tube down that she would co-operate with dialysis for many hours several times a week. There is also the ethical implications of the 'justice' and whether the state or individual could bear these costs in a women who is uncooperative and terminally ill. The argument overlooks the recent move to shared decision making to address the inequality in discussions between people and health professionals. Health services around the world avoid difficult conversations about terminal illness. The issue here is not so much reducing the argument to an interesting ethical dilemma. It is more about it not standing up to any real world analysis. An experienced intensive care clinician would not hesitate about being honest and empathetic and explaining to the daughter about the terminal nature of the condition and not focussing on individual interventions for each individual clinical problem
Author Response
Reply to Rev 2 Comments and Suggestions for Authors
I come at this review being an intensive care specialist and agree with the statements by the authors that the paper lacks clinical reality. The patient has a terminal condition - dementia, the commonest cause of death in the elderly. It is not accurate to use the word 'diagnosis' in the context of this case report. The patient has many so-called co-morbidities or chronic health problems the sum of which add up to a clinical condition which has no specific 'diagnostic' category about from terms such as frailty. It is not correct to assume this woman will leave hospital alive. That involves examining the individual challenges separately eg renal failure = can be cured by dialysis. Nor does it consider the person's practical situation of being on permanent dialysis even if she did survive. It is highly unlikely in view of the difficulty getting a simple NG tube down that she would co-operate with dialysis for many hours several times a week. There is also the ethical implications of the 'justice' and whether the state or individual could bear these costs in a women who is uncooperative and terminally ill. The argument overlooks the recent move to shared decision making to address the inequality in discussions between people and health professionals. Health services around the world avoid difficult conversations about terminal illness. The issue here is not so much reducing the argument to an interesting ethical dilemma. It is more about it not standing up to any real world analysis. An experienced intensive care clinician would not hesitate about being honest and empathetic and explaining to the daughter about the terminal nature of the condition and not focussing on individual interventions for each individual clinical problem
Thank you for reading our manuscript in detail. English proof reading is done (Certification attached). I hope this is now acceptable for publication.
Author Response File: Author Response.docx
Round 2
Reviewer 1 Report
While the paper is improved I still feel it needs work on it readability to make it publishable.
The background is improved and gives a clearer set up for the rest of the commentary. However, I found the layout of the paper to inhibit the flow. The authors seem to have added some subheadings but not followed through with these. '2.1 First criticism'. Where or what is the second criticism? Please set this out more clearly for the reader.
line 77 – suggest instead of ‘We will criticize one paper…’ perhaps ‘we will focus on one paper’ or ‘we will draw on X paper to illustrate our points’
Line 183 – suggest not using the word criticise, especially as you go on to say you are not singling them out for criticism – again suggest saying something line ‘we will draw on one paper as an example’ or ‘will focus on the paper by X’
Lines 186-188 – sentence doesn’t quite make sense
Line 216 – type at the end of the quote – page and reference for this quote should be included at the end
Line 220 – 315 The details of the approaches appear to be quote from the original paper and should be referenced accordingly.
Author Response
Rev 1 . Comments and Suggestions for Authors
While the paper is improved I still feel it needs work on it readability to make it publishable.
The background is improved and gives a clearer set up for the rest of the commentary. However, I found the layout of the paper to inhibit the flow. The authors seem to have added some subheadings but not followed through with these. '2.1 First criticism'. Where or what is the second criticism? Please set this out more clearly for the reader.
Thank you for your comment. We have re-organize the subheadings.
line 77 – suggest instead of ‘We will criticize one paper…’ perhaps ‘we will focus on one paper’ or ‘we will draw on X paper to illustrate our points’
We have changed to we will focus on one paper.
Line 183 – suggest not using the word criticise, especially as you go on to say you are not singling them out for criticism – again suggest saying something line ‘we will draw on one paper as an example’ or ‘will focus on the paper by X’
We have changed to we will draw on one paper that took the Category 4 approach as an example.
Lines 186-188 – sentence doesn’t quite make sense
We have deleted the sentence.
Line 216 – type at the end of the quote – page and reference for this quote should be included at the end
Done.
Line 220 – 315 The details of the approaches appear to be quote from the original paper and should be referenced accordingly.
Done.
Once again, thank you for reading our manuscript and useful comments.
