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Covert surveillance by doctors for life-threatening Munchausen's syndrome by proxy.

An exchange in recent issues of the journal raises important questions about the ethics of covert video surveillance by doctors when they suspect lifethreatening Munchausen's syndrome by proxy. (This is the condition in which psychologically disturbed parents usually mothers inflict harm upon their children, especially and most dangerously, suffocation, in order, it is hypothesized, to gain medical attention for their children and thus, vicariously, for themselves.) First it is important to distinguish two linked but clearly different moral issues. The paper by Dr Donald Evans (1) primarily concerned whether or not covert video surveillance and associated investigations in such cases should still be regarded as research, and therefore still require assessment by Research Ethics Committees (RECs) before implementation. However, the response to his paper from Professor David Southall and Dr Martin Samuels (2) primarily concerned the moral justification of covert video surveillance by medical and nursing staff, in certain sorts of extreme cases. So far as submission to RECs is concerned, it seems important to start by reiterating what was not clear in the paper by Dr Evans but which was made explicit in the response by Professor Southall and Dr Samuels namely that Professor Southall and Dr Samuels sent the protocol for their proposed covert surveillance to the local REC. What, however, Dr Evans was pointing out was that they had not sent it for review as a research proposal. This was true for they believed and argued that it no longer constituted research the technique had been, in their opinion, sufficiently researched previously (with REC approval) and was now an established method of clinical practice in the very rare circumstances for which it was considered appropriate. Nonetheless they had sent their protocol to the local REC, arguing their case that it should not need assessment by that body since it no longer constituted research but was now established clinical practice. In doing so they were obviously inviting the REC to agree with them that the protocol was not something with which the REC should concern themselves equally obviously they were giving the REC an opportunity to disagree with their reasoning and require that the protocol should be assessed as a clinical research project. Once the REC had been given the protocol, responsibility for deciding whether or not it should be assessed as clinical research had properly passed to a body set up to make such decisions, namely the REC. Clearly in this particular case the local REC agreed that the proposed protocol did not constitute clinical research and therefore did not fall within their remit. Instead, they apparently recommended that the protocol should be reviewed by a hospital ethics committee. Once such a committee had been established for they are rare in the United Kingdom