Dominic Wilkinson

COVID: Media Must Rise Above Pitting Scientists Against Each other – Dealing With the Pandemic Requires Nuance

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Trish Greenhalgh, University of Oxford and Dominic Wilkinson, University of Oxford

At the start of the pandemic, there was a striking sense of shared resolve and solidarity. Facing a public health crisis greater than any in living memory, people were largely united in their support of difficult measures to protect the vulnerable, safeguard the health system and sustain key workers.

There were, of course, differences of opinion. For example, some disagreed about the severity of the threat posed by COVID, about the wisdom of different national approaches to lockdown, about the timing of restrictions, and the effectiveness face masks.

More recently, there has also been disagreement on how vaccines should be distributed, whether vaccine passports are a good idea, and whether vaccination should be mandatory for certain occupations)

Throughout the pandemic, scientists attempting to explain their findings have had to deal with unprecedented levels of dissent, anger and abuse from the lay public and occasionally from other scientists.

Since the government lifted COVID restrictions on July 19, views on how best to handle the pandemic have become more polarised than ever, broadly splitting into two camps: the “open up” camp and the “not yet” camp. Continue reading

COVID: Why We Should Stop Testing in Schools

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Education Secretary Gavin Williamson has announced the end of school “bubbles” in England from July 19, following the news that 375,000 children did not attend school for COVID-related reasons in June.

Under the current system, if a schoolchild becomes infected with the coronavirus, pupils who have been in close contact with them have to self-isolate for ten days. In some cases, whole year groups may have to self-isolate.

Such mass self-isolation is hugely disruptive. Yet despite the clamour to switch to other protective measures, such as rapid testing of pupils who have been in close contact with an infected pupil, the public service union Unison has supported self-isolation as “one of the proven ways to keep cases under control”. Continue reading

Urgency, Delayed Decision-making and Ethics in the Court of Protection

By Dominic Wilkinson, 24th June 2021

cross post from the Open Justice Court of Protection Project

On 11th June 2021,  I was a public observer (via MS Teams) of a case in the Court of Protection: Case No. 1375980T Re GU (also blogged about by Jenny Kitzinger here).

The case was (though I did not know it beforehand) related closely to issues that I have written about over a number of years (for example hereherehere ). It was an urgent hearing before Mr Justice Hayden concerning clinically-assisted nutrition and hydration (CANH) for a 70 year old man, GU, who has been in a prolonged disorder of consciousness for seven years.

I have read the judgments from many similar cases in the UK, from the first ever case concerning a feeding tube for a vegetative patient heard in (what is now) the Supreme Court in 1992 (the case of  Tony Bland, injured in the Hillsborough football stadium disaster), through to the most recent Supreme Court case of Re. Y, at which the court ruled that it is not mandatory to bring cases concerning CANH-withdrawal to court unless there is disagreement about best interests, or the decision is finely balanced (report here). I’m also familiar with the judgments in other jurisdictions (e.g. Schiavo in the USA,  Lambert in France) and have been involved in deliberation in clinical ethics committees about cases with similar features.

Yet, this was my first time hearing open deliberations in the Court of Protection. It was a fascinating and thought-provoking experience. Continue reading

Care home staff vaccination – press release

Two (contrasting) perspectives on the news this morning about planned mandatory vaccination of care home workers.

Professor Julian Savulescu

“The proposal to make vaccination mandatory for care home workers is muddle-headed. Vaccination should be mandatory for the residents, not the workers. It is the residents who stand to gain most from being vaccinated.  Young care workers have little to gain personally from vaccination and there are now lethal risks, as well as uncertain long term consequences of novel vaccines. They have already risked their own lives during the pandemic. Some will be immune from past infection. Those remaining should be offered incentives, including financial incentives, to be vaccinated, not coerced. Vaccines like hepatitis and influenza may be mandatory, but they have been around for years and have established safety profiles.

“It’s too soon to be talking about mandates. We’re still researching rare but potentially serious side-effects that have been thrown up by national monitoring, for example a possible link between Pfizer and myocarditis. We don’t have the full picture on how well they prevent transmission. Public Health England data about how transmission is only available for the first dose and it is currently at up to 50%. Meanwhile the level of protection afforded to vaccinated individuals themselves is holding up very well in terms of hospitalisation and death even against the new variants. With the level of confidence we have encouragement to vaccinate is warranted, and incentives are warranted. Mandates should only be made on the basis of bulletproof safety and efficacy data, including transmission data.”

Prof Dominic Wilkinson & Dr Jonathan Pugh

“In the earlier phase of the pandemic, some of the most medically vulnerable members of our community, patients in care homes and acutely ill patients in hospitals, ended up catching coronavirus from those caring for them. Some patients and care home residents died from infections that they caught from their caregivers.”

“That is a tragic and distressing situation that we must do everything possible to avoid repeating.

First, we should ensure that all those who are high risk have access to vaccination. There are still approximately 10% of older adult care home residents who have not had a 2nd dose of the vaccine.

Second, those who work in the frontline with vulnerable high risk patients have an ethical obligation to take all reasonable measures to prevent spread of the vaccine to those they are caring for. They must follow guidance about the use of measures like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.

In England, as of 10th June, 17% of adult care home workers have not had the COVID-19 vaccine.

There is a strong ethical case that care home workers (and NHS staff) who have not had the COVID vaccine should be redeployed to areas other than frontline care.
It would be ethical to make COVID vaccination (in the absence of a medical exemption) a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.

If vaccines are made mandatory for health care and care home workers, they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.”

Pfizer Jab Approved for Children, but First Other People need to be Vaccinated

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Moderna and Pfizer have released data suggesting that their vaccines are well tolerated in adolescents and highly effective in preventing COVID-19. Canada, the US and the EU have already authorised the Pfizer vaccine in children as young as 12. And the UK has just approved the use of the Pfizer vaccine in children aged 12 to 15. But there may a case for holding out on an immediate rollout, for several reasons.

Whether a vaccine is beneficial for someone depends on three things: how likely they are to become seriously ill from the infection, how effective the vaccine is, and the risks of vaccination. Continue reading

Phobias, Paternalism and the Prevention of Home Birth

By Dominic Wilkinson,

Cross post from the Open Justice Court of Protection blog

In a case in the Court of Protection last week, a judge authorised the use of force, if necessary, to ensure that a young woman gives birth in hospital rather than at home.

The woman (call her ‘P’) has severe agoraphobia, and has barely left her home in four years. Her doctors believe that it would be best for her to deliver her baby in hospital. But P has an overwhelming fear of leaving her home and cannot agree to this. Their particular concern is that P might develop a serious complication during her home birth, need emergency transport to hospital, but be unwilling or unable to agree to this because of the severity of her phobia.

At the conclusion of a three-day hearing, Mr Justice Holman declared that P lacked capacity to make the relevant decisions and ordered that it was lawful and in her best interests for medical staff to transfer her to hospital a few days before her estimated due date, and for medical professionals to offer her a choice of induction of labour or Caesarean Section in hospital.  He also gave permission for the use of restraint, if necessary, in the event that she refuses to go to hospital voluntarily.

On the face of it, this looks like an extremely concerning infringement of a patient’s autonomy – a view that has been expressed by members of the public responding to media reports (e.g. see the blog post here).   We normally think that adults should be free to make decisions about their medical care, including the freedom to refuse treatments that doctors are recommending. Decisions about place of birth and mode of birth are deeply personal decisions that can be hugely important for many women. For that reason, doctors and courts should be extremely loathe to infringe upon them.

Is it justified in this case, then, to physically restrain P and treat her against her wishes? In particular, is it justified to do this pre-emptively, before a complication develops? Continue reading

General Anaesthesia in End of Life Care – GAEL.

by Dominic Wilkinson @Neonatalethics

Our paper General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery has been published today in Anaesthesia. It is part of a series of work led by researcher Antony Takla, together with Julian Savulescu and Dominic Wilkinson. The recent paper is a collaboration with Professor Jaideep Pandit, Professor of Anaesthesia at Oxford.

 

Continue reading

Press Release: New Tavistock Legal Ruling on Puberty Blockers

The legal decision this morning, in the Family division of the High Court, provides important clarification. It is likely to be a relief to young people with gender dysphoria and their families.
In December, the High Court found that young people under 16 with gender dysphoria were highly unlikely to be able to understand the complexities and uncertainties of puberty blocking treatment. That meant that they could not consent (on their own) to treatment. The court recommended that doctors and families go to court to seek permission to start treatment.
That decision has caused great uncertainty for a large number of vulnerable teenagers with gender dysphoria who had previously been started on treatment or were awaiting treatment. It wasn’t clear whether they would be able to receive puberty blockers.
The decision today clarifies that parents of young people with gender dysphoria can consent to puberty blocking treatment on behalf of the young person. Where the parents, doctors and young person are all in agreement about this, there is no need to go to court.
 
This court decision reinforces a long established ethical approach to medical treatment in children and young people. The views of the child or young person should be sought. If the young person is sufficiently mature they may be able to consent on their own to the treatment in some cases. But where that isn’t the case, parents are able to consent to treatment that would be in the young person’s best interests (ie would be best overall for them). That ethical approach has long been adopted, in this country and others, for young people needing surgery or chemotherapy or other medical treatment. It applies to extremely important life and death decisions (for example about stopping life support). It also applies to puberty blockers.
Debate about the role of puberty blockers in young people and children is likely to continue. But this decision means that where doctors believe that it would be best for the young person to have this treatment, the young person wants the treatment and parents consent, the treatment can legally be provided.”
Professor Dominic Wilkinson
Professor of Medical Ethics, University of Oxford
Consultant Neonatologist

No conflicts of interest

Is it Irrational Not to Have a Plan? Should There Have Been National Guidance on Rationing in the NHS?

By Dominic Wilkinson and Jonathan Pugh.

This is a crosspost from the Journal of Medical Ethics Blog.

This is an output of the UKRI Pandemic Ethics Accelerator project.

Last April, in the first wave of the COVID-19 pandemic, a number of academics, lawyers, doctors and ethicists wrote publicly about the need for national ethical guidance relating to resource allocation (e.g., see here, here, here). At the time there was concern that there would be insufficient intensive care beds to meet the needs of critically ill patients, and many thought that there needed to be clear guidance to doctors to tell them what to do if that occurred.

While a number of professional groups produced guidelines (for example, the British Medical Association, Royal College of Physicians, Intensive Care Society), no national guidance was ever produced. (A draft guideline was developed but rejected in early April 2020).

Almost 12 months and two pandemic waves later, in a legal ruling last week, Justice Swift refused the application of a number of COVID-affected families who had sought a judicial review on the absence of national guidelines. The ruling is not yet publicly available, but it appears that there were three legal arguments: that there was a statutory obligation to have contingency plans in case demand exceeded capacity, that rationing in the absence of national guidance would violate Article 8 of the Human Rights Act, and that it was “irrational” not to have a national guideline. Swift J apparently rejected all three of these claims.

We will focus here on the third of these – the most ethical of the arguments.

“iii) Rationality – it is irrational not to have a national guideline.”

Continue reading

DNACPR Orders in a Pandemic: Misgivings and Misconceptions.

by Dominic Wilkinson @Neonatalethics

This week, the Care Quality Commission (CQC) published an interim report into resuscitation decisions during the COVID-19 pandemic. According to a number of media outlets, the report found that in the first wave of the crisis inappropriate and possibly unlawful ‘do not resuscitate’ orders were used “without the consent of patients and families” (see eg Telegraph, Sky).

There are real concerns and important questions to answer about policies and care for patients in care homes and in the community during the pandemic. However, the media stories, and the CQC report itself appear to illustrate two ethical misconceptions.

 

Continue reading

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