By Charles Foster and Jonathan Herring
Scene 1: An Intensive Care Unit
Like many patients in ICU, X is incapacitous. He also needs a lot of care. Much of that care involves needles. Late at night, tired and harassed, Nurse Y is trying to give X an intravenous injection. As happens very commonly, she sticks herself with the needle.
Nurse Y is worried sick. Perhaps she will catch HIV, hepatitis, or some other serious blood-borne infection? She goes tearfully to the Consultant in charge.
‘Don’t worry’, he says. ‘We’ll start you on the regular post-exposure prophylaxis. But to be even safer, we’ll test some of X’s blood for the common infections. I doubt he’ll be positive, but if he is, we’ll start you straight away on the necessary treatment. We needn’t take any more blood: there are plenty of samples already available.’
A sample of blood is submitted for analysis. Continue reading
Studies have shown that regular physical activity has benefits for mental health: exercise can help people to recover from depression and anxiety disorders. However, not all people like exercise, and a mental disorder like depression can additionally decrease motivation for physical activity. So the disorder itself might inhibit behaviour that helps to overcome it.
We would assume that pressurising people is no solution here: several studies have shown that restricting freedom of choice or control increases stress in both humans and animals. However, new research tentatively indicates that controllability might play a smaller role than expected when it comes to exercise, and that even forced exercise might protect against depression and anxiety symptoms:
I have just watched someone die. Just one person. But a whole ecosystem has been destroyed. Everyone’s roots wind round everyone else’s. Rip up one person, and everyone else is compromised, whether they know it or not. This is true, too, for everything that is done to anyone. Death just points up, unavoidably, what is always the case.
This is trite. But it finds little place in bioethical or medico-legal talk. There, a human is a discrete bio-economic unit, and there’s a convention that one can speak meaningfully about its elimination without real reference to other units.
In some medico-legal contexts this is perhaps inevitable. There have to be some limits on doctors’ liability. Hence some notion of the doctor-patient relationship is probably inescapable, and the notion requires an artificially atomistic model of a patient.
But ethics can and should do better. Continue reading
Whatever your view of abortion, there are too many abortions, and too many of them are too late. Even abortion’s fiercest advocates don’t pretend that it’s a Good Thing – just the lesser of two evils.
In 2010 there were 189,574 abortions in England and Wales – an 8% increase in a decade. The tightly policed regime envisaged in 1967, when the Act became law, hasn’t existed for ages, if indeed it ever did. There is abortion on demand, whatever the statute book says.
1967 was a long time ago. There have been many medical advances and societal changes since then. It’s time to take stock of the Act.
That’s what a recently announced cross-party commission, to be chaired by Fiona Bruce MP, will do.
It will focus, rightly, on two issues: medical advances and attitudes to discrimination. Continue reading
It will be interesting to watch the reception of a recent Court of Protection case, as yet unreported, in which a woman with profound learning difficulties was found to have capacity to decide not to terminate her pregnancy.
As so often, the case decided nothing new. But it is a timely reminder of the trite but often overlooked principle that capacity is not an all or nothing thing. The question: ‘Does she have capacity?’ is always dangerously incomplete. The correct question is always ‘Does she have capacity to decide X?’
There was no doubt that she did not have capacity to manage many aspects of her affairs. She was in the bottom 1% of the population so far as intellectual function was concerned. Deputies were appropriately appointed. But, so far as the continuation of her pregnancy was concerned, so what?
It was decided as a matter of fact that she had capacity to decide whether or not to continue with, or to terminate, the pregnancy. And that meant that the Court of Protection had no jurisdiction to decide the matter. No best interests determination could lawfully be made. Continue reading
(Cross-posted from the Journal of Medical Ethics blog)
The Liverpool Care Pathway provides a rubric for managing the care terminally ill as they approach death. A helpful pamphlet explaining what it is and what it does is available here. Ideally, I’d quote the lot; but for the sake of efficiency, I’ll make do with an edited quotation:
What is the Liverpool Care Pathway (LCP)?
The LCP is a pathway/ document that outlines this best care, irrespective of your relative/ friend’s diagnosis or whether they are dying at home, in hospital, in a hospice or a care home.
Medication will be reviewed and any medication that is not helpful at this time may be stopped and new medication may be prescribed so that if a symptom should occur there would be no delay in responding.
It may not be possible to give medication by mouth at this time, so medication may be given by injection or sometimes if needed, by a continuous infusion by a small pump called a Syringe Driver, which will be tailored to individual needs.
It may not be appropriate to continue some tests at this time; these may include blood tests or blood pressure and temperature monitoring.
The staff should talk to you about maintaining your relative’s/ friend’s comfort; this should include discussion regarding position in bed, use of a special mattress and regular mouth care. You may want to be involved in elements of care at this time.
Diminished need for food and drink
Initially, as weakness develops, the effort of eating and drinking may simply have become too much and at this time help with feeding might be appreciated.
Your relative/friend will be supported to take food and fluids by mouth for as long as possible.
When someone stops eating and drinking it can be hard to accept, even when we know they are dying. It may be a physical sign that they are not going to get better. Your relative/friend may neither want or need food and/or drink and decisions about the use of artificial fluids (a drip) will be made in the best interests of your relative/friends for this moment in time. This decision will be explained to you and reviewed regularly.
This can be paraphrased further: medically futile treatment may be withdrawn; the main criterion for administering drugs will be symptom alleviation rather than life extension; some testing may be discontinued; it’s possible that there’ll come a point when artificial nutrition and hydration are no longer in the patient’s best interest, and they might be withdrawn if and when that point is reached.
None of this is particularly cheery; but death rarely is. Continue reading
Podcast of Uehiro Seminar given by Gwen Adshead
‘The Bad Seed’ was a popular 1954 novel in which a well brought up young girl begins to manifest behaviour characteristic of a criminal psychopath. As the plot develops, the girl’s mother discovers that her own mother was a serial killer who was executed when she was herself a girl.
In this Uehiro Seminar, Gwen Adshead Forensic Psychotherapist at Bluebird House & Broadmoor Hospital explores this idea of the ‘bad seed’ using research into those who exhibit ‘callous and unemotional’ traits when children. In contrast to the theme of the novel, Dr Adshead points out that the causes of behaviour even for individuals who exhibit violent behaviour consistently both as children and adults are mediated by factors other than genetic predisposition. For example, there is a relationship between childhood physical abuse and neglect and delinquency and violence in later life. Dr Adshead argues that a more constructive approach to addressing violence in society might be to explore causes such as parenting rather than focusing disproportionate attention on the children. The lecture and discussion that follows raise fundamental issues to do with our attitude to genetic and other predictors of subsequent violence in adult life, the question of how resources should be allocated to address such problems, and how blame fits within this research framework.
You can listen to the podcast of the seminar here
Paul Troop and Sabrina Stewart
UPDATE: AUDIO NOW AVAILABLE HERE.
Forthcoming talk: If I could just stop loving you: Anti-love biotechnology and the ethics of a chemical break-up
|Date & Time:||30th Nov 2012 4:00pm-5:30pm|
Abstract: “Love hurts” – as the saying goes – and a certain degree of pain and difficulty in intimate relationships is unavoidable. Sometimes it may even be beneficial, since, as it is often argued, some types (and amounts) of suffering can lead to personal growth, self-discovery, and a range of other essential components of a life well-lived. But other times, love is downright dangerous. Either it can trap a person in a cycle of violence, as in some domestic abuse cases, or it can prevent a person from moving on with her life or forming healthier relationships. There other cases of problematic love as well:
Last week, Steven Farrow was convicted of murdering a grandmother and a vicar. 77 year old Betty Yates was stabbed in the face. He had planned to crucify the vicar but had left behind his hammer an nails, instead covering his dead body in pornographic DVDs, party poppers and condoms. Though Farrow is likely to spend the rest of his life in jail, the family members questioned why he had been free in the first place.