Clinical Ethics

Damages and communitarianism

By Charles Foster

The Lord Chancellor recently announced that the discount rate under the Damages Act 1996 would be decreased from 2.5% to minus 0.75%. This sounds dull. In fact it is financially tectonic, and raises some important ethical questions.

In the law of tort, damages are intended to put a claimant in the position that she would have been in had the tort not occurred. A claimant who, as result of negligence on the part of a defendant, suffers personal injury, will be entitled to, inter alia, damages representing future loss of earnings, the future cost of care and, often, private medical and other treatment.

Where damages are awarded as a lump sum, there is a risk of over-compensating a claimant. Suppose that the claimant is 10 years old at the time of the award, and will live for 70 years, and the future care costs are £1000 a year for life. Should the sum awarded be £1000 x 70 years = £70,000? (70, here, is what lawyers call the ‘multiplier’). It depends on the assumption one makes about what the claimant will do with the lump sum. If she invests it in equities that give her (say) an annual 5% return, £70,000 would over-compensate her.

In the case of Wells v Wells1, the House of Lords decided that, to avoid the risk of under-compensation, claimants should be treated as risk-averse investors. It should be assumed, said the House, that the discount rate should be fixed by reference to the return on index-linked gilts – Government securities. The rate was 2.5% from 2001 until February of this year. The reasons for the change to minus 0.75% are hereContinue reading

How do medical professionals decide on treatment options for children?

Following widespread media coverage about the court case where baby Charlie Gard’s parents were told that his life support would be removed against their wishes, Dominic Wilkinson appeared on BBC’s Newsnight to discuss the factors that doctors take into account when making such difficult decisions.

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Four myths about IVF in older women

Dominic Wilkinson, @Neonatalethics

Reports that a 62-year-old Spanish woman has given birth after IVF treatment have led many to question whether there should be age limits with such treatment. Lina Alvarez, a doctor in north-west Spain, isn’t the oldest person to have had success with IVF. Earlier this year, in India, Daljinder Kaur is said to have given birth at the age of 72, prompting calls from the Indian Medical Council for a ban on fertility treatment in women over the age of 50.

In many countries where there is funding assistance for IVF there is a limit to obtaining treatment over a certain age. In Britain, for example, the bar is set at age 42. But Alvarez received private treatment. So why care about her age? And what business is it of the rest of us whether she has access to IVF?

There are several arguments that typically surface in debates about age and fertility treatment – and they are all deeply flawed. Continue reading

Guest Post: Mind the accountability gap: On the ethics of shared autonomy between humans and intelligent medical devices

Guest Post by Philipp Kellmeyer

Imagine you had epilepsy and, despite taking a daily cocktail of several anti-epileptic drugs, still suffered several seizures per week, some minor, some resulting in bruises and other injuries. The source of your epileptic seizures lies in a brain region that is important for language. Therefore, your neurologist told you, epilepsy surgery – removing brain tissue that has been identified as the source of seizures in continuous monitoring with intracranial electroencephalography (iEEG) – is not viable in your case because it would lead to permanent damage to your language ability.

There is however, says your neurologist, an innovative clinical trial under way that might reduce the frequency and severity of your seizures. In this trial, a new device is implanted in your head that contains an electrode array for recording your brain activity directly from the brain surface and for applying small electric shocks to interrupt an impending seizure.

The electrode array connects wirelessly to a small computer that analyses the information from the electrodes to assess your seizure risk at any given moment in order to decide when to administer an electric shock. The neurologist informs you that trials with similar devices have achieved a reduction in the frequency of severe seizures in 50% of patients so that there would be a good chance that you benefit from taking part in the trial.

Now, imagine you decided to participate in the trial and it turns out that the device comes with two options: In one setting, you get no feedback on your current seizure risk by the device and the decision when to administer an electric shock to prevent an impending seizure is taken solely by the device.

This keeps you completely out of the loop in terms of being able to modify your behaviour according to your seizure risk and – in a sense – relegates some autonomy of decision-making to the intelligent medical device inside your head.

In the other setting, the system comes with a “traffic light” that signals your current risk level for a seizure, with green indicating a low, yellow a medium, and red a high probability of a seizure. In case of an evolving seizure, the device may additionally warn you with an alarm tone. In this scenario, you are kept in the loop and you retain your capacity to modify your behavior accordingly, for example to step from a ladder or stop riding a bike when you are “in the red.”

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Our special treatment of patients in a vegetative state is a form of cruel and unusual punishment

by Professor Dominic Wilkinson, @Neonatalethics

Professor of Medical Ethics, Consultant Neonatologist

 

Our society has good reason to provide special treatment to people with severe brain injuries and their families.

But our current “special treatment” for a group of the most severely affected people with brain injuries leads to devastating, agonising, protracted and totally preventable suffering.

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Invited Guest Post: Healthcare professionals need empathy too!

Written by Angeliki Kerasidou & Ruth Horn, The Ethox Centre, Nuffield Department of Population Health, University of Oxford

 

Recently, a number of media reports and personal testimonies have drawn attention to the intense physical and emotional stress to which doctors and nurses working in the NHS are exposed on a daily basis. Medical professionals are increasingly reporting feelings of exhaustion, depression, and even suicidal thoughts. Long working hours, decreasing numbers of staff, budget cuts and the lack of time to address patients’ needs are mentioned as some of the contributing factors (Campbell, 2015; The Guardian, 2016). Such factors have been linked with loss of empathy towards patients and, in some cases, with gross failures in their care (Francis, 2013). Continue reading

Veterinarians and the best interests of animals

By Charles Foster

English law has traditionally, for most purposes, regarded animals as mere chattels. There is now animal welfare legislation which seeks to prevent or limit animal suffering, but provided that legislation is complied with, and that no other relevant laws (eg those related to public health) are broken, you are free to do what you want with your animal.

Veterinary surgeons are in an interesting position. The UK regulatory body for veterinarians, the Royal College of Veterinary Surgeons (‘RCVS’) publishes a Code of Professional Conduct. This provides, inter alia:

‘1.1  Veterinary surgeons must make animal health and welfare their first consideration when attending to animals.’

‘2.2  Veterinary surgeons must provide independent and impartial advice and inform a client of any conflict of interest.’ 

‘First consideration’ in 1.1 is a rather weasly formulation. Does it mean that it is the overriding consideration, trumping all others, however weighty those others might be? Or the one that veterinarians ought to consider first, before moving on to other criteria which might well prevail? Continue reading

Video Series: Dominic Wilkinson on Conscientious Objection in Healthcare

Associate Professor and Consultant Neonatologist Dominic Wilkinson (Oxford Uehiro Centre for Practical Ethics) argues that medical doctors should not always listen to their own conscience and that often they should do what the patient requests, even when this conflicts with their own values.

Engineering a Consensus:   Edit Embryos for Research, Not Reproduction

Written by Dr Chris Gyngell, Dr Tom Douglas and Professor Julian Savulescu

A crucial international summit on gene editing continues today in Washington DC. Organised by the US National Academy of Sciences, National Academy of Medicine, the Chinese Academy of Sciences, and the U.K.’s Royal Society, the summit promises to be a pivotal point in the history of the gene editing technologies.

Gene editing (GE) is a truly revolutionary technology, potentially allowing the genetic bases of life to be manipulated at will. It has already been used to create malaria-fighting mosquitoes, drought resistant wheat, hornless cows and cancer killing immune cells. All this despite the fact GE only become widely used in the past few years. The potential applications of GE in a decade are difficult to imagine. It may transform the food we eat, the animals we farm, and the way we battle disease. Continue reading

The reproducibility problem and the status of bioethics

There is a long overdue crisis of confidence in the biological and medical sciences. It would be nice – though perhaps rather ambitious – to think that it could transmute into a culture of humility.

A recent comment in Nature observes that: ‘An unpublished 2015 survey by the American Society for Cell Biology found that more than two-thirds of respondents had on at least one occasion been unable to reproduce published results. Biomedical researchers from drug companies have reported that one-quarter or fewer of high-profile papers are reproducible.’

Reproducibility of results is one of the girders underpinning conventional science. The Nature article acknowledges this: it is accompanied by a cartoon showing the crumbling edifice of ‘Robust Science.’

As the unwarranted confidence of scientists teeters and falls, what will – and what should – happen to bioethics?

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