by Dominic Wilkinson @Neonatalethics
Consultant neonatologist, Director of Medical Ethics
Next week, junior doctors in England
and Wales will be taking part in industrial action for 15 hours over two successive days. This is the latest in a series of stoppages since late last year, and relates to a dispute over proposed changes to junior doctors’ contracts and pay. It is the first strike, (and the first in the UK since the establishment of the NHS), to include all medical care, including emergency treatment. Junior doctors will not be at work in accident and emergency departments, intensive care units, operating theatres and hospital wards between 8 and 5 on both of those days.
There are a series of questions raised by these strikes. There are disputed claims about the impact of contract changes on take home pay, on working conditions for doctors and on patient care. There are different views about the actual impact of next week’s strike on patients, on public opinion, or on negotiations about the new contract. But for the purposes of this article, I am going set those specific questions aside, and focus on a more general question. Should doctor strikes (particularly emergency care strikes) be legal, should they be allowed? Continue reading
The World Health Organisation is to hold an emergency meeting after considerable concern about the zika virus in South America. The epidemic has been of considerable concern particularly because it has been linked to microcephaly (unusually small heads) in newborn babies that can lead to potentially devastating brain problems.
There is fear that this virus (if it is the cause) could spread throughout the Americas, including North America. There is no vaccine or treatment for the virus, and no known treatment for children who suffer brain damage in the womb. Officials in Columbia, Ecuador, El Salavador and Jamaica have recommended that women avoid or defer becoming pregnant to prevent their babies being affected. But is it ethical to use birth control to control Zika microcephaly? Continue reading
By Dominic Wilkinson @Neonatal Ethics, Director of medical ethics
Why should we care about what happens to future generations? What reason do we have to sacrifice our own well-being and interests for the sake of people who will exist after we are dead?
Last night Professor Sam Scheffler from NYU gave the first of the 2015 Uehiro lectures on this controversial and challenging topic. http://media.philosophy.ox.ac.uk/uehiro/HT16_UL_Scheffler1.mp3
Medical science continues to push at the boundaries of life and death with new drugs and technologies that can extend life or improve health. But these advances come at a cost. And that inevitably raises difficult questions about whether public health systems should pay for such treatments – and, if so, how much. For example, should the NHS fund the new breast cancer drug Kadycla which comes with a £90,000 price tag per patient?
Some countries make these difficult decisions by looking at the cost-effectiveness of new treatments. How much does the new treatment cost and how effective is it compared with existing treatments? Treatments may help patients live longer, or they may improve a patient’s quality of life (or both). Kadycla appears to extend life by about six months.
One mathematical way of combining these elements uses the concept of a Quality-Adjusted Life Year saved, or QALY. As an example, a treatment that extends life for one year but at a “quality” level of half normal it said to save 0.5 QALY. When treatments are assessed this way, health systems can then use a threshold to work out a maximum cost that is affordable. The National Institute for Health and Care Excellence (NICE) uses a threshold of £20,000-£30,000 for each Quality-Adjusted Life Year saved (QALY). This would mean (assuming full quality of life), that the NHS would be prepared to pay £10,000-15,000 for a course of Kadycla.
by Dominic Wilkinson @Neonatalethics
A critically ill infant in intensive care (let us call him Jonas) has serious congenital abnormalities affecting his liver and brain.1 Doctors looking after Jonas suspect that he may have a major genetic problem. They have recommended testing for Jonas, to help determine whether he does have this problem.
However, Jonas’ parents have refused consent for the genetic test. They are concerned that the test could be used to discriminate against Jonas and against them; they have repeatedly indicated that they will not agree to it being performed.
Could it ever be ethical to perform genetic testing on a child against parental wishes?
By Dominic Wilkinson, @Neonatalethics
Earlier this year, the Lancet published a trial (the ‘ACT’ trial) involving 100,000 babies at risk of being born prematurely in developing countries. Half of the mothers in the ACT trial did not receive a simple cheap medicine that has been previously shown in multiple trials and meta-analysis to reduce the risk of death for premature babies. From the ACT trial results, it appears that 89 additional babies died as a result of their mothers taking part in the trial.
Surely this is an egregious example of unethical research? It appears to be in breach of the World Medical Association Declaration of Helsinki standards. Why did ethics committees allow the research? Why did a major journal like the Lancet publish it? Why aren’t bioethicists and activist and advocacy groups like Public Citizen jumping up and down in outrage?
By Dominic Wilkinson @Neonatalethics
At the bedside of a critically ill infant at 5am this morning I was tempted to tweet the latest meme, adding my voice to a chorus of NHS clinicians over the weekend. Last week, in a speech to the King’s fund, Health Minister Jeremy Hunt launched a drive towards 7 day NHS. In particular, he focused on consultant contracts, proposing that newly qualified hospital doctors will be required to work weekends as a condition of employment.
by Dominic Wilkinson @Neonatalethics
In California, in the last week, there have been further motions in a long running lawsuit relating to a brain-dead child. Oakland teenager Jahi McMath died after a tonsillectomy in December 2013. However, her parents rejected the medical diagnosis of brain death, and despite a Californian court providing judicial backing for doctors’ determination, organized for her to have a tracheostomy and be transferred to another medical facility. More than 18 months later it appears that Jahi’s heart is still beating and she is still connected to a breathing machine somewhere in New Jersey. Continue reading
The Court of Protection is due to review very soon the case of a teenager with a relapsed brain tumour. The young man had been diagnosed with the tumour as a baby, but it has apparently come back and spread so that according to his neurosurgeon he has been “going in and out of a coma”. In February, the court heard from medical specialists that he was expected to die within two weeks, and authorized doctors to withhold chemotherapy, neurosurgery and other invasive treatments, against the wishes of the boy’s parents.
However, three months after that ruling, the teenager is still alive, and so the court has been asked to review its decision. What should we make of this case? Were doctors and the court wrong?
by Dominic Wilkinson @NeonatalEthics
Over the last week, the media has been full of the story of Artur Lubas*. Lubas was the co-pilot of a Germanwings flight, and is thought to have deliberately crashed a plane into a mountainside in a form of murder-suicide, killing 149 others in the process.
There are a range of ethical questions in the Germanwings tragedy. Carissa Veliz, writing on this blog yesterday, pointed to the ethics of disclosure of medical information – either in order to prevent a tragedy, or after a tragedy has occurred. There have been questions about screening of pilots for illness. Others have raised concerns about the unfair media attention on depression in the last week.
Here, I wish to draw attention to a separate question. One suggestion in the last week has been that Lubas’ extreme action was driven in part by a desire for attention. He apparently told a former girlfriend that “I will do something that will change the whole system, and then all will know my name and remember it”.
But this raises an interesting question: the intense media focus on the Germanwings tragedy, and on Lubas in particular, appears to have given him exactly what he wanted. Should we be worried about that, and is there anything we can do about it? Continue reading