Caesarean Sections, Autonomy and Consent
In the past week in the UK, an Italian woman has claimed that a health trust had carried out a Caesarean section on her against her will. Whilst details of the case are still emerging, it appears that the woman had been detained under the Mental Health Act whilst pregnant after suffering a panic attack (which, it is reported, was possibly a result of a failure to take medication for a pre-existing mental health condition). Having been hospitalized for a number of weeks, the woman was given a Caesarean section whilst under sedation without consent. It appears that a health trust had been granted permission to carry out the procedure from the Court of Protection. Further to this, Essex social services also decreed that the mother was unfit to raise the child, and took the child into its care. Continue reading
Keeping pace?
If you receive an implanted pacemaker for your heart, does it become your property? When it is no longer any use to you (because you have died), do you have to give it back?
The new offence of ‘wilful neglect’ – what’s new?
It was announced last week that a new offence of ‘wilful neglect or mistreatment’ is to be created for NHS hospital staff whose conduct amounts to the deliberate or reckless mistreatment of patients. This offence will be modeled on an existing offence under the Mental Capacity Act which punishes the wilful neglect or ill-treatment of patients lacking capacity. Currently, a medical worker convicted of this offence faces a maximum sentence of five years imprisonment, or an unlimited fine. The sanctions for the proposed new offence are likely to be of a similar severity.
The creation of the offence comes in the wake of the inquiry into the widespread negligence that occurred at Mid Staffordshire hospital. Intended principally to deter healthcare workers from mistreating patients, the new offence has been proposed following review of patient safety. The leader of the review, Professor Don Berwick, emphasized that patient safety must become the top priority and that the measure was needed to target the worst cases of a ‘couldn’t care less’ attitude that led to ‘wilful or reckless neglect or mistreatment’.
Concerns about its impact
Whilst most would agree that patient safety should clearly be a priority, there has been concern that the new criminal sanction could create a ‘climate of fear’ amongst healthcare workers and that individual workers will be penalised for mistakes that are the result of inadequate staffing or simple human error, rather than blameworthy acts of malice. Continue reading
Financial Incentives, Coercion and Psychosis
In a recent editorial in the British Medical Journal, Tim Kendall draws attention to a recent study that suggests that modest financial incentives can significantly improve adherence in people treated with depot drugs for schizophrenia and other psychoses in the UK. This study looks set to reignite the debate regarding the moral permissibility of offering financial incentives as a part of medical care. Whilst those who support this practice point out that we already offer non-financial rewards to many patients, others have criticised the practice as, among other things, amounting to coercion. In this post, I shall contest this particular objection to the practice of offering financial incentives to patients as part of medical care. Continue reading
Abortion ‘on grounds of gender’: Like it or not, the DPP was right
There has been a recent storm over the DPP’s decision not to prosecute two doctors in relation to their referral of two women for abortion. The cases were widely represented as cases of abortion on grounds of gender. They came to light in the course of an undercover investigation by the Daily Telegraph of practice in English abortion clinics ( see also here and here).
The DPP has published detailed reasons for his decision. They are well worth reading.
An abortion is only lawful if two medical practitioners are of the opinion, held in good faith, that one of the lawful grounds for abortion is made out. One of the grounds (overwhelmingly the commonest, and the one said to be relevant in both of the cases considered by the DPP), is that ‘the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.’: Abortion Act 1967, s. 1(1)(a).
The Act does not say anywhere that the gender of the fetus is a relevant criterion. But it plainly could be. Take two examples: Continue reading
Announcement: “Brave New Love” in AJOB:Neuroscience – peer commentaries due October 7
Announcement: “Brave New Love” – peer commentaries due October 7
Dear Practical Ethics readers,
The paper, “Brave new love: the threat of high-tech ‘conversion’ therapy and the bio-oppression of sexual minorities” by Brian D. Earp, Anders Sandberg, and Julian Savulescu has been accepted for publication in the American Journal of Bioethics: Neuroscience. Proposals for open peer commentaries are due this Monday October 7th.
The article may be accessed here, or at the following link: http://editorial.bioethics.net. Be sure to select AJOB:Neuroscience from the drop-down menu of journals. Here is an abstract of the argument:
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Abstract: Our understanding of the neurochemical bases of human love and attachment, as well as of the genetic, epigenetic, hormonal, and experiential factors that conspire to shape an individual’s sexual orientation, is increasing exponentially. This research raises the vexing possibility that we may one day be equipped to modify such variables directly, allowing for the creation of “high-tech” conversion therapies or other suspect interventions. In this paper, we discuss the ethics surrounding such a possibility, and call for the development of legal and procedural safeguards for protecting vulnerable children from the application of such technology. We also consider the more difficult case of voluntary, adult “conversion” and argue that in rare cases, such attempts might be permissible under strict conditions.
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Open Peer Commentary articles are typically between 500-1500 words and contain no more than 10 references. A guide to writing an Open Peer Commentary is available under the Resources section “Instructions and Forms” at http://editorial.bioethics.net. AJOB:Neuroscience asks that by Monday, October 7, 2013 you submit a short summary of your proposed Open Peer Commentary (no more than 1-2 paragraphs). Please submit your proposal online via the AJOB:Neuroscience Editorial site, following the instructions provided there. They ask that you do not prepare a full commentary yet. Once they have evaluated your proposal, they will contact you via email to let you know whether or not they were able to include you on the final list of those to be asked to submit an Open Peer Commentary.
You will then have until Friday, October 25, 2013 to submit your full Open Peer Commentary.
A not-so-great escape: suicide in prison
Christian Brown is a newly qualified junior doctor with an interest in psychiatry and ethics.
Early last month, Ariel Castro, convicted kidnapper, rapist, and murderer, used a bed sheet and a window-ledge to commit suicide in his prison cell. He was just four weeks into a life sentence. Recently on this blog, Rebecca Roache wrote a post about the possibility of enhancing prison sentences – today, I’d like to consider the right-to-die of inmates, and the role of medical professionals in their suicidal behaviour.
Inside the walls of our high security prisons, small numbers of prisoners face life-long sentences, deprived of all but the minimum of human contact, and confined for most of the day to their cells. Some people argue that it can be rational to commit suicide – for the purposes of this post, I’ll refer to suicidal acts which are voluntary, informed, and the individual shown to have mental capacity, as ‘rational suicide’. If one accepts this, it is hard to imagine a more subjectively powerful circumstance in which to kill oneself than at the outset of a life sentence. Indeed, suicide rates among prisoners are around six times higher than those of the general male population. Of course, a proportion of these cases will not meet the criteria for ‘rational suicide’, but let’s consider those that do. Continue reading
Is compassion a necessary component of healthcare?
Last week, the Daily Mail reported on Dr Anna Smajdor’s paper in which she argues that compassion ‘is not a necessary component’ of healthcare. This claim contrasts interestingly with Jeremy Hunt’s recent proposal that all student nurses should have to prove that they are capable of caring by spending a year on wards carrying out basic tasks. This proposal, along with the suggestion that pay be linked to levels of kindness would, according to Hunt, go some way to improving the standard of NHS care. The motivating idea behind Hunt’s proposals is that lack of compassion amongst NHS staff is partly responsible for poor care and, in some cases, for cultivating a ‘culture of cruelty’.
So is compassion a necessary component of healthcare? Is an adequate standard of care necessarily unattainable when compassion amongst staff is absent? In considering these questions I do not intend to embark on a detailed critique of Dr Smajdor’s paper. Instead, I will begin from her main ideas and use them to motivate a general discussion of the role of compassion in healthcare. According to the report, Dr Smajdor argues for two main claims: 1) that compassion is not a necessary component of healthcare – that acceptable standards can be attained without it – and 2) that compassion can actually be dangerous for healthcare workers, possibly resulting in impaired standards of care. Continue reading
Let’s Talk About Death: Millennials and Advance Directives
Sarah Riad, College of Nursing and Health Sciences, University of Massachusetts Boston
Melissa Hickey, School of Nursing, Avila University
Kyle Edwards, Uehiro Centre for Practical Ethics, University of Oxford
As advances in medical technology have greatly increased our ability to extend life, the conversation on end-of-life care ethics has become exceedingly complex. With greater options both to end life early and extend it artificially, advance directives have arisen in an effort to preserve patient autonomy in situations in which he or she becomes incapable of making a medical decision. However, most people—especially young adults—do not think to plan for such moments of incapacity and the potentiality of an untimely death. With a youthful sense of invincibility comes a lack of foresight that prevents us from confronting these issues. The reality is that unexpected events happen. When they do, it is often very difficult to imagine what a person would have wanted and make medical decisions accordingly on his or her behalf. In this post, we suggest both a transition from action-based to value-based advance directives and an interactive website that would make the contemplation of these issues and the construction of a value-based advance directive appealing to and accessible for Millennials, the 20-somethings of today. Continue reading
Safety First? How the Current Drug Approval System Lets Some Patients Down
Andrew Culliford, whose story is featured in the Daily Mail, is one of the estimated 7 in 100,000 people living with Motor Neuron disease, a progressive degenerative disease which attacks muscles, leaving those affected eventually unable even to breathe unassisted. For Andrew, a young father who has a severe form of the disease, it means a two to five year life expectancy.
Like Les Halpin and Jenn McNary, the mother of twins afflicted with a similar rare disease, he has a simple request: earlier access to medicines that might help improve or extend his life.
The US introduced a mandatory pre-approval process for pharmaceutical drugs after over 100 people were killed by an untested drug formulation . Today, each drug must go through a series of strictly controlled trials, including Phase 1 tests on healthy volunteers, followed by Phases 2 and 3 which test the drug and dosages on smaller and then larger patient groups. The process is estimated to cost $500 million per drug and to take 8 – 12 years.
The process is designed to ensure the efficacy of drugs has been scientifically demonstrated to a very degree of confidence, and to ensure that patient safety is sufficiently protected. In many ways it has been a triumph of science and regulation.
But it has been a failure for one small group of patients: those with rare, imminently lethal diseases, for whom there are no existing good treatments. Those who will die in less than 8 years. It is these patients who are asking to have access to untested medicines, and to avoid placebo controlled trials, where half the participants are given no drug at all. Les has proposed innovative methods of patient recording data. I have discussed this proposal previously on this blog , and in a joint paper with Les Halpin and clinicians.
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