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.
“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… Read More »Press Release: New Tavistock Legal Ruling on Puberty Blockers
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.”
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.
Read More »DNACPR Orders in a Pandemic: Misgivings and Misconceptions.
by Prof Dominic Wilkinson @Neonatalethics
Last month, in an emergency hearing, the High court in London heard a case that characterises a familiar problem in medical ethics. A 15 year old adolescent (known as ‘X’) with a long-standing medical condition, Sickle Cell disease, had a very low blood count and required an urgent blood transfusion. However, X is a Jehovah’s Witness and did not wish to receive blood as it was contrary to her religious beliefs. X’s doctors believed that she was at risk of very serious health consequences without a blood transfusion (a stroke, or even death).
Of no great surprise to anyone, the court authorised the emergency blood transfusion for X. Although X was “mature and wise beyond her years”, and judged to be ‘Gillick competent’ (see below), the judge made the decision in her best interests.
That decision is consistent with many previous cases that have come to the courts in the UK and overseas (see here, here, here )[1]. It is very similar to the case in Ian McEwan’s novel and film “The Children Act” (the book, had been based on real cases before the courts). The courts, in the UK at least, have always decided to over-rule under-eighteens who wish to refuse potentially life-saving treatment. Once the teenager reaches the age of eighteen, the decision is different, however. At that point, if they are judged to have “capacity”, (ie they have the ability to use, understand, and communicate the information necessary for a decision) they can refuse even if the treatment would certainly save their life.
Although the decision is unsurprising, the judge made a comment implying that future cases might not always reach the same conclusion. X’s lawyer argued that the traditional legal approach may be “in need of urgent re-analysis and review”, and the judge appeared to agree that these arguments needed careful consideration (not possible acutely given the urgency of X’s case).
Should the ethical and legal approach to adolescents who refuse treatment change?
Read More »Refusal Redux. Revisiting Debate About Adolescent Refusal of Treatment.
Dominic Wilkinson, University of Oxford
Two months ago I received an email from a colleague inviting me to join a global campaign to support a form of vaccine research that would involve deliberately infecting volunteers with COVID-19. This might seem like a strange idea. Some people have raised concerns about this research. Some even think that it would violate the Hippocratic oath for a doctor to expose research participants to harm in this way.
But as a medical doctor, an ethicist and a researcher, I strongly support COVID-19 challenge trials. I replied immediately and have joined over 150 academics on an open letter advocating preparation for these trials. This week, there are reports that the first of these trials will start in London in 2021. Special research facilities are being developed, and several thousand young people in the UK have already volunteered to be part of such a trial.Read More »Coronavirus: Why I Support the World’s First COVID Vaccine Challenge Trial
By Dominic Wilkinson @Neonatalethics and Michael Dunn @ethical_mikey
In a high court case reported last week, a judge strongly criticised a London hospital’s clinical ethics committee (CEC). The case related to disputed treatment for a gravely ill nine-year old child. There had been a breakdown in the relationship between the clinical team and the child’s parents. Prior to going to court, the clinicians had referred the case to the CEC. The committee had heard evidence from the medical professionals involved, and apparently reached consensus that further invasive life prolonging treatments were not in the child’s best interests. However, the committee had not involved the parents in the meeting. The judge found this omission striking and regrettable. She noted
“a lack of involvement by patients and/or their families is itself an issue of medical ethics and I am most surprised that there is not guidance in place to ensure their involvement and/or participation. … the absence of any prior consultation or participation, cannot be good practice and should generally be unacceptable.”
Read More »Must Clinical Ethics Committees Involve Patients or Families in their Meetings?
Dominic Wilkinson, University of Oxford
It is mid-March 2020. James is a 29-year-old junior doctor working in a London hospital. Last week, James cared for a man who had become sick after returning from abroad. The man had been treated in isolation and is now improving. However, James has since become unwell. He developed a cough and fever, but then rapidly became breathless.
James has been admitted to his own hospital with signs of severe acute respiratory distress syndrome. Despite intensive treatment, James’ lungs are full of fluid and his oxygen levels are critically low. His kidneys have shut down, and his blood pressure is unstable.
The medical team caring for James has referred him to the regional extracorporeal membrane oxygenation (ECMO) centre – a potentially life-saving treatment that is used for some patients with severe organ failure.
But the ECMO centre has received several referrals. While James is young and fit, he also has features that suggest he may die even with ECMO, and there are other patients who would have a higher chance of recovery.
Should James receive preferential treatment?Read More »Pandemic Ethics: Should Frontline Doctors and Nurses Get Preferential Treatment?
With all the concern at present about the coronavirus outbreak in China (and the rest of the world), we will host a special series on the blog relating to ethical issues during pandemics. We last ran a series on this topic in 2009 during the Swine flu outbreak. In this blog, I’ll collect together blogs… Read More »Pandemic Ethics – Resources 2020
Dominic Wilkinson, University of Oxford
When new guidance relating to the outcome and medical care of babies born extremely prematurely was recently released, it led some to call for UK abortion law to be revised.
This was because one of the new recommendations from the British Association of Perinatal Medicine is that it is sometimes appropriate to provide resuscitation and active medical treatment for babies born at 22 weeks gestation (four and a half months before their due date). This is a week earlier than was recommended in the last version of the framework, published in 2008.
The argument goes that the new guidance creates a “contradiction in British law” because extremely premature infants can now be resuscitated before the point in pregnancy where abortion law changes.
A spokesperson for campaign group Right to Life UK said: “In one room of a hospital, doctors could be working to save a baby born alive before 24 weeks whilst in another room a doctor could perform an abortion which would end the life of a baby at the same age. Surely this contradiction needs to end?”Read More »Lifesaving Treatment for Babies Born at 22 weeks Doesn’t Mean Abortion Law Should Change.
