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Clinical Ethics

Forced Physical Exercise as an Intervention for Mental Disorders?

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:

Read More »Forced Physical Exercise as an Intervention for Mental Disorders?

What happens when you die

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.Read More »What happens when you die

Too long in gestating: an overdue inquiry into the Abortion Act

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.Read More »Too long in gestating: an overdue inquiry into the Abortion Act

Abortion and the cognitively impaired mother

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.Read More »Abortion and the cognitively impaired mother

Informed consent deserves a little less respect

The conclusions of a ‘citizens’ jury’, reported recently in the British Medical Journal [1] shed light on some important weaknesses in the doctrine of ‘informed consent’. The doctrine is commonly thought of as canonical. Be careful about questioning its exalted status: you’ll be branded paternalistic at best, and the indictment may well involve unflattering comparisons with Dr. Mengele.

The ‘jury’, composed of 25 women,  commented on how a leaflet on breast cancer screening should be re-drafted. The jury preferred:

– the term ‘overtreatment’ to ‘over-diagnosis’

-to express benefits in the language of lives saved rather than deaths avoided

– to talk about ‘benefits’ and ‘risks’ rather than ‘pros’ and ‘cons’

– to begin the leaflet by an up-beat reference to the numbers of lives saved by screening, followed by the caveat that a small number of women would be over-treated.

What was the priority: reassurance or accuracy? The majority (15), wanted both; 3 thought that reassurance was most important; 7 thought that accuracy was the priority.

How should one list the benefits and harms? Four thought they should be listed together in the same sentence, 8 that they should be listed separately, and 12 for mentioning them first separately and then together.

The point of all this  is that there are innumerable different ways, all of which would be smiled on by Bolam [2], in which entirely accurate information can be conveyed. And yet tiny nuances are seen by the receivers of the information as significant.Read More »Informed consent deserves a little less respect

The Liverpool Care Pathway in the News: Even by the Mail’s Standards, this is Low

(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/ treatment

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. Read More »The Liverpool Care Pathway in the News: Even by the Mail’s Standards, this is Low

The Bad Seed: Facts and Values in the Study of Childhood Antisocial Behaviour

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… Read More »The Bad Seed: Facts and Values in the Study of Childhood Antisocial Behaviour

The ethics of a chemical break-up

 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
Description:

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:

Read More »The ethics of a chemical break-up

Could there be a Third Way for Criminal Psychopaths?

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.

Read More »Could there be a Third Way for Criminal Psychopaths?

Nine to five philosophers

Owen Barfield was lunching in C.S. Lewis’s rooms. Lewis, who was then a philosophy tutor, referred to  philosophy as ‘a subject’. ‘”It wasn’t a subject to Plato”, said Barfield, “It was a way.”’1 It would be dangerous for a modern professional philosopher to say that her philosophy was her ‘way’. I can well imagine the… Read More »Nine to five philosophers