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Critical Care

The Continuing Tragedies of Home Birth and the Rights of the Future Child

By Lach De Crespigny and Julian Savulescu

Windsor Coroner’s Court has heard that a mother died within hours of giving birth at home after a private midwife committed a horrifying catalogue of errors . According to reports, the woman had previously delivered twins by emergency caesarean section, one of which later died. Her husband said his wife was ‘brainwashed’ into having a home birth by the midwife, who insisted it was safe. The Royal College of Obstetricians and Gynaecologists advise delivery in hospital after caesarean section so that an emergency caesarean delivery can be carried out if necessary. The midwife denied trying to persuade the couple to have a home birth. However she has greater responsibilities than this; as professionals we should try to persuade women to deliver in hospital if this is a safer option. But the midwife seems to have prioritized homebirth over life itself when she reportedly stated:

“Claire had a great pregnancy, she had a really lovely spontaneous birth at home and I hope Simon in time will remember that”

Read More »The Continuing Tragedies of Home Birth and the Rights of the Future Child

The AAP report on circumcision: Bad science + bad ethics = bad medicine

By Brian D. Earp See Brian’s most recent previous post by clicking here. See all of Brian’s previous posts by clicking here. Follow Brian on Twitter by clicking here.   UPDATED as of 27 May, 2013. See the bottom of the post. The AAP report on circumcision: Bad science + bad ethics = bad medicine For… Read More »The AAP report on circumcision: Bad science + bad ethics = bad medicine

Obligatory Ventilation: why Elective Ventilation should not be elective

On the BBC’s Moral Maze this evening, the question of elective ventilation was discussed at some length. (For those who missed it, the program is still available here). There were several striking features of that discussion, but one argument that stood out was the argument against elective ventilation based on the importance of respecting the autonomy of patients, and the absence of consent, This has been the basis of previous ethical concerns about Elective Ventilation.

But actually, it seems to me that the consent/autonomy argument is completely upside down.* Patient autonomy provides one of the strongest arguments in favour of elective ventilation. So strong, in fact, that the proposed form of Elective Ventilation should arguably not be ‘elective’. It is morally obligatory that we embrace Elective Ventilation.Read More »Obligatory Ventilation: why Elective Ventilation should not be elective

Back from the grave: Should we allow Elective Ventilation?

Mary is 62 years old. She is brought to hospital after she collapsed suddenly at home. Her neighbour found her unconscious, and called the ambulance. When they arrived she was deeply unconscious and at risk of choking on her own secretions. They put a breathing tube in her airway, and transported her urgently to hospital.

When Mary arrives she is found to have suffered a massive stroke. A brain scan shows very severe bleeding inside her brain. In fact the picture on the scan and her clinical state is described by the x-ray specialist as ‘devastating’. She is not clinically brain dead, but there is no hope. The emergency department doctors have contacted the neurosurgical team, but they have decided not to proceed with surgery as her chance of recovery is so poor.

In Mary’s situation, the usual course of events is to contact family members urgently, to explain to them that there is nothing more that can be done, and to remove her breathing tube in the emergency department. She would be likely to die within minutes or hours. She would not be admitted to the intensive care unit – if called, the ICU team would be likely to say that she is not a “candidate” for intensive care. However, new guidance from the National Institute of Clinical Effectiveness, released late last year, and endorsed in a new British Medical Association working paper, has proposed a radical change to this usual course of events.Read More »Back from the grave: Should we allow Elective Ventilation?

Nothing to lose? Killing is disabling

In a provocative article forthcoming in the Journal of Medical Ethics (one of a new series of feature articles in the journal) philosophers Walter Sinnott Armstrong and Franklin Miller ask ‘what makes killing wrong?’ Their simple and intuitively appealing answer is that killing is wrong because it strips an individual of all of their abilities – acting, moving, communicating, thinking and feeling.

So what, you might ask? If this is right, say Sinnott-Armstrong and Miller, it means that it would be just as bad to commit an act that caused someone to be in a permanent vegetative state, as it would to kill them.Read More »Nothing to lose? Killing is disabling

The patient vanishes

by Dominic Wilkinson

If a patient’s family refuse to allow withdrawal of breathing machines should doctors provide long-term support in an intensive care unit for a patient who is clinically brain dead? Should doctors provide heart-lung bypass (ECMO) for a child with anencephaly? Should doctors perform a tracheostomy and provide a long-term breathing machine for a patient in a documented persistent vegetative state?Read More »The patient vanishes

Ethical Lessons From Locked-In Syndrome: What Is a Living Hell?

A recent important study by Stephen Laureys and colleagueson what it is like to be to experience severe brain damage has been widely reported. (eg, http://abcnews.go.com/Health/Wellness/locked-patients-life/story?id=12984627). Laureys and colleagues surveyed the views of people with “locked-in” syndrome. This syndrome, which typically occurs after certain kinds of stroke, results in the person unable to move his arms or legs and unable to speak. In some cases, they can move their eyes and communicate through eye movements but in other cases, the eyes are paralysed. They are awake and aware.

Many people would think this is a living hell, imprisoned in one’s own body, with limited if any means of communication. But Laureys et al found differently when they actually asked patients who were in this condition. According to the ABC,

“More than half of patients coping with a form of nearly complete paralysis called locked-in syndrome indicated — through eye blinks in some cases — that they were getting some satisfaction in life, though 8 percent had often thought of suicide.

“Among 65 patients who had developed the syndrome a median of eight years previously, only 18 characterized their lives as “somewhat on the bad side” or worse… Seventeen patients indicated that they felt as well, or almost as well, as in their happiest times before becoming locked-in. Another 21 gave their overall quality of life lesser but still positive marks.”

So what can we learn from this study?Read More »Ethical Lessons From Locked-In Syndrome: What Is a Living Hell?

Is it ethical to force-feed prisoners on a hunger strike?

by Alexandre Erler

The question, which generated debate a few years ago in the context of the US detention camp at Guantanamo Bay, is now arising again in Switzerland, where imprisoned cannabis farmer Bernard Rappaz has been on hunger strike for about three months now, in protest against a prison sentence he considers excessive. Rappaz was sentenced to five years and eight months behind bars for trading in cannabis and various other offenses. The Federal Court, Switzerland’s highest instance, has ruled that Rappaz should be force-fed if necessary, but doctors in charge of him have refused to obey those orders. A criminal law Professor has argued that according to the Swiss Penal Code, these doctors should be prosecuted, as their refusal amounts to civil disobedience. How should we regard such a legal implication? Is it ethically acceptable, perhaps even required, to force feed someone like Bernard Rappaz?

Read More »Is it ethical to force-feed prisoners on a hunger strike?

Is professional integrity a futile argument?

by Dominic Wilkinson

In an earlier post this week I argued that there are only two substantive reasons for doctors not to provide treatment that they judge futile – either on the basis of a judgement that treatment would harm the patient (a form of paternalism), or on the basis that providing treatment would harm others (on the basis of distributive justice). I rejected the idea that professional integrity provided an additional reason to withhold or withdraw treatment.

Read More »Is professional integrity a futile argument?

Break my bones, but don’t let me die! Should doctors provide ‘futile’ CPR?

by Dominic Wilkinson

Two recent cases in a Toronto hospital illustrate a dilemma that hospital doctors face all too frequently. What should they do if patients or their representatives insist on treatment that the doctor believes would be futile? Should they just go along with the patient despite their misgivings? Alternatively, should they unilaterally withhold treatment if they feel it would be inappropriate to provide it?

Read More »Break my bones, but don’t let me die! Should doctors provide ‘futile’ CPR?