Dominic Wilkinson’s Posts

COVID: Media Must Rise Above Pitting Scientists Against Each other – Dealing With the Pandemic Requires Nuance

Krakenimages/Shutterstock

Trish Greenhalgh, University of Oxford and Dominic Wilkinson, University of Oxford

At the start of the pandemic, there was a striking sense of shared resolve and solidarity. Facing a public health crisis greater than any in living memory, people were largely united in their support of difficult measures to protect the vulnerable, safeguard the health system and sustain key workers.

There were, of course, differences of opinion. For example, some disagreed about the severity of the threat posed by COVID, about the wisdom of different national approaches to lockdown, about the timing of restrictions, and the effectiveness face masks.

More recently, there has also been disagreement on how vaccines should be distributed, whether vaccine passports are a good idea, and whether vaccination should be mandatory for certain occupations)

Throughout the pandemic, scientists attempting to explain their findings have had to deal with unprecedented levels of dissent, anger and abuse from the lay public and occasionally from other scientists.

Since the government lifted COVID restrictions on July 19, views on how best to handle the pandemic have become more polarised than ever, broadly splitting into two camps: the “open up” camp and the “not yet” camp. Continue reading

COVID: Why We Should Stop Testing in Schools

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Education Secretary Gavin Williamson has announced the end of school “bubbles” in England from July 19, following the news that 375,000 children did not attend school for COVID-related reasons in June.

Under the current system, if a schoolchild becomes infected with the coronavirus, pupils who have been in close contact with them have to self-isolate for ten days. In some cases, whole year groups may have to self-isolate.

Such mass self-isolation is hugely disruptive. Yet despite the clamour to switch to other protective measures, such as rapid testing of pupils who have been in close contact with an infected pupil, the public service union Unison has supported self-isolation as “one of the proven ways to keep cases under control”. Continue reading

Urgency, Delayed Decision-making and Ethics in the Court of Protection

By Dominic Wilkinson, 24th June 2021

cross post from the Open Justice Court of Protection Project

On 11th June 2021,  I was a public observer (via MS Teams) of a case in the Court of Protection: Case No. 1375980T Re GU (also blogged about by Jenny Kitzinger here).

The case was (though I did not know it beforehand) related closely to issues that I have written about over a number of years (for example hereherehere ). It was an urgent hearing before Mr Justice Hayden concerning clinically-assisted nutrition and hydration (CANH) for a 70 year old man, GU, who has been in a prolonged disorder of consciousness for seven years.

I have read the judgments from many similar cases in the UK, from the first ever case concerning a feeding tube for a vegetative patient heard in (what is now) the Supreme Court in 1992 (the case of  Tony Bland, injured in the Hillsborough football stadium disaster), through to the most recent Supreme Court case of Re. Y, at which the court ruled that it is not mandatory to bring cases concerning CANH-withdrawal to court unless there is disagreement about best interests, or the decision is finely balanced (report here). I’m also familiar with the judgments in other jurisdictions (e.g. Schiavo in the USA,  Lambert in France) and have been involved in deliberation in clinical ethics committees about cases with similar features.

Yet, this was my first time hearing open deliberations in the Court of Protection. It was a fascinating and thought-provoking experience. Continue reading

Mandatory Vaccination for Care Workers: Pro and Con

By Dominic Wilkinson and Julian Savulescu
An edited version of this was published in The  Conversation 

The UK government is set to announce that COVID-19 vaccination will become mandatory for staff in older adult care homes. Staff will be given 16 weeks to undergo vaccination; if they do not, they will face redeployment from frontline services or the loss of their job. The government may also extend the scheme to other healthcare workers.

It is crucial to achieve a high vaccine uptake amongst older adult care home staff due to the high mortality risk faced by residents. ONS Data suggest that there has been a 19.5% increase in excess deaths in care homes since the beginning of the pandemic, with COVID-19 accounting for 24.3% of all care home resident deaths.

According to SAGE, 80% of staff working in care homes with older adult residents (and 90% of the residents themselves) need to be vaccinated in order to confer a minimum level of protection to this vulnerable population. In mid-April, only 53% of older adult care homes in England were meeting these thresholds, whilst, as of the 10th June, 17% of adult care home workers in England have not had a single dose of the COVID-19 vaccine.

Mandating vaccination would increase vaccine uptake in care home workers, but would be a significant intrusion into individual freedom. Is it ethically justifiable?

Continue reading

Care home staff vaccination – press release

Two (contrasting) perspectives on the news this morning about planned mandatory vaccination of care home workers.

Professor Julian Savulescu

“The proposal to make vaccination mandatory for care home workers is muddle-headed. Vaccination should be mandatory for the residents, not the workers. It is the residents who stand to gain most from being vaccinated.  Young care workers have little to gain personally from vaccination and there are now lethal risks, as well as uncertain long term consequences of novel vaccines. They have already risked their own lives during the pandemic. Some will be immune from past infection. Those remaining should be offered incentives, including financial incentives, to be vaccinated, not coerced. Vaccines like hepatitis and influenza may be mandatory, but they have been around for years and have established safety profiles.

“It’s too soon to be talking about mandates. We’re still researching rare but potentially serious side-effects that have been thrown up by national monitoring, for example a possible link between Pfizer and myocarditis. We don’t have the full picture on how well they prevent transmission. Public Health England data about how transmission is only available for the first dose and it is currently at up to 50%. Meanwhile the level of protection afforded to vaccinated individuals themselves is holding up very well in terms of hospitalisation and death even against the new variants. With the level of confidence we have encouragement to vaccinate is warranted, and incentives are warranted. Mandates should only be made on the basis of bulletproof safety and efficacy data, including transmission data.”

Prof Dominic Wilkinson & Dr Jonathan Pugh

“In the earlier phase of the pandemic, some of the most medically vulnerable members of our community, patients in care homes and acutely ill patients in hospitals, ended up catching coronavirus from those caring for them. Some patients and care home residents died from infections that they caught from their caregivers.”

“That is a tragic and distressing situation that we must do everything possible to avoid repeating.

First, we should ensure that all those who are high risk have access to vaccination. There are still approximately 10% of older adult care home residents who have not had a 2nd dose of the vaccine.

Second, those who work in the frontline with vulnerable high risk patients have an ethical obligation to take all reasonable measures to prevent spread of the vaccine to those they are caring for. They must follow guidance about the use of measures like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.

In England, as of 10th June, 17% of adult care home workers have not had the COVID-19 vaccine.

There is a strong ethical case that care home workers (and NHS staff) who have not had the COVID vaccine should be redeployed to areas other than frontline care.
It would be ethical to make COVID vaccination (in the absence of a medical exemption) a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.

If vaccines are made mandatory for health care and care home workers, they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.”

Pfizer Jab Approved for Children, but First Other People need to be Vaccinated

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Moderna and Pfizer have released data suggesting that their vaccines are well tolerated in adolescents and highly effective in preventing COVID-19. Canada, the US and the EU have already authorised the Pfizer vaccine in children as young as 12. And the UK has just approved the use of the Pfizer vaccine in children aged 12 to 15. But there may a case for holding out on an immediate rollout, for several reasons.

Whether a vaccine is beneficial for someone depends on three things: how likely they are to become seriously ill from the infection, how effective the vaccine is, and the risks of vaccination. Continue reading

Phobias, Paternalism and the Prevention of Home Birth

By Dominic Wilkinson,

Cross post from the Open Justice Court of Protection blog

In a case in the Court of Protection last week, a judge authorised the use of force, if necessary, to ensure that a young woman gives birth in hospital rather than at home.

The woman (call her ‘P’) has severe agoraphobia, and has barely left her home in four years. Her doctors believe that it would be best for her to deliver her baby in hospital. But P has an overwhelming fear of leaving her home and cannot agree to this. Their particular concern is that P might develop a serious complication during her home birth, need emergency transport to hospital, but be unwilling or unable to agree to this because of the severity of her phobia.

At the conclusion of a three-day hearing, Mr Justice Holman declared that P lacked capacity to make the relevant decisions and ordered that it was lawful and in her best interests for medical staff to transfer her to hospital a few days before her estimated due date, and for medical professionals to offer her a choice of induction of labour or Caesarean Section in hospital.  He also gave permission for the use of restraint, if necessary, in the event that she refuses to go to hospital voluntarily.

On the face of it, this looks like an extremely concerning infringement of a patient’s autonomy – a view that has been expressed by members of the public responding to media reports (e.g. see the blog post here).   We normally think that adults should be free to make decisions about their medical care, including the freedom to refuse treatments that doctors are recommending. Decisions about place of birth and mode of birth are deeply personal decisions that can be hugely important for many women. For that reason, doctors and courts should be extremely loathe to infringe upon them.

Is it justified in this case, then, to physically restrain P and treat her against her wishes? In particular, is it justified to do this pre-emptively, before a complication develops? Continue reading

Cross Post: End-of-Life Care: People Should Have the Option of General Anaesthesia as They Die

Written by Dominic Wilkinson and Julian Savulescu

Dying patients who are in pain are usually given an analgesic, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they can be given a sedative – something to make them more relaxed and less distressed at the end of life. We have recently written about a third approach: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.

There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep. Continue reading

General Anaesthesia in End of Life Care – GAEL.

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.

 

Continue reading

Press Release: Medical and ethical experts say ‘make general anaesthesia more widely available for dying patients’

General anaesthesia is widely used for surgery and diagnostic interventions, to ensure the patient is completely unconscious during these procedures. However, in a paper published in Anaesthesia (a journal of the Association of Anaesthetists) ethics and anaesthesia experts from the University of Oxford say that general anaesthesia should be more widely available for patients at the end of their lives.

Painkilling medications (analgesia) are commonly given to dying patients. But they may not be enough, leading to the use of continuous deep sedation (also known as “palliative” or “terminal” sedation).

“However, for some patients these common interventions are not enough. Other patients may express a clear desire to be completely unconscious as they die,” explains co-author Professor Julian Savulescu, Uehiro Chair of Practical Ethics, University of Oxford, UK. “Some dying patients just want to sleep. Patients have a right to be unconscious if they are dying. We have the medical means to provide this and we should.”

The authors make clear that their proposal is not about assisted dying, currently illegal in the UK. Instead, their focus is on options available to ensure that patients are comfortable at the end of their lives.

Put simply, some patients will want to be certain they are unconscious and unaware as their final moments arrive.

“The desire to be unconscious as a means of eliminating the experience of physical or mental suffering is understandable,” says co-author Jaideep Pandit, Professor of Anaesthesia at Oxford University Hospitals NHS Foundation Trust, UK. “Unconsciousness through general anaesthesia offers the highest chance of making sure that the patient is unaware of going through an adverse process.”

He adds that “although general anaesthesia in end-of-life care has been used and described in the UK since 1995, modern multidisciplinary guidelines will be needed before this can be offered more widely. Raising this issue now is important, especially in view of international trends showing increased use of general anaesthesia for dying patients.”

Informed consent will, say the authors, be crucial in helping patients understand implications of general anaesthesia for end-of-life care, and the other options they have to manage their final days.

“It is vital that patients are informed of all the legal options available to them to relieve suffering at the end of life. That includes analgesia, sedation and, potentially now, anaesthesia,” says co-author Professor Dominic Wilkinson, Director of Medical Ethics, Uehiro Centre for Practical Ethics at the University of Oxford, UK. “The risks and benefits of each should be explained. Patients should be free to choose the option, or combination of options, that best meet their values.”

In a separate survey of the general public, published recently in the journal PLOS One, Professors Wilkinson and Savulescu found a high level of support for access to deep sedation in dying patients. Some 88% of those surveyed said they would like the option of a general anaesthetic if they were dying. About two thirds (64%) said they would personally choose to have an anaesthetic at the end of life.

Professor Wilkinson adds “members of the general public appear to value the option of deep sleep and complete relief from pain if they were dying. Our previous research indicates that the public believes that patients should be given this choice.”

The authors counter any concerns that the use of general anaesthesia for end-of-life care could hasten death. Studies show no statistically significant difference in mean survival time between patients at the end of life who receive continuous deep sedation and those who do not. In several countries, propofol infusion as used for general anaesthesia has been continued for up to 14 days. “This stresses the point that the purpose of administering anaesthesia is not to hasten death but simply to achieve unconsciousness.” explains co- author Antony Takla, Research Associate at the Uehiro Centre for Practical Ethics, University of Oxford.

The authors believe the UK medical community should prepare for increased requests for general anaesthesia for end-of-life care, based on current trends in Western Europe and Scandinavia.

They conclude: “we have described a potential role for general anaesthesia in end-of-life care. This has, in reality, been available to UK patients since the 1990s, but is not commonly discussed or provided. There is a strong ethical case for making this option more widely available. This does not imply that existing palliative care practice is deficient. Indeed, we might see that general anaesthesia in end-of-life care is requested by, or suitable for, very few patients.”

“However, the number of patients involved should not alone determine whether this issue is regarded as ethically important. Even if complete unconsciousness is desired by only a few patients, there is a moral imperative for national anaesthesia, palliative care and nursing organisations to prepare for the possibility that general anaesthesia in end-of-life care may be requested by some patients, and to work collaboratively to develop clear protocols to address all of the practical, ethical and medicolegal issues concerned.”

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