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End of life decisions

DNACPR Orders in a Pandemic: Misgivings and Misconceptions.

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.

 

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We’re All Vitalists Now

By Charles Foster

It has been a terrible few months for moral philosophers – and for utilitarians in particular. Their relevance to public discourse has never been greater, but never have their analyses been so humiliatingly sidelined by policy makers across the world. The world’s governments are all, it seems, ruled by a rather crude vitalism. Livelihoods and freedoms give way easily to a statistically small risk of individual death.

That might or might not be the morally right result. I’m not considering here the appropriateness of any government measures, and simply note that whatever one says about the UK Government’s response, it has been supremely successful in generating fear. Presumably that was its intention. The fear in the eyes above the masks is mainly an atavistic terror of personal extinction – a fear unmitigated by rational risk assessment. There is also a genuine fear for others (and the crisis has shown humans at their most splendidly altruistic and communitarian as well). But we really don’t have much ballast.

The fear is likely to endure long after the virus itself has receded. Even if we eventually pluck up the courage to hug our friends or go to the theatre, the fear has shown us what we’re really like, and the unflattering picture will be hard to forget.

I wonder what this new view of ourselves will mean for some of the big debates in ethics and law? The obvious examples are euthanasia and assisted suicide.Read More »We’re All Vitalists Now

Diet, Changing Desires, and Dementia

Written by Ben Davies

Last week saw the launch of a campaign (run by the group Vegetarian For Life) that seeks to ensure that older people in care who have ethical commitments to a particular diet are not given food that violates those commitments. This is, as the campaign makes clear, a particularly pressing issue for those who have some form of dementia who may not be capable of expressing their commitment.

Those behind the campaign are quite right to note that people’s ethical beliefs should not be ignored simply because they are in care, or have a cognitive impairment (see a Twitter thread where I discuss this with a backer of the campaign). But the idea that one’s dietary ethics must be ‘for life’ got me thinking about a more well-established debate about Advance Directives. (I should stress that what I say here should not be taken to be imputing any particular motivation or philosophical commitments to those behind the campaign itself.)

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Abolish Medical Ethics

Written by Charles Foster

In a recent blog post on this site Dom Wilkinson, writing about the case of Vincent Lambert, said this:

If, as is claimed by Vincent’s wife, Vincent would not have wished to remain alive, then the wishes of his parents, of other doctors or of the Pope, are irrelevant. My views or your views on the matter, likewise, are of no consequence. Only Vincent’s wishes matter. And so life support must stop.’

The post was (as everything Dom writes is), completely coherent and beautifully expressed. I say nothing here about my agreement or otherwise with his view – which is comfortably in accord with the zeitgeist, at least in the academy. My purpose is only to point out that if he is right, there is no conceivable justification for a department of medical ethics. Dom is arguing himself out of a job.Read More »Abolish Medical Ethics

Guest Post: How Should We Evaluate Deaths?

Written by: Carl Tollef Solberg, Senior Research Fellow, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen.
Espen Gamlund, Professor of Philosophy, Department of Philosophy, University of Bergen.

In 2015, there were 56.4 million deaths worldwide (WHO 2017).[i] Most people would say that the majority of these deaths were bad. If this is the case, why is it so, and are these deaths equally bad?

Death is something we mourn or fear as the worst thing that could happen—whether the deaths of close ones, the deaths of strangers in reported accidents or tragedies, or our own. And yet, being dead is not something we will ever live to experience. This simple truth raises a host of challenging philosophical questions about the negativity surrounding our sense of death, and how and for whom exactly it is harmful. The question of whether death is bad has occupied philosophers for centuries, and the debate emerging in the philosophical literature is referred to as the “badness of death.” Are deaths primarily negative for the survivors, or does death also affect the decedent? What are the differences between death in fetal life, just after birth, or in adolescence? When is the worst time to die? These philosophical questions, although of considerable theoretical interest, is particularly relevant for how we evaluate deaths in global health, and policy-makers spending money to finance different health programs need to know how to answer them. Read More »Guest Post: How Should We Evaluate Deaths?

In Praise Of Dementia

By Charles Foster

Statistically there is a good chance that I will ultimately develop dementia. It is one of the most feared conditions, but bring it on, I say.

It will strip me of some of my precious memories and some of my cognitive function, but it will also strip me of many of the neuroses that make life wretched. It may (but see below) make me anxious because the world takes on an unaccustomed form, but surely there are worse anxieties that are dependent on full function – such as hypochondriacal worries, or the worry that comes from watching the gradual march of a terminal illness. On balance the trade seems a good one.Read More »In Praise Of Dementia

UK Supreme Court Decision Means Patients No Longer Forced to Live

By Mackenzie Graham

On July 30, The UK’s Supreme Court ruled that there is no requirement to obtain court approval before withdrawing clinically assisted nutrition and hydration (CANH), when there is agreement between physicians and the family that this is in the best interests of the patient.

In the judgement, Lady Black writes:

“If the provisions of the MCA [Mental Capacity Act] 2005 are followed and the relevant guidance observed, and if there is agreement upon what is in the best interests of the patient, the patient may be treated in accordance with that agreement without application to the court.”

Until now, requests to withdraw CANH needed to be heard by the Court of Protection to determine if withdrawing treatment was in the patient’s best interest. In addition to being emotionally difficult for families, this is a time-consuming and expensive process, and often results in the patient dying before a judgement is rendered.

I think this decision has much to be said in its favour. First, it means that when there is agreement that continued treatment is no longer in the best interests of a patient with a prolonged disorder of consciousness, these patients are no longer being ‘forced to live’ until the Court affirms that being allowed to die is in their best interests. In many cases, court decisions take months, meaning that a patient is forced to be kept alive, against their best interests and the wishes of their family. Making the decision to withdraw care from a loved one is highly distressing, and this is likely further compounded by the burden and distraction of court proceedings.

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The Dangers Of Deferring To Doctors

By Charles Foster

(Image: tctmd.com)

There is a dizzying circularity in much medical law. Judges make legal decisions based on the judgments of rightly directed clinicians, and rightly directed clinicians make their judgments based on what they think the judges expect of them. This is intellectually unfortunate. It can also be dangerous.

There are two causes: Judges’ reluctance to interfere with the decisions of clinicians, and doctors’ fear of falling foul of the law.

In some ways judicial deference to the judgment of professionals in a discipline very different from their own is appropriate. Judges cannot be doctors. The deference is best illustrated by the famous and ubiquitous Bolam test, which is the touchstone for liability in professional negligence cases.1 A doctor will not be negligent if their action or inaction would be endorsed by a responsible body of professional opinion in the relevant specialty.

In the realm of civil litigation for alleged negligence this deference is justified. The problem arises when the deference is exported to legal arenas where it should have no place. The classic example relates to determinations of the ‘best interests’ of incapacitous patients. Something done in relation to an incapacitous patient will only be lawful if it is in that patient’s best interests.Read More »The Dangers Of Deferring To Doctors