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Do Not Attempt Resuscitation orders: should you discuss with the patient?

Do Not Attempt Resuscitation orders: should you discuss with the patient?

The Court of Appeal has stated that a statement in a capacitous patient’s medical notes that resuscitation should not be attempted (a ‘Do Not Attempt Resuscitation’ Order – DNAR), should usually only be inserted after consultation with the patient: see R (Tracey) v Cambridge University Hospitals NHS Foundation Trust and others [2014] EWCA Civ 822 (17 June 2014).

The facts have been widely aired in the media: see, for example, here.

Mrs. Tracey had terminal lung cancer. Her clinicians indicated in the notes that no attempts at resuscitation should be made. Her family found out about this, and were outraged, saying that the DNAR order should not have been made without consultation with Mrs. Tracey. Their quarrel was not with the medical appropriateness of the determination that resuscitation would not be in Mrs. Tracey’s best interests, but with the procedure  – the failure to consult.  This, they said, violated Mrs. Tracey’s rights under Article 8 of the ECHR.

The Resuscitation Council, intervening, said that a requirement to consult with the patient would interfere with clinicians’ ability to deliver individual and compassionate care. A patient might, for instance, be very distressed by a discussion about a possible DNAR order.

The outcome can be briefly stated:

  • Mrs. Tracey’s Article 8 rights were engaged by recording the DNAR in the notes. This followed from, inter alia, Pretty v UK (2002) 35 EHRR 1.
  • Her Article 8(1) rights were violated by failing to involve her in the process
  • Article 8(2) required the policy adopted by a Trust in relation to DNAR orders to be sufficiently clear and accessible: see Purdy v DPP [2009] UKHL 45; [2010] 1 AC 345.
  • The absence of a mandatory national DNAR policy was not a violation of Article 8. Local policies would, if properly formulated, satisfy the demands of Article 8(2)
  • The concerns of the Resuscitation Council were real, but could be met by an important caveat: there should be consultation with the patient unless the clinician ‘thinks that the patient will be distressed by being consulted and that distress might cause the patient harm.’Read More »Do Not Attempt Resuscitation orders: should you discuss with the patient?

Should Vegetarians Consider Eating Insects?

In the last few years, there has been a push from various bodies—including the UN—to get Western countries to adopt eating insects as an alternative to meat. Insects have been hailed as a type of super food. They are: rich in protein; environmentally friendly to harvest; sustainable; and, they’re already eaten, and enjoyed, in many other parts of the world. There have been a number of occasions recently that I’ve been asked, as a (moral) vegetarian, for my thoughts on eating insects. “What if…?” and “Would you…?” questions are quite a common occurrence for veggies, but this one actually got me thinking.Read More »Should Vegetarians Consider Eating Insects?

Destroying one ecosystem and constructing another: biodiversity offsetting and particular value

Suppose that the government is proposing a new policy regarding buildings of historical significance. Rather than simply banning the destruction of ‘listed’ buildings, the new policy would allow their destruction, provided that whoever destroys the building agrees to construct, somewhere nearby, a new building of a similar size, in a similar style, exhibiting a similar range of architectural innovations, and of a similar level of beauty. Blenheim Palace could be flattened and built over with a shopping mall and carpark, provided that mall developers agreed to construct a replica of the palace somewhere nearby.

Most would be disturbed by such a policy. Part of the reason that they would be disturbed, I presume, is that it seems to manifest a failure to recognise the true value of historical buildings. Not all of the value of historical buildings consists in their possession of generic properties like ‘being beautiful’, ‘being in the baroque style’ or ‘using space to dramatic effect’. Some of their value is value that they have as particular objects, and that could thus not be realised in any other object. Part of the value of Blenheim Palace derives from it’s being the birthplace of Winston Churchill. This value could not be realised in a replica of the palace built 5 miles down the road.

Of course, no-one is proposing a policy of sort I’ve just outlined. I bring it up because I think reflecting on this kind of case may throw some light on recent discussion regarding biodiversity offsetting (see, for example, here, here  and here).Read More »Destroying one ecosystem and constructing another: biodiversity offsetting and particular value

Howick on What Counts as a Placebo

The use of placebos in medicine raises a large number of serious ethical issues. Do they involve deceiving patients, or violating their autonomy in some way? Are they harmful to certain patients, in research trials where the actual treatment being trialled is thought likely to be successful? Can placebos – if medically warranted – be funded through a health care budget? All these questions require us to be able to say what a placebo is, and that is more tricky than one might think.Read More »Howick on What Counts as a Placebo

Two Tales of Marshmallows and their Implications for Free Will

Patricia Churchland, a prominent Neurophilosopher, just published a book on neuroscience and its ethical implications which led to a rather nasty exchange in the New York Review of Books with fellow philosopher Colin McGinn.  His pointed, to put it mildly, criticism of her work was based on philosophical considerations about the implications neuroscience has, or, as he argues, lacks, for the philosophy of mind. This criticism evoked two sentiments in me. First, I felt a strong sense of hopelessness for a world in which not even two philosophers can engage in a sober, respectful argument about something they disagree on; not even under the tutelage of the editors of the New York Review of Books, one of the so-called sanctuaries of intellectualism. Good luck Palestine and Israel! Thereafter, I remembered the unease I at times felt as a psychologist when hearing or reading about Churchland’s work.

Read More »Two Tales of Marshmallows and their Implications for Free Will

Reading in a connected age

There is no doubt that the internet has transformed our lives in multiple ways. Here I will focus on the ways in which it has transformed our cognitive environment. I’m writing these words in Australia; as soon as I press “publish” they will be available to readers all over the world. For an academic, the “tyranny of distance” is greatly reduced by the web: it doesn’t matter where I am or where the journal is; I can have immediate access and I can email the author queries as easily from Melbourne as from London. Notoriously, it has made information available in quantities many people report they find overwhelming.Read More »Reading in a connected age

Not cricket? Law, convention, ethics, and that run-out

Sporting contests are philosophically interesting, as well as enjoyable, because sports and games are full of rules and conventions, which inevitably raise issues of interpretation and give rise to passion about ethics and the spirit of the game. The recent run-out of English batsman, Jos Buttler by the Sri Lankan bowler, Sachithra Senanayake in the deciding one-day international match is a case in point. Buttler was run out at the non-striker’s end by the bowler almost in his delivery stride after Buttler had backed up too far The anger, complaint and tutt-tutting in the English media, amounted to a sort of slightly stifled outrage (if that is a possible condition). But there is general agreement that Senanayake did nothing against the laws (rules) of the game, so for those shocked by the run out, there is recourse to such things as violating the spirit of cricket, ungentlemanly behaviour, and the ethics of the matter. (For an interesting discussion of this and other examples of legal but improper behaviour in cricket, such as not “walking” when you know you are “out”, see Samir Chopra and David Coady, “Not Cricket” in Sport in Society: Culture, Commerce, Media, Politics, 2007.)

To be clear on the law, Law 42.11 from the International Cricket Council’s playing regulations for international cricket states that “the bowler is permitted, before releasing the ball and provided he has not completed his usual delivery swing, to attempt to run out the non-striker”.

This could hardly be clearer, so the current debate implicitly or explicitly acknowledges that there is a difference between law and morality, or, less grandly perhaps, the rules and the ethos of an activity. So, it is worth looking more closely at what happened. According to newspaper reports, Buttler had already twice been warned by the bowler when out of his crease as the bowler was about to enter his delivery stride. In spite of this he was well down the pitch when Senanayake broke the bails and appealed. The umpire asked the Sri Lankan captain, Angelo Matthews whether he wanted to withdraw the appeal and he declined to do so. The batsman trudged unhappily from the field, and after the match Alastair Cook, the England captain, when shaking hands with the victorious captain, apparently delivered angry words about the incident.

Read More »Not cricket? Law, convention, ethics, and that run-out

Should the NHS fund Weight Watchers schemes?

The National Institute for Health and Care Excellence (NICE) recently recommended that the NHS should learn from commercial weight loss programmes such as Weight Watchers, Rosemary Conley and Slimming World. The NICE guidelines suggested that doctors should take a “respectful” and “non-judgemental” tone when helping patients to lose weight. As well as this, GPs were encouraged to continue to identify overweight patients for referral to state-funded commercial weight loss schemes, run by companies such as Weight Watchers, with obese adults being given priority.

The plan is estimated to cost hundreds of millions of pounds, but is also likely to save the NHS vast amounts in the long run, if successful in reducing obesity. Approximately 1 in 4 adults in the UK are obese, a condition that is linked with other ailments such as diabetes, heart disease and some cancers. The costs to the NHS attributable to people being overweight and obese are projected to reach £9.7 billion by 2050. Figures show that Weight Watchers and similar schemes manage to reduce participant’s body weight by 3 per cent, and NICE believe that even this small amount will help in the long term. Is it right, therefore, that the NHS subsidise the cost of these commercially run weight loss schemes?

Read More »Should the NHS fund Weight Watchers schemes?