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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?

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

Genetically Modifying Mosquitoes to ‘Bite the Dust’? Ethical Considerations

At some point, most people will have questioned the necessity of the existence of mosquitoes. In the UK at least, the things that might prompt us into such reflection are probably trivial; in my own case, the mild irritation of an itchy and unsightly swelling caused by a mosquito bite will normally lead me to rue the existence of these blood-sucking pests. Elsewhere though, mosquitoes lead to problems that are far from trivial; in Africa the Anopheles gambiae mosquito is the major vector of malaria, a disease that is estimated to kill more than 1 million people each year, most of whom are African children.Read More »Genetically Modifying Mosquitoes to ‘Bite the Dust’? Ethical Considerations

The Right to Forget the Stock Market’s blemished Past

One of the great pleasures of studying human behaviour is to see that what we find in our experiments, what we theorize in our papers and textbooks – as unlikely and counterintuitive it appears to be – actually predicts what happens in so-called real life. Take, for instance, the current build-up of a stock-market bubble in the UK, happening even more dramatically in the US. In the UK, the FTSE 100 is on its way to surpass the record set during the high times of the dotcom bubble and already surpassed the levels reached during the 2008 financial bubble; in the US the Dow Jones has already reached new record highs. Despite having recently experienced the devastating consequences of a stock market bubble bursting, banks and investors return a few years later to the same hyperbolic forecasts and predictions, and start to build up another bubble. It is as if the past did not exist. Compare this behaviour with the following anecdote, which most business school students probably know.

Read More »The Right to Forget the Stock Market’s blemished Past

Can we solve the world’s problems by offering a large enough prize?

On the 22nd of October 1707, more than 1400 British sailors died when a British naval fleet sank in stormy weather off the Isles of Scilly. The disaster was later attributed to failings in navigation and sailors’ difficulty in determining their location at sea. This was a perennial problem at the time, and had persisted despite intense scientific research. Seven years later, the UK government passed the Longitude Act, offering 20,000 pounds (more than 2 million pounds in today’s money) to anyone who could develop a method for reliably determining longitude at sea. The longitude prize was eventually won by John Harrison, a self-educated Lincolnshire clockmaker.

Yesterday, 300 years after the original Longitude act, the UK Technology Strategy Board launched a £10 million pound prize competition, a new ‘Longitude prize’. The money will be awarded to a scientist or group of scientists who come up with a solution to one of a set of major global challenges – inadequate food/clean water supply for everyone, antibiotic resistance, spinal cord injury, dementia, the large carbon impact of air-flight.

The new Longitude prize is the latest in a series of innovation inducement competitions over time. These competitions have offered monetary rewards for solving problems as diverse as the development of butter substitutes, the first trans-Atlantic air flight, reusable aircraft for space flight, or an alternative fertilizer to bird poo. One novel feature of the 2014 Longitude prize is that it is seeking public input into the specific challenge to be targeted. Public voting will decide which of the six global challenges above are to be the focus of the prize.

But are innovation prizes an effective or appropriate way to solve major global scientific challenges?Read More »Can we solve the world’s problems by offering a large enough prize?

Personal Genome Project UK email disaster: If you can’t guarantee privacy, at least try to ensure trust

It’s not often that you can write on a topic in ethics whilst rolling around laughing, so I shall take this rare opportunity to make a few comments on the ludicrous breach of privacy that occurred last night when the Personal Genome Project messed up something as simple as an email list.

I’d expressed an interest in taking part in this project which aims to sequence the genomes of hundreds of thousands of people and make these available, together with trait information, to researchers. There are clear potential worries about privacy here, as there is a potential to identify individuals from such a rich source of information. Nonetheless, I was excited to take part. After all, many of the people I know and love the most would not be alive today were it not for advances in medical science which have helped to treat diseases such as cancer and type 1 diabetes. In the past, many have risked life and limb for medical science. What was the potential of a little breach of privacy to worry about? Besides which, there has been considerable attention to ethics, privacy, and security around this project. There’s a whole ethics crew. Presumably they only hire the crème de la crème of data and IT experts. Surely these guys could be trusted to use our information wisely, and to do all they could to prevent irresponsible use?Read More »Personal Genome Project UK email disaster: If you can’t guarantee privacy, at least try to ensure trust

Is Home Birth Really As Safe As Hospital Birth? “Woman-centred Care” vs “Baby-centred Care”

Imagine that you and your partner are having a baby in hospital. Tragically something goes wrong unexpectedly during birth and the baby is born blue. He urgently needs resuscitation if there is to be a chance of preventing permanent severe brain damage. How long would it be reasonable for doctors to wait before starting resuscitation? 15 minutes? 5 minutes? 1 minute?

What would be a reasonable excuse for delaying the commencement of resuscitation? They wanted to get a cup of coffee? The mother wanted to hold the baby first? The mother had catastrophic bleeding and this needed urgent attention?

If it were my baby, I would not want any delay in starting resuscitation. And there would be no justification for delaying resuscitation except some more serious, more urgent problem for another patient, such as the mother.

Yet when people choose homebirth, delay is precisely what they choose. It is simply not possible to start advanced resuscitation in the home within minutes. And their reason is not typically some relevant competing health concern that necessitates delivery at home.

Choosing home birth is choosing delay if some serious problem arises which requires immediate resuscitation.

Read More »Is Home Birth Really As Safe As Hospital Birth? “Woman-centred Care” vs “Baby-centred Care”

Reporters Shouldn’t Embrace Bias

For a long time, objectivity and impartiality were perceived to be noble and uncontroversial goals for journalists.  Objectivity is straightforwardly appealing – we want information that is accurate and undistorted by reporters’ personal politics.  However, there is of late some pushback against that view (often called ‘The View from Nowhere’, which has apparently become such common parlance in the industry that the Wikipedia entry focuses on the term’s use in journalism rather than Nagel’s book whose title inspired the movement).  The idea, roughly, is that personal bias is unavoidable among journalists (and indeed the public in general).  It is hypocritical to claim to offer impartial reporting because that impartiality can never be achieved; instead, reporters should simply embrace their normative perspectives and be up front about it and its influence on their work.  But this move is a serious mistake, one that will subvert the central internal purpose of journalism and only serve to promote greater ignorance about the world.  Read More »Reporters Shouldn’t Embrace Bias

The No harm principle, an ethical principle for economic policy advisors?

In a recent article in the New York Times, Harvard economics professor Gregory Mankiw points out that economic policy advice always relies on political-philosophical standpoints and, inspired by medical ethics, suggests that economists that give policy advice should apply the No harm principle rather than promote policy based on uncertain predictions and political-philosophical convictions. By applying his interpretation of this principle, he claims that economists should not endorse either the Affordable care act, or higher minimum wage because these are in fact policies that cause harm.

It is refreshing with an economist who recognises that there is no such thing as purely scientific, value-free economic policy advice, and it is interesting to consider whether ethical principles can be introduced to deal with biases inherent to policy advice and with uncertainties innate to economic predictions. However, Mankiw’s proposal is as biased as the policy advice he addresses, and his proposed version of the No harm principle is at best a poor re-articulation of his own ideological convictions.Read More »The No harm principle, an ethical principle for economic policy advisors?