While I must agree the analogy of the siamese twins do provide a better understanding of some of the issues dealt with by Thomson there is one fatal law not addressed with this analogy. In law of evidence it must always be considered whether the probative value of evidence outweighs the possible prejudice using said evidence could hold. Applying that to this scenario it can be argued that the person attached to the unconscious violinist has an understanding a a frame of reference to what life was like before the incident, what life is like during the attachment and what life could be like after attachment. There is thus a clear understanding of what is being sacrificed and the changes forward this will have. The same can be said for a pregnant woman contemplating abortion. She knows what life was life before pregnancy what life is like during pregnancy and what changes to except after the birth of the child, thus enabling her to make an informed decision. The same can however not be said for the siamese twins as Elizabeth has no framework to base the standard of her life on. Elizabeth only knows what life is like attached to Catherine as she has never been independent of her. Elizabeth can thus not make an informed decision as she has no idea what life will be like without Catherine (she could become depressed for the loss of a loved one she has known her entire life, or she could end up regretting her decision much later on in life when it is too late [if a woman gets an...
While I must agree the analogy of the siamese twins do provide a better understanding of some of the issues dealt with by Thomson there is one fatal law not addressed with this analogy. In law of evidence it must always be considered whether the probative value of evidence outweighs the possible prejudice using said evidence could hold. Applying that to this scenario it can be argued that the person attached to the unconscious violinist has an understanding a a frame of reference to what life was like before the incident, what life is like during the attachment and what life could be like after attachment. There is thus a clear understanding of what is being sacrificed and the changes forward this will have. The same can be said for a pregnant woman contemplating abortion. She knows what life was life before pregnancy what life is like during pregnancy and what changes to except after the birth of the child, thus enabling her to make an informed decision. The same can however not be said for the siamese twins as Elizabeth has no framework to base the standard of her life on. Elizabeth only knows what life is like attached to Catherine as she has never been independent of her. Elizabeth can thus not make an informed decision as she has no idea what life will be like without Catherine (she could become depressed for the loss of a loved one she has known her entire life, or she could end up regretting her decision much later on in life when it is too late [if a woman gets an abortion today and in six years decides she now wants children she can most probably still get pregnant and have a child] ), and in this instance the possible prejudice outweighs the probative value.
There should be legal barriers to putting a human embryo in anything but a human female, and it should be the same for the woman that supplied the egg. There should also be legal barriers to making eggs from XY people and sperm from XX people.
Of course it’s not discrimination to forbid making embryos unethically, where there is no right to. It is a supportable basis to restrict procreation. It wouldn’t be medicine to make a transgender woman pregnant or make her eggs, that’s not healthy. It’d be commerce, and unhealthy. PS: there are no "women" with XY chromosomes (!)
Dr Anthony-Pillai is wrong to argue that the BMA and Royal College of Physicians’ guidance on decisions about clinically-assisted nutrition and hydration (CANH) is dangerous in overlooking the symptomatic benefit that CANH can provide.
Our guidance, which was developed over a period of 18 months, in conjunction with a range of medical, legal, and ethical experts, is professional guidance, setting out the process that needs to be followed in order to comply with the law and good practice. We are clear that the guidance should be read in conjunction with the most up-to-date clinical guidelines when reaching a decision, and that any significant divergence from established practice must be justified. It is the clinical guidance which is the most appropriate home for discussion on assessing and responding to symptomatic distress. For patients who are in a prolonged disorder of consciousness (PDOC), this will be the clinical guidelines on PDOC from the Royal College of Physicians – who were the joint authors of our guidance. (These guidelines are currently under review by the RCP’s PDOC guideline development group following recent changes to the law. The updated version is expected to be published in early 2020.)
We do not, as Dr Anthony-Pillai suggests, only “implicitly acknowledge” that CANH can provide symptomatic benefit. We explicitly state at the outset, in determining the scope of the guidance, that “clinical benefit” encapsulates not just prolonging some...
Dr Anthony-Pillai is wrong to argue that the BMA and Royal College of Physicians’ guidance on decisions about clinically-assisted nutrition and hydration (CANH) is dangerous in overlooking the symptomatic benefit that CANH can provide.
Our guidance, which was developed over a period of 18 months, in conjunction with a range of medical, legal, and ethical experts, is professional guidance, setting out the process that needs to be followed in order to comply with the law and good practice. We are clear that the guidance should be read in conjunction with the most up-to-date clinical guidelines when reaching a decision, and that any significant divergence from established practice must be justified. It is the clinical guidance which is the most appropriate home for discussion on assessing and responding to symptomatic distress. For patients who are in a prolonged disorder of consciousness (PDOC), this will be the clinical guidelines on PDOC from the Royal College of Physicians – who were the joint authors of our guidance. (These guidelines are currently under review by the RCP’s PDOC guideline development group following recent changes to the law. The updated version is expected to be published in early 2020.)
We do not, as Dr Anthony-Pillai suggests, only “implicitly acknowledge” that CANH can provide symptomatic benefit. We explicitly state at the outset, in determining the scope of the guidance, that “clinical benefit” encapsulates not just prolonging someone’s life, but also the provision of symptomatic relief (page 16 of the guidance).
With regard to how clinical information is to be used and weighed as part of the best interests decision, we are clear that all relevant clinical information should be taken into consideration. This will include information about the patient’s current condition, the quality of his or her life (from his or her perspective), and the patient’s experience of pain and distress and how it is being managed –including consideration of the symptomatic relief CANH is providing.
All of this information should be considered alongside information about the patient’s wishes, feelings, beliefs and values – past and present – to reach a decision about what is in the patient’s best interests. When the discussion is about the withdrawal of CANH, all of that information must be sufficiently robust to rebut the strong presumption that it will be in the patient’s best interests to prolong his or her life. At all times, the decision must be focused on what is right for that individual patient.
Further, an important requirement of the guidelines is that, if a decision is made to withdraw CANH, an appropriate palliative care plan must be in place to manage any symptoms that might arise. The RCP guidelines provide specific advice and palliative care protocols to ensure optimal palliative care in this situation.
The real danger to patients lies with doctors acting in a way that is not in the best interests of the patient – whether that is by continuing treatment for too long, and forcing them to continue a life that they would not want, or by withholding or withdrawing treatment too soon and depriving patients of the opportunity to live a life they would value. Our guidance aims to ensure that does not happen.
It is possible to over think and over analyse the issue of conscientious objection (CO).
CO is a right derived from the human right to Freedom of Conscience, religion and belief.
Human rights are personal.
They belong to each individual person.
It is not possible to be impersonal or impartial when one's human rights are threatened.
Human rights are invisible when they are respected.
When they are denied they become visible.
The Health (Regulation of Termination of Pregnancy )Act 2018 in Ireland has excluded me and other
healthcare workers from our human right to Freedom of Conscience and the derivate right of CO.
Doctors and nurses (and their students and trainees) in Ireland are the only healthcare workers with the legal right to CO in this Act.
I am an Irish pharmacist.
I value my human rights.
Freedom of conscience is my right as a human being.
CO is my right as a human being.
The article assumes that discerning a category of terminally ill persons will be done fairly readily, with some minor controversy that can be ignored. This is not the case. Most of us now will die after a long period of decline, from any of a long list of illnesses and conditions associated with aging. The mean length of self-care disability for persons who make it to 65 years old is about 2 years. We built the concept of a 6 month prognosis on the experience with certain highly fatal cancers, where the usual time from onset of a clearly fatal course to death was well under 6 months. This trajectory is not the experience of persons dying with various causes of frailty, as most of us will experience. We will know that our Parkinson's or Alzheimer's or frailty (or whatever) will worsen through to death, but the timing of the dying will depend mostly on rather random events - an infection, a fall, or some such event when we have so little resilience. Another way to look at it is to try to define the statistical meaning of a prognosis of less than 6 months. Is it 51% likely to die within 6 months, or 91%, or 99%? To many people, this sounds like a silly set of questions, but the difference in the population made "eligible" for PAD (or hospice) is more than 1000-fold at each of these thresholds. And the "error rate" at 1 or 2 years is very different for different illnesses. A person who has a 51% chance of dying within 6 months from a ne...
The article assumes that discerning a category of terminally ill persons will be done fairly readily, with some minor controversy that can be ignored. This is not the case. Most of us now will die after a long period of decline, from any of a long list of illnesses and conditions associated with aging. The mean length of self-care disability for persons who make it to 65 years old is about 2 years. We built the concept of a 6 month prognosis on the experience with certain highly fatal cancers, where the usual time from onset of a clearly fatal course to death was well under 6 months. This trajectory is not the experience of persons dying with various causes of frailty, as most of us will experience. We will know that our Parkinson's or Alzheimer's or frailty (or whatever) will worsen through to death, but the timing of the dying will depend mostly on rather random events - an infection, a fall, or some such event when we have so little resilience. Another way to look at it is to try to define the statistical meaning of a prognosis of less than 6 months. Is it 51% likely to die within 6 months, or 91%, or 99%? To many people, this sounds like a silly set of questions, but the difference in the population made "eligible" for PAD (or hospice) is more than 1000-fold at each of these thresholds. And the "error rate" at 1 or 2 years is very different for different illnesses. A person who has a 51% chance of dying within 6 months from a neuromuscular disease probably still has a 30% likelihood of being alive at one year - and 20% at 2 years. There's a long "tail" to the survival curve. The person who can be known to have a 51% chance of dying from lung cancer within 6 months has only a few percent chance to be alive at a year. Again, I know that readers' tolerance for these statistics is slim, but consider - can you reliably categorize most people who are living with eventually fatal illnesses as "terminally ill" at the 6 month criterion? Since most of us will be in a situation that is difficult to categorize for a very long time, it seems to me that relying on the "terminally ill" criterion has become silly - for PAD and for hospice eligibility.
Foster considers that is it not ethically nor lawfully acceptable to withdraw life-sustaining treatment from patients with Permanent Disorder of Consciousness(1) (PDOC). Though we agree the proposition has strong grounds to be made, we conclude that stating this to be the case “under any circumstances” may be oversimplifying the issue. We look at the case of W v M 2011 where withdrawal of life-sustaining treatment was denied and compare it to the cases of Airedale NHS Trust v Bland 1993 and Briggs v Briggs 2016 in which it was deemed legal to withdraw life-sustaining treatment from PDOC patients on the grounds of best interests. We also discuss some points in which Beauchamp and Childress’s ethical principles regarding ‘non-maleficience’ and ‘respect for autonomy’ do not align with Foster’s view, such as advanced directives and treatment side effects.
Withdrawal of life-sustaining treatment is unlawful
Foster makes a strong argument regarding the ambiguity surrounding the issues of removing life-sustaining treatment. Cases such as W v M 2011(2) exemplify how this uncertainty has affected the legal stance on this issue. M had suffered from a non-traumatic brain injury resulting in a ‘minimally conscious state’ (MCS), with intermittent periods of awareness. Though M was still left with the ability to have joyful experiences, she also had to endure periods of significant pain. Previously, M had expressed her wishes to never be wholly dependent o...
Foster considers that is it not ethically nor lawfully acceptable to withdraw life-sustaining treatment from patients with Permanent Disorder of Consciousness(1) (PDOC). Though we agree the proposition has strong grounds to be made, we conclude that stating this to be the case “under any circumstances” may be oversimplifying the issue. We look at the case of W v M 2011 where withdrawal of life-sustaining treatment was denied and compare it to the cases of Airedale NHS Trust v Bland 1993 and Briggs v Briggs 2016 in which it was deemed legal to withdraw life-sustaining treatment from PDOC patients on the grounds of best interests. We also discuss some points in which Beauchamp and Childress’s ethical principles regarding ‘non-maleficience’ and ‘respect for autonomy’ do not align with Foster’s view, such as advanced directives and treatment side effects.
Withdrawal of life-sustaining treatment is unlawful
Foster makes a strong argument regarding the ambiguity surrounding the issues of removing life-sustaining treatment. Cases such as W v M 2011(2) exemplify how this uncertainty has affected the legal stance on this issue. M had suffered from a non-traumatic brain injury resulting in a ‘minimally conscious state’ (MCS), with intermittent periods of awareness. Though M was still left with the ability to have joyful experiences, she also had to endure periods of significant pain. Previously, M had expressed her wishes to never be wholly dependent on anyone. Consequently, her family sought a declaration under the Mental Capacity Act 2005, stating that it was in M’s best interests to withdraw clinically assisted nutrition and hydration (CANH). Baker J argued, however, that despite M’s wish to withdraw CANH, she had the capacity for experiential interests that included significantly positive aspects. The ruling therefore supported the notion that CANH should persist, overriding her wishes. There is a medical and societal interest to preserve life and we acknowledge that in some situations it is illegal to withdraw life-sustaining treatment.
Lawful withdrawal of life-sustaining treatment
However, reflecting on the case of Airedale NHS Trust v Bland 1993(3), highlights situations where the omission of life-sustaining treatment can be lawful. Bland, a victim of the Hillsborough disaster, had been left in a persistent vegetative state (PVS) with no previously expressed wishes. Although Foster argues that the uncertainties surrounding PDOC mean that best interests can never be concluded, in the case of Bland, it was argued that a person in a PVS could not have best interests. Furthermore, the Mental Capacity Act 2005(4) states that is legal to provide a treatment when it is in the patient’s best interests. Thus, if it is no longer in the patient’s best interests to receive the treatment, it can legally be withdrawn. If the treatment were not in the patient’s best interests, this law means continuation would constitute a crime of battery and trespass against the person. Removing CANH not in the patient’s best interests would therefore be legal and consistent with duty of care.
Furthermore, in the case of Briggs v Briggs 2016(5), the Court of Protection deemed the removal of CANH to be in the best interests of a patient left in a MCS, despite knowing death was the inevitable consequence. After a road traffic accident, Briggs had been left in a MCS with no official advanced directive. However, he had previously made it known that should such a situation occur, he would not want life-sustaining treatment. Charles J argued that this was a decision that P would have made; therefore it should prevail over preservation of life. This therefore shows that continuing CANH is not the lawful course of action in every circumstance, as it may not be in the best interests of all MCS patients.
Ethical arguments
Another way to approach these issues would be to consider the ethical implications. One ethical argument, stemming from Beauchamp and Childress’s Principles of Biomedical Ethics(6) is non-maleficence, ‘do no harm’. From a legal standpoint, Bland 1993 concluded that a continuation of a treatment that was not in a patient’s best interests, without prior consent from the patient, would constitute a crime of battery. Furthermore, as CANH is a medical treatment, it also has side effects. It could be argued that if CANH is not in a patient’s best interests, then the risk of side effects outweighs the benefit of continuing. Therefore, in some situations, it is not ethically advisable to continue life-sustaining treatment.
Another of Beauchamp and Childress’s Principles of Biomedical Ethics(6) is respect for autonomy. Foster argues advanced directives cannot be applicable as it is “impossible to know whether the state in which the patient is, is in fact in anything like the state contemplated at the time the decision was made”(1). However, taking this stance would mean that advance directives for unconscious patients, whether PDOC or not, could never be followed. It could be argued that all unconscious patients are in a different state to the one they were in when they contemplated their advanced decision. Taking this view is wholly paternalistic and undermines the patient’s ability to demonstrate bodily autonomy through an advanced directive. Not only does rejecting a patient’s bodily autonomy violate the humanity of the patient, it also reduces faith in the medical profession(7).
It is worth noting that the ethics of the other two principles of Beauchamp and Childress’s biomedical ethics, justice and beneficence, are much more complicated to discuss as these pertain to resource allocation. As Foster rightfully mentions, it is expensive to maintain patients in PDOC. However, discussing resource allocation would mean having to argue that the interests of other patients override the interests of PDOC patients. Therefore, we agree that if this argument were to be made, there would need to be revision of the law regarding societal interest to preserve life.
Summary
We agree that in some scenarios it may be unethical or illegal to withdraw life-sustaining treatment, however we also believe that it is an oversimplification to say that it is “never” ethical or legal. In some legal cases, such as Airedale NHS Trust v Bland 1993 and Briggs v Briggs 2016, it has been ruled that withdrawal of CANH from a patient in a PDOC is legal. Ethically, it could be argued that in some situations, continuing life-sustaining treatment violates the principles of non-maleficence and respect for autonomy. Whilst perhaps society has a fear of death and a societal interest to preserve life, it is important that these judgments do not affect our ability to objectively act in a legal and ethical way. Withdrawal of life-sustaining treatment is a complicated issue so we believe it is important not to over-simply the matter by claiming that it is never legal or ethical.
References
[1] Foster C. It is never lawful or ethical to withdraw life-sustaining treatment from patients with prolonged disorders of consciousness. Journal of Medical Ethics. Published Online: 14 February 2019. doi: 10.1136/medethics-2018-105250
[2] Mullock A. Best interests and the sanctity of life after W v M. Journal of Medical Ethics. 2013 Sep;39(9):553-4. doi: 10.1136/medethics-2012-100907
[3] Szawarski P, Kakar V. Classic Cases Revisited: Anthony Bland and Withdrawal of Artificial Nutrition and Hydration in the UK. Journal of the Intensive Care Society. 2012;13(2):126-129. doi:10.1177/175114371201300209.
[5] Kitzinger J, Kitzinger C, Cowley J. When ‘Sanctity of Life’ and ‘Self-Determination’ clash: Briggs versus Briggs [2016] EWCOP 53 – implications for policy and practice. Journal of Medical Ethics. 2017;43:446-449. doi: 10.1136/medethics-2016-104118.
[6] Beauchamp T, Childress J. Principles of biomedical ethics, 5th ed. NY: Oxford University Press; 2001.
[7] Murgic L, Hébert PC, Sovic S, Pavlekovic G. Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country. BMC Med Ethics. 2015;16(1):65. doi:10.1186/s12910-015-0059-z
In the footnote to his article Dr Finegan makes reference to the debate in Ireland over conscientious objection in the context of any legislation tabled pursuant to the abortion referendum in 2018. Dr Finegan intended his counter-arguments to apply to GPs and other healthcare professionals who he rightly states are significantly part of a public health service.
As an Irish pharmacist I wish to draw attention to the lack of provision for conscientious objection for pharmacists in the final Health (Termination of Pregnancy) Bill 2018. In Ireland only doctors and nurses have the protection of their right to conscientious objection in the legislation. Pharmacists and other healthcare professionals are excluded.
My human right to freedom of conscience, religion and belief is not provided for or protected in the Health (Regulation of Termination of Pregnancy) Bill 2018. Conscientious objection is a right derived from the right to freedom of conscience, religion and belief.
There was no pre-legislative scrutiny of this Bill and the human rights implications for pharmacists and other healthcare professionals do not appear to have been considered.
Conscientious objection is not provided explicitly in the Pharmaceutical Society of Ireland (PSI) , Code of Conduct for Pharmacists (2009). There is no mention of freedom of conscience, religion and belief and/or conscientious objection. There was no explicit mention of freedom of conscience, religi...
In the footnote to his article Dr Finegan makes reference to the debate in Ireland over conscientious objection in the context of any legislation tabled pursuant to the abortion referendum in 2018. Dr Finegan intended his counter-arguments to apply to GPs and other healthcare professionals who he rightly states are significantly part of a public health service.
As an Irish pharmacist I wish to draw attention to the lack of provision for conscientious objection for pharmacists in the final Health (Termination of Pregnancy) Bill 2018. In Ireland only doctors and nurses have the protection of their right to conscientious objection in the legislation. Pharmacists and other healthcare professionals are excluded.
My human right to freedom of conscience, religion and belief is not provided for or protected in the Health (Regulation of Termination of Pregnancy) Bill 2018. Conscientious objection is a right derived from the right to freedom of conscience, religion and belief.
There was no pre-legislative scrutiny of this Bill and the human rights implications for pharmacists and other healthcare professionals do not appear to have been considered.
Conscientious objection is not provided explicitly in the Pharmaceutical Society of Ireland (PSI) , Code of Conduct for Pharmacists (2009). There is no mention of freedom of conscience, religion and belief and/or conscientious objection. There was no explicit mention of freedom of conscience, religion and belief and/or conscientious objection in the draft Code of Conduct issued for public consultation by the PSI in July 2018.
The Irish Human Rights and Equality Commission (IHREC) published a commentary on the draft legislation https://www.ihrec.ie/app/uploads/2018/09/Observations-on-General-Scheme-... .
The IHREC recommended that the conscientious objection provisions be made to apply more broadly than currently ,to provide for the possibility of conscientious objection by the broader range of health and social care professionals with whom a pregnant woman or girl may come into contact. This recommendation is IHREC No. 20.
Irish pharmacists have the same human rights as Irish doctors and nurses. However Irish pharmacists are not mentioned in the conscientious objection section of the Bill. Irish pharmacy students will not be protected in the same way as Irish medical students/trainees and nursing students.
This unequal treatment is a very grave matter for many Irish pharmacists.
Pharmacists and other healthcare professionals are now ‘less equal’ than doctors and nurses.
It is generally agreed in most jurisdictions that all competent patients must be fully informed about any proposed treatment, including medications, and have the absolute right to either consent to or refuse treatment. This introduces the dread word “competent” that is often mistakenly taken as being required as a demonstration of insight. It is also often assumed that a person suffering a condition such as schizophrenia is incapable of insight. The Supreme Court of Canada, in 2003, in Starson v. Swayze laid this one to rest. The appellant knew that he had schizophrenia, its nature and effects, and was appealing a decision of a lower court that he should be forcibly given antipsychotic medication on a continuing basis. He argued that he had the right to decide for himself when he should take the medication and when he could avoid it so that he could work without the thought-numbing effect of the drug. His profession required clear thinking.
The court found for him, noting that he knew the nature of his condition and was capable i.e. competent to make these decisions for himself. He had, in other words, insight.
What a self centered world we have become, it is a shame that you cannot see the most basic principals of human life for what they really are. This is beyond the argument of abortion, this is murder. To engage in a sexual act is to take the risk of creating a child, a human, and in every sense of the word, that being is a person. Such a decision is yours to make, but should you procure a child, intended or not, wanted or unwanted, burden or no, that child is placed in your care. You can choose to give that child to another through adoption if you truly are unable, but to resort to such measures to save yourself a little possible remorse is just disgusting. Imagine the remorse knowing that you took your child, whom you will inevitably think of years down the road as the article speculates, and did not even give them the chance for life, instead, you killed them. An irreversible decision that was never yours to make. Life is precious, yet so often in this world where we in the name of "betterment of society" we choose to take advantage of the most innocent of children, and place their needs far below our wants. It is sick and shameful. Each person is of value, it is not something a parent or any other can choose to give or take away, it is inherent and a basic human right. As is life. We can make excuses to justify any action if we are twisted enough, but such things always have been and always will be wrong.
Nathan Hodson is quite correct in his conclusions that the rulings in the awful situation of Dr Hadiza Bawa-Garba are not good news for doctors, but I am not convinced that the analysis starts in the right place. Most of the focus in the article (and almost everywhere else) is on what the GMC has done following the decision of the MPTS not to strike Dr B-G off the register, and, in general, the opinion is that the body shoud not have done what it did. In my opinion, this is the wrong place to start - questions should be asked about how a relatively routine error led to a conviction at all.
As a lecturer in medical law and ethics, I find it strange in the extreme that a) the police felt that they should forward this to the Crown Prosecution Service (CPS) for prosecution, b) that the CPS went forward with the prosecution, and c) that the jury found Dr B-G guilty given the evidence available. Whilst the final part will remain a complete mystery because the law requires that what happens in the jury room must not be divulged, there is need to examine the decisions that led from a tragic but not remarkable incident in a hospital to a cause-celebre which has ruptured both public and professional trust in the GMC, and the law of gross negligence manslaughter. At the very least, there should be an appeal heard into Dr Bawa-Garba's convictions, but really there needs to a full and frank investigation into how this case ever got through the courtroom door. There was no...
Nathan Hodson is quite correct in his conclusions that the rulings in the awful situation of Dr Hadiza Bawa-Garba are not good news for doctors, but I am not convinced that the analysis starts in the right place. Most of the focus in the article (and almost everywhere else) is on what the GMC has done following the decision of the MPTS not to strike Dr B-G off the register, and, in general, the opinion is that the body shoud not have done what it did. In my opinion, this is the wrong place to start - questions should be asked about how a relatively routine error led to a conviction at all.
As a lecturer in medical law and ethics, I find it strange in the extreme that a) the police felt that they should forward this to the Crown Prosecution Service (CPS) for prosecution, b) that the CPS went forward with the prosecution, and c) that the jury found Dr B-G guilty given the evidence available. Whilst the final part will remain a complete mystery because the law requires that what happens in the jury room must not be divulged, there is need to examine the decisions that led from a tragic but not remarkable incident in a hospital to a cause-celebre which has ruptured both public and professional trust in the GMC, and the law of gross negligence manslaughter. At the very least, there should be an appeal heard into Dr Bawa-Garba's convictions, but really there needs to a full and frank investigation into how this case ever got through the courtroom door. There was nothing about her conduct that was " ... so bad in all the circumstances as to amount ... to a criminal act or omission" (R v Adomako, [1994] 3 WLR 288, per Lord Mackay), which suggests that the chances of a successful prosecution were very small, and so should not have been actively prosecuted. To put it baldly, something smells very unpleasant regarding the whole prosecution.
Given the reality that Dr Bawa-Garba is a doctor convicted of manslaughter, and the MPTS found good reasons not to strike her off the GMC register, the GMC did not have any option but to use the powers it has to question the decision. The GMC's mandate includes "where necessary, tak[ing] action to prevent a doctor from putting the safety of patients, or the public's confidence in doctors, at risk." (https://www.gmc-uk.org/about/what-we-do-and-why/our-mandate). In principle, having a doctor convicted of manslaughter remain on the register would undermine confidence in doctors. The GMC is generally widely regarded by the public as being over-protective of doctors at the expense of others - see, for example, the criticism of the GMC when no doctors were disciplined following the Mid-Staffordshire enquiry. Regardless of whether the GMC agreed with the MPTS decision, they had no option but to appeal. However, it could not have anticipated the huge public interest, and unexpected vitriol levelled at the body, for following its mandate.
On a slightly different note, that the Court of Appeal came to a completely different decision than the High Court in this case, and also in the less-reported case of Raychaudhuri v General Medical Council [2018] EWCA Civ 2027, suggests that there is a problem in the law that needs clarifying. Whilst it is no doubt a relief to the doctors involved that their cases ended there, we need a case to go to the Supreme Court for clarity in this area.
While I must agree the analogy of the siamese twins do provide a better understanding of some of the issues dealt with by Thomson there is one fatal law not addressed with this analogy. In law of evidence it must always be considered whether the probative value of evidence outweighs the possible prejudice using said evidence could hold. Applying that to this scenario it can be argued that the person attached to the unconscious violinist has an understanding a a frame of reference to what life was like before the incident, what life is like during the attachment and what life could be like after attachment. There is thus a clear understanding of what is being sacrificed and the changes forward this will have. The same can be said for a pregnant woman contemplating abortion. She knows what life was life before pregnancy what life is like during pregnancy and what changes to except after the birth of the child, thus enabling her to make an informed decision. The same can however not be said for the siamese twins as Elizabeth has no framework to base the standard of her life on. Elizabeth only knows what life is like attached to Catherine as she has never been independent of her. Elizabeth can thus not make an informed decision as she has no idea what life will be like without Catherine (she could become depressed for the loss of a loved one she has known her entire life, or she could end up regretting her decision much later on in life when it is too late [if a woman gets an...
Show MoreThere should be legal barriers to putting a human embryo in anything but a human female, and it should be the same for the woman that supplied the egg. There should also be legal barriers to making eggs from XY people and sperm from XX people.
Of course it’s not discrimination to forbid making embryos unethically, where there is no right to. It is a supportable basis to restrict procreation. It wouldn’t be medicine to make a transgender woman pregnant or make her eggs, that’s not healthy. It’d be commerce, and unhealthy. PS: there are no "women" with XY chromosomes (!)
Dr Anthony-Pillai is wrong to argue that the BMA and Royal College of Physicians’ guidance on decisions about clinically-assisted nutrition and hydration (CANH) is dangerous in overlooking the symptomatic benefit that CANH can provide.
Our guidance, which was developed over a period of 18 months, in conjunction with a range of medical, legal, and ethical experts, is professional guidance, setting out the process that needs to be followed in order to comply with the law and good practice. We are clear that the guidance should be read in conjunction with the most up-to-date clinical guidelines when reaching a decision, and that any significant divergence from established practice must be justified. It is the clinical guidance which is the most appropriate home for discussion on assessing and responding to symptomatic distress. For patients who are in a prolonged disorder of consciousness (PDOC), this will be the clinical guidelines on PDOC from the Royal College of Physicians – who were the joint authors of our guidance. (These guidelines are currently under review by the RCP’s PDOC guideline development group following recent changes to the law. The updated version is expected to be published in early 2020.)
We do not, as Dr Anthony-Pillai suggests, only “implicitly acknowledge” that CANH can provide symptomatic benefit. We explicitly state at the outset, in determining the scope of the guidance, that “clinical benefit” encapsulates not just prolonging some...
Show MoreIt is possible to over think and over analyse the issue of conscientious objection (CO).
CO is a right derived from the human right to Freedom of Conscience, religion and belief.
Human rights are personal.
They belong to each individual person.
It is not possible to be impersonal or impartial when one's human rights are threatened.
Human rights are invisible when they are respected.
When they are denied they become visible.
The Health (Regulation of Termination of Pregnancy )Act 2018 in Ireland has excluded me and other
healthcare workers from our human right to Freedom of Conscience and the derivate right of CO.
Doctors and nurses (and their students and trainees) in Ireland are the only healthcare workers with the legal right to CO in this Act.
I am an Irish pharmacist.
I value my human rights.
Freedom of conscience is my right as a human being.
CO is my right as a human being.
This is personal.
This is very simple.
The article assumes that discerning a category of terminally ill persons will be done fairly readily, with some minor controversy that can be ignored. This is not the case. Most of us now will die after a long period of decline, from any of a long list of illnesses and conditions associated with aging. The mean length of self-care disability for persons who make it to 65 years old is about 2 years. We built the concept of a 6 month prognosis on the experience with certain highly fatal cancers, where the usual time from onset of a clearly fatal course to death was well under 6 months. This trajectory is not the experience of persons dying with various causes of frailty, as most of us will experience. We will know that our Parkinson's or Alzheimer's or frailty (or whatever) will worsen through to death, but the timing of the dying will depend mostly on rather random events - an infection, a fall, or some such event when we have so little resilience. Another way to look at it is to try to define the statistical meaning of a prognosis of less than 6 months. Is it 51% likely to die within 6 months, or 91%, or 99%? To many people, this sounds like a silly set of questions, but the difference in the population made "eligible" for PAD (or hospice) is more than 1000-fold at each of these thresholds. And the "error rate" at 1 or 2 years is very different for different illnesses. A person who has a 51% chance of dying within 6 months from a ne...
Show MoreAbstract
Foster considers that is it not ethically nor lawfully acceptable to withdraw life-sustaining treatment from patients with Permanent Disorder of Consciousness(1) (PDOC). Though we agree the proposition has strong grounds to be made, we conclude that stating this to be the case “under any circumstances” may be oversimplifying the issue. We look at the case of W v M 2011 where withdrawal of life-sustaining treatment was denied and compare it to the cases of Airedale NHS Trust v Bland 1993 and Briggs v Briggs 2016 in which it was deemed legal to withdraw life-sustaining treatment from PDOC patients on the grounds of best interests. We also discuss some points in which Beauchamp and Childress’s ethical principles regarding ‘non-maleficience’ and ‘respect for autonomy’ do not align with Foster’s view, such as advanced directives and treatment side effects.
Withdrawal of life-sustaining treatment is unlawful
Foster makes a strong argument regarding the ambiguity surrounding the issues of removing life-sustaining treatment. Cases such as W v M 2011(2) exemplify how this uncertainty has affected the legal stance on this issue. M had suffered from a non-traumatic brain injury resulting in a ‘minimally conscious state’ (MCS), with intermittent periods of awareness. Though M was still left with the ability to have joyful experiences, she also had to endure periods of significant pain. Previously, M had expressed her wishes to never be wholly dependent o...
Show MoreIn the footnote to his article Dr Finegan makes reference to the debate in Ireland over conscientious objection in the context of any legislation tabled pursuant to the abortion referendum in 2018. Dr Finegan intended his counter-arguments to apply to GPs and other healthcare professionals who he rightly states are significantly part of a public health service.
As an Irish pharmacist I wish to draw attention to the lack of provision for conscientious objection for pharmacists in the final Health (Termination of Pregnancy) Bill 2018. In Ireland only doctors and nurses have the protection of their right to conscientious objection in the legislation. Pharmacists and other healthcare professionals are excluded.
My human right to freedom of conscience, religion and belief is not provided for or protected in the Health (Regulation of Termination of Pregnancy) Bill 2018. Conscientious objection is a right derived from the right to freedom of conscience, religion and belief.
There was no pre-legislative scrutiny of this Bill and the human rights implications for pharmacists and other healthcare professionals do not appear to have been considered.
Conscientious objection is not provided explicitly in the Pharmaceutical Society of Ireland (PSI) , Code of Conduct for Pharmacists (2009). There is no mention of freedom of conscience, religion and belief and/or conscientious objection. There was no explicit mention of freedom of conscience, religi...
Show MoreIt is generally agreed in most jurisdictions that all competent patients must be fully informed about any proposed treatment, including medications, and have the absolute right to either consent to or refuse treatment. This introduces the dread word “competent” that is often mistakenly taken as being required as a demonstration of insight. It is also often assumed that a person suffering a condition such as schizophrenia is incapable of insight. The Supreme Court of Canada, in 2003, in Starson v. Swayze laid this one to rest. The appellant knew that he had schizophrenia, its nature and effects, and was appealing a decision of a lower court that he should be forcibly given antipsychotic medication on a continuing basis. He argued that he had the right to decide for himself when he should take the medication and when he could avoid it so that he could work without the thought-numbing effect of the drug. His profession required clear thinking.
The court found for him, noting that he knew the nature of his condition and was capable i.e. competent to make these decisions for himself. He had, in other words, insight.
What a self centered world we have become, it is a shame that you cannot see the most basic principals of human life for what they really are. This is beyond the argument of abortion, this is murder. To engage in a sexual act is to take the risk of creating a child, a human, and in every sense of the word, that being is a person. Such a decision is yours to make, but should you procure a child, intended or not, wanted or unwanted, burden or no, that child is placed in your care. You can choose to give that child to another through adoption if you truly are unable, but to resort to such measures to save yourself a little possible remorse is just disgusting. Imagine the remorse knowing that you took your child, whom you will inevitably think of years down the road as the article speculates, and did not even give them the chance for life, instead, you killed them. An irreversible decision that was never yours to make. Life is precious, yet so often in this world where we in the name of "betterment of society" we choose to take advantage of the most innocent of children, and place their needs far below our wants. It is sick and shameful. Each person is of value, it is not something a parent or any other can choose to give or take away, it is inherent and a basic human right. As is life. We can make excuses to justify any action if we are twisted enough, but such things always have been and always will be wrong.
Nathan Hodson is quite correct in his conclusions that the rulings in the awful situation of Dr Hadiza Bawa-Garba are not good news for doctors, but I am not convinced that the analysis starts in the right place. Most of the focus in the article (and almost everywhere else) is on what the GMC has done following the decision of the MPTS not to strike Dr B-G off the register, and, in general, the opinion is that the body shoud not have done what it did. In my opinion, this is the wrong place to start - questions should be asked about how a relatively routine error led to a conviction at all.
As a lecturer in medical law and ethics, I find it strange in the extreme that a) the police felt that they should forward this to the Crown Prosecution Service (CPS) for prosecution, b) that the CPS went forward with the prosecution, and c) that the jury found Dr B-G guilty given the evidence available. Whilst the final part will remain a complete mystery because the law requires that what happens in the jury room must not be divulged, there is need to examine the decisions that led from a tragic but not remarkable incident in a hospital to a cause-celebre which has ruptured both public and professional trust in the GMC, and the law of gross negligence manslaughter. At the very least, there should be an appeal heard into Dr Bawa-Garba's convictions, but really there needs to a full and frank investigation into how this case ever got through the courtroom door. There was no...
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