There was extensive media comment this weekend about the Court of Protection’s decision to authorise the force-feeding of a seriously anorexic former medical student with a critically low BMI. The woman, referred to only as “E,” is 32 and following sustained sexual abuse as a child has suffered from an eating disorder since she was 11. Without urgent medical treatment, including involuntary feeding, she will die. She has had four episodes of treatment in specialist eating disorder units and one in an alcohol treatment unit. With great reluctance, E, her parents, and the professionals involved in her care came to the conclusion that all available treatment options had been exhausted. She was transferred to a community hospital for palliative care and put on an “end of life” care pathway. After five weeks on the pathway, her Local Authority bought her case to the Court of Protection concerned that it needed further investigation. more…

The recent case of a young Jehovah’s Witness in a sickle cell crisis refusing essential blood products and being allowed to die confirms what should by now be widely known: a competent and informed adult has a right to refuse medical treatment even where the refusal will result in his or her death. Although there were some concerns that the young man’s choice was being influenced by his mother, also a Witness, an independent doctor confirmed that he had capacity and was making a free choice. A clear restatement then of established law: outwith mental health legislation a doctor providing treatment in the face of a competent adult refusal is effectively assaulting the patient. As Lord Donaldson stated in an influential judgment Re:T: more…

During the years when the Book of Revelations was being laid down, some time apparently in the first century AD, human populations were likely, with some exceptions, to be small, imperilled, and surrounded by a seemingly infinite planet. Officially at least, on October the 31st this year the population of the earth reached seven billion. And there are times when, psychologically at least, the planet seems to have shrunk to the size of a smartphone. As I blogged here following a recent BMJ conference, climate change looks set to release all four horseman of the apocalypse. Population growth might well be the fifth. more…

There are four horsemen of the apocalypse: conquest, war, famine (or pestilence) and death, and climate change will unleash all of them. I was at a BMJ conference recently that explored some of the health and security impacts of climate change and these grim riders were everywhere to be seen. Put simply, climate change will alter the distribution of human necessities like food and fresh water. Green places will become barren, rivers will run dry. The need to secure access to these basic goods will drive people to war. Add to this the death toll from severe weather events – droughts, hurricanes, floods – and changing distributions of infectious disease vectors and you can feel the heat of the breath of the horses on your neck. more…

On coming into force, the Mental Capacity Act (MCA), by deftly drawing together common law and permitting, via new powers of attorney, the nomination of substitute health decision makers, looked set to move practice in anticipatory decision making into a new era. The MCA is certainly a good act. It is supported by principles, focuses on the interests of the incapacitated adult, and creates obligations on would be decision makers to ensure adults exercise any residual capacity. That it would also make unambiguously legible the law relating to advance directives and permit the delegation of decision making powers in health and welfare suggested it would also provide welcome additional support to patient autonomy. Our decisions, it made clear, will be able to reach beyond our declining capacity. more…

I have recently been enjoying a brief flurry of reviews of Catherine Hakim’s Honey Money: The Power of Erotic Capital. Hakim’s book has been bounding up the notoriety charts, which is less than surprising given the hyperventilatingly simple premise that has caught the eye of reviewers. Hakim – a senior researcher at the LSE – declares that a conspiratorial alliance of religious fundamentalists, feminists, and male chauvinists has for too long supressed the real value of the “sexual capital” of young women. Hakim identifies what she calls a “sex deficit,” a disequilibrium in desire between men and women so significant that if sexually attractive – and therefore in her view younger – women were able to claim their real value in the market place, a sea-change in power relations between men and women would surely follow. Prostitution, to put it baldly, will be the undoing of patriarchy. more…

Once in a while I make a mistake at work – in spite of my best intentions, the human will out. By and large though, people are little inconvenienced by my blunders. And where they are, and where I cannot put them right, I am usually happy to apologise. Taken in the right way there can also be something tutelary about a mistake: if you sit and look at it for long enough it is bound to teach you something, a dark light if you will. Besides, in these clamorous times, humility is a much underexplored virtue, and one almost always closer to the truth than its opposing vice, pride. As Iris Murdoch put it, “humility is not a peculiar habit of self-effacement, rather like having an inaudible voice, it is a selfless respect for reality and one of the most difficult and central of all the virtues.” more…

Being a self-sacrificing soul I recently enrolled myself in a critical piece of public health research: I gave up alcohol for January. If appetite is the new front-line in health, if our desires are becoming the death of us, then self-restraint must be the new penicillin, and, to squeeze the analogy a little, the Petri-dish is any human heart. Just how difficult could it be to up-end the glass for a month? more…

I was at the Frontline Club recently, watching how the world changes. A grandiose claim perhaps, the latter, but the occasion was a debate on the journalistic impact of the Wikileaks phenomenon. Vaughan Smith, the club’s owner, is currently giving handsome houseroom to Julian Assange, Wikileaks’ founder. In journalistic terms a slightly starry line-up: Ian Katz, deputy editor of The Guardian, David Aaronovitch of The Times, Gavin Macfayden, director of the Centre for Investigative Journalism, Assange’s lawyer Mark Stephens, the event adroitly chaired by Richard Gisbert from Al-Jazeera. more…

I recently attended a seminar concerned with human rights violations of women forced or coerced into sterilisation, a joint undertaking by the Open Society Institute and the International Federation of Health and Human Rights Organisations. For a week I was a guest in a handsome villa in snow-softened Salzburg with health professionals and human rights activists from across the globe. Although the focus of the meeting was on eliminating the practice, fairly early on the tricky issue of spousal consent emerged. In some cultures either custom or law – sometimes both – dictate that a married person can only request sterilisation with the consent of his or her spouse. Human rights law – and much of bioethics – regard such a practice as a violation of autonomy rights. Several doctors from the south though were rendered uneasy by the strength of the denunciation. The simple assertion of autonomy rights in cultures where spousal consent was the norm did not necessarily lead to benign outcomes. Medicine, they argued needed to be seen as a practice embedded in and sympathetic with – though not uncritical of – culture, not standing in lofty opposition. Besides, wasn’t there a flavour of ethical imperialism here, western values cloaking themselves in the garb of universalism? more…