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clinical ethics

Intentionally Exposing Patients to HIV: When Might it be Ethical?

7 Jun, 14 | by BMJ

Guest Post by Bram Wispelwey, Ari Zivotofsky, and Alan Jotkowitz

Much has been made of the fact that over the last two decades HIV has transformed from an inevitable, agonising killer into a controllable chronic disease.  But have we reached a point where infecting someone with HIV in order to avoid other, potentially worse health outcomes might be justified?  In the realm of organ transplantation we found that if we are not yet there, perhaps we should be.

Our paper was in part inspired by what many considered a shocking ruling by former Israeli Chief Rabbi Eliyahu Bakshi-Doron, who decreed that it was consistent with Jewish religious law for HIV-negative individuals to receive HIV-positive organ transplants, even if the evidence indicates a possibility for the recipient to contract the disease.  Many considered this opinion premature because only recently had HIV-positive individuals been found to be good candidates for solid organ transplantation, and doctors in South Africa were still in the early research stages of examining kidney transplantation between HIV-positive individuals.  But in examining the ethical considerations of autonomy, beneficence, non-maleficence, and justice, we argue in our paper that Rabbi Bakshi-Doron’s opinion is ethically sound.

Focusing on the history of HIV in transplantation and using a comparison to current practice with regard to another infectious disease, cytomegalovirus, we demonstrate that disallowing HIV-negative candidates from receiving HIV-positive organs would be a significant limit on patient autonomy.  The elimination of the ban on this type of potentially life-saving (and improving) donation may also represent a more socially just option, as it would expand the donor pool and engender cost savings. HIV-positive to HIV-positive donation will soon be a reality in several countries; it’s time to think about going one step further.

 

Read the full paper here.

Oh, and while we’re talking about media hype…

1 Apr, 14 | by Iain Brassington

… there’s this, from last week’s Independent:

Thousands of unborn foetuses incinerated to heat UK hospitals

The bodies of more than 15,000 unborn foetuses have been incinerated in the UK, an investigation has found, with some treated as “clinical waste” and others burned to heat hospitals.

The practice was carried out by 27 NHS trusts, with at least 15,500 bodies burned over the last two years alone.

Ten of those trusts admitted to burning more than 1,000 sets of remains along with other hospital rubbish, while two said they were incinerated in “waste-to-energy” furnaces that generate energy used to power and heat hospitals.

Gasp!  One kind of human tissue is disposed of in the same way as other kinds of human tissue!

From the tone of the reporting, one would only be mildly surprised to find people employed to encourage abortions in order that hospitals can save money on fuel.

Except that that’s nonsense.  If clinical waste is incinerated in waste-to-heat plants, it doesn’t follow that it’s being incinerated to provide heating; rather, it’s that the heat from the incinerator is captured and put to use, rather than being wasted.  For sure, the physics is the same; but the emphasis makes a heck of a difference.  (And, as PZ points out, for abortus* to be an effective fuel would require them to be “the most energy-dense substance in the world”.)  So what we actually have is a situation in which an abortus is incinerated.

And the problem with that is…?

Um…

Well, I’m sure there must be one, because health minister Dan Poulter is reported as describing the practice as “totally unacceptable”, and Poulter is an honourable man.

Actually, there is a few things that might strike us as questionable – though as we’ll see, the fact that something prompts a question doesn’t really tell us much, since some questions can be answered easily.   more…

What should we Think about Belgium’s Child Euthanasia Law?

15 Feb, 14 | by Iain Brassington

With any luck, the nuts real-world work schedule of the past few months* will begin to ease in a few days, so I should be able to start blogging more frequently soon; but I thought I’d take a moment out from writing jurisprudence lectures to do some thinking out loud about Belgium’s recent change to its euthanasia law, which legalises it for children.  This is partly because it’s interesting in its own right, and partly because I’m debating it on Radio 4’s Sunday programme this week.  I’ve drafted this post before the interview’s recorded, but I’m not publishing it until after (though before the broadcast); let’s see how my thoughts here pan out on air…**

For reference, the text of the law is available here in French, and here in Dutch – thank goodness for A/S levels.  A decent précis provided by AP is hosted here; and Christian Munthe has an unofficial translation here.

OK: so, what should we think about it? more…

Medical Information for Sale?

21 Jan, 14 | by Iain Brassington

Reader Keith emailed me a week or so ago to tip me off about the government’s plans to allow private firms to access medical information.  It’s a story that has subsequently been picked up by  - inter alia - The Guardian.

As with the last post I made here, I’m going to have to cry off from saying much in my own right – I’ve got lectures that need to be written, and I need at least to go through the motions of being competent – but I would draw your attention the Christian Munthe’s take on the matter.

Touch wood, I’ll be able to get back to more frequent blogging soon.

Aintree University Hospital NHS Foundation Trust v James: Best Interests and Futility under the Judicial Microscope

14 Nov, 13 | by BMJ

Guest post by Daniel Sokol, barrister at 12 King’s Bench Walk / King’s College London.

Eight years after coming into force, the Mental Capacity Act 2005 has finally reached the scrutiny of the Supreme Court in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67.

David James was a professional musician, and a family man.  He had three children, three grandchildren, and many friends.  In May 2012, he acquired an infection in hospital which resulted in his admission to the critical care unit.  He was put on a ventilator.  In the following months, his condition fluctuated.  At one point, his heart stopped and he required 6 minutes of CPR.  He later underwent a tracheostomy, and received artificial nutrition and hydration.  Two months after his admission in hospital, he lost the capacity to make decisions about his medical treatment.  In spite of this, Mr James was able to recognise his wife and son, to kiss them, to follow their movements with his eyes, and, on occasion, to smile.  His prospects of leaving the hospital were nonetheless slim.

In September 2012, the hospital sought a number of declarations from the Court of Protection, one of which was that it would be in Mr James’ best interests not to receive certain treatments, including CPR, in the event of his deterioration.  The family disagreed.  They felt he still enjoyed life and that, each time he contracted an infection, he managed to pull through.

The judge at first instance refused to make the declarations.  He did not consider the treatments to be futile or unduly burdensome.

The hospital trust appealed to the Court of Appeal.  By then, Mr James’s condition had deteriorated dramatically.  He was comatose, or semi-comatose, and completely ventilator-dependent.  The Court allowed the appeal and made the declarations.  On 31st December 2012, Mr James suffered a cardiac arrest and died.

Mr James’s widow appealed to the Supreme Court. more…

Biases in Clinical Ethics Consultation

19 Sep, 13 | by Iain Brassington

Guest post by Morten Magelssen, Reidar Pedersen, and Reidun Førde

Read the full paper here.

A difficult case involving a patient in an intensive care unit is brought to a clinical ethics consultant.  The ethics consultant argues that intensive care is futile and should be withdrawn.  The clinicians are grateful for the advice, and, with the assent of the patient’s relatives, decide to withdraw intensive care accordingly.

Clinical ethics consultation – by committees or individual consultants – involves reflection upon ethically and medically challenging cases.  When reflection is carried out in a systematic manner, then ideally the ethically salient points are brought out and discussed in a comprehensive and unbiased way.

But what if the consultation itself introduces new biases and implicit value judgments?  We won’t take a stand on how often this in fact happens, but rather draw attention to how easily it may occur and the dangers involved.  In our JME article we identify six sources of bias – or conflicts of interest – in clinical ethics consultation. For instance, in the case above, the ethics consultant could be biased towards the interests of health-care professions, or towards the hospital’s interests in keeping costs down and maintaining an unblemished public image.  In general, we argue, the potential for harmful biases is greater when the consultation is performed by an individual consultant rather than by a committee.

The introduction of new, harmful biases through ethics consultation, a process intended to reduce biases, would be problematic (and somewhat ironic).  Especially considering that, in the eyes of clinicians, the conclusion and advice of ethics consultation may appear to bear a stamp of ”ethically approved”.

We are fundamentally optimistic about the positive role clinical ethics consultation can play in aiding clinicians in the management of ethically complex cases.  However, ensuring the quality of clinical ethics case deliberations is vital.  Although biases can never be completely eradicated, the identification of potentially significant biases is an important part of quality improvement.

How Magic can help Teach Students about Medical Ethics

24 Aug, 13 | by Iain Brassington

Guest post by Daniel Sokol, KCL

For some time, I have been interested in the relationship between magic and medical ethics.  Five years ago, I gave a talk in Prague on how to use magic in medical ethics education.  More recently, I held a workshop on Magic for Anaesthetists, which touched on ethical issues in anaesthesia.  My latest ‘guest’ lecture is entitled Magic, Medicine and Medical Ethics and examines the ways in which the work of professional magicians can shed light on the art and ethics of medicine.

This blog is for those who teach medical ethics.  It explains how a magical effect can help convey ideas in a memorable and thought-provoking way.  I am grateful to Gerry Griffin, a fantastic card magician from the United States, for permission to use one of his effects.  I respectfully ask readers to keep the secret to themselves.

more…

Consent and Treatment Cascades: The case of giving birth

20 Aug, 13 | by David Hunter

Apologies for my long absence – moving to Australia turned out to take up quite a bit of time, and make it hard for me to access and write on the blog… Still now I am here and in far more practical role than my previous appointment (I’m now in a medical school rather than a philosophy department) I thought I might make a relatively practical post…

A medical treatment cascade is where one intervention leads to another and another and so on. Theses can occur in several contexts, for example with my first wife Kerry who had Cystic Fibrosis, she took morphine to aid her breathing. This had the side effect of causing her severe nausea for which she took another drug which itself had side effects of dizziness and lightheadedness for which she took another drug to counter act (ironically this other drug actually blocked the receptors that morphine works on rendering it useless as a treatment in the process, something we discovered only after a review of all her medication a year later). Likewise it can be the case that a routine scan picks up on something that wasn’t being searched for, and that this leads to an operation which itself has complications to remove something that may well be benign.

However perhaps the most well known treatment cascade is in regards to the delivery of children in hospital, which is commonly referred to by the natural birth movement as the cascade of interventions. (While I don’t intend to endorse everything the natural birth movement suggests – particular the more radical fringe who are in favour of unattended birthing – nonetheless, research seems to support the existence of this phenomena). The cascade here happens in part because of the psycho-social aspects of child birth (in particular that feeling comfortable, confident and relaxed contributes to smoother births) and in part because some interventions improve safety in some regards but simultaneously are likely to hinder progression of labour. The classic cascade of interventions in child birth goes like this.

In the early stages of labour you arrive at the hospital wanting a relatively natural birth in a safe environment. You are offered continuous fetal heart monitoring to determine whether the foetus is distressed at any time and thus whether the process needs to be hurried along, which you consent to because of course the safety of your child is paramount to you. This either involves having a belt strapped around your waist or involves having an electrode “attached” to the head of the infant – in either case this significantly limits the ability of the woman to move around, change position and be comfortable, making it likely to delay the progress of labour. So given that labour doesn’t appear to be progressing six hours later you are offered pictocin to induce labour and hurry things along. This works however one of the side effects of pictocin is significantly increased levels of pain, and while you had intended to not have pain killers, you reluctantly consent to an epidural after another 3 hours because it is simply too much for you. This has the effect of removing the pain, but also your ability to feel what is happening “down there”, so progress again stalls. Later exhausted after 36 hours of labour you consent to a caesarian section – with typically much higher risk of death and worse outcomes for both the mother and the child.

 

There isn’t much work on these treatment cascades in the ethics literature, but they seem to me to be of moral concern for three reasons: 1. they predictably lead to unwanted/worse outcomes for patients, 2. resource allocation, and 3. Informed consent.

 

I’m going to focus on informed consent but I will briefly describe the ethical issues in regards to the first two concerns. So firstly we might be concerned about reducing or minimising treatment cascades for patients because they are typically associated with worse or unintended outcomes. Now of course not all cascades are predictable, but where they are this gives us a reason to at least attempt to minimise them. Secondly treatment cascades are also problematic in terms of resource allocation, because typically they lead to sub-optimal outcomes (in the case of pregnancy C-section rates are far higher than they should be in most Western countries and this predictably leads to worse outcomes) and because each step along the cascade represents an investment of health care resources (another reason why we shouldn’t think about resource allocation as a series of one off cases) leading in the worst case (for example as happened with Kerry) a significant waste of resources where money is being expended for literally no patient benefit, since the various treatments simply cancel each other out.

 

The reason that treatment cascades are worrying in regards to informed consent is that while you consent to the first treatment, you do not consent (at that stage) to the further treatments it leads to. This is problematic because typically cascades present as emergency or urgent situations and hence the quality of consent can be quite low, with the patient feeling rail roaded into a particular decisions because the treatment is needed. This is particularly problematic when the risks of each intervention are progressively higher and more serious, since the initial decision seems so low risk that it may have been made relatively lightly without reflection on the possible consequences, but ultimately leads to a high risk decision.

 

So what can be done?

First and most obviously we can resist ending up in cascades in the first place – this is particularly the case when the initial intervention which leads to the cascade is of minimal medical value – in the case of routine continuous fetal monitoring for example outcomes are no better than that of traditional methods of monitoring the child’s heart rate intermittently – via either listening with a pinard stethoscope or via doppler – while they may improve outcomes when there is reason to already be concerned, as a routine measure they decrease rather than improve outcomes. The main benefits are managerial – a smaller team can manage more women using continuous fetal monitoring because they don’t need to be present regularly to check heart rates – but that doesn’t seem an overwhelming reason for recommending what is arguably a worse standard of care. But of course not all interventions that lead to cascades are of this nature. In these cases I’m inclined to think it would be better practice if the risk of the cascade was flagged up front for the patient, so that the initial consent contains some awareness of the possible risks down the track. While this will still be non-ideal in terms of informed consent, it is at least better.

Emmerich on Fitness to Practise

30 Jul, 13 | by Iain Brassington

Having asked out loud whether anyone could explain a couple of odd FtP decisions, I got this from Nathan Emmerich, offering sociological pop at an answer… 

Iain wondered if anyone could explain the morality that underlies a couple of recent Fitness to Practise decisions made by the GMC.  Well, more accurately he wondered if anyone could explain the “public perception” or “public confidence” aspect of the GMC’s Fitness to Practice guidelines.  Never one to shirk a challenge, I thought I would give it a go…

The first thing to note is that one has to change, or perhaps expand, the terms of the debate.  As a discipline applied philosophical bioethics tends to focus on “ethics”, “ethical reasoning” and codified rules over what I (and some others) would call “morality”.  For our present purposes the starkest way to express the idea is by appeal to the historical morality of the UK medical profession, which used to be based on the idea of the British gentleman of a certain class and standing (and, obviously, race and gender).

This morality was uncodified – it had no explicit ethics.  Indeed, more than this, it was held to be uncodifiable both in principle and as a matter of morality.  It was thought it would be wrong to codify gentlemanly (medical) morality as to do so would open the way to, first, individuals who merely followed rules rather than being the correct sort of persons or having the right character.  Second, it would lead to people who did not have the right character or standing attempting to second-guess the decisions of medical professionals or gentlemen.  Such a thing was, of course, intolerable.

There is no denying that there was a lot wrong with this ‘moral culture’, and a range of factors has been influential in the modification of medical morality from this historical position to the one we have today.  However, “medical morality” has vanished completely, indeed, it is impossible for it to do so: the medical profession (indeed any profession or cultural group) has some underlying moral ethos.  Some cultures, like modern medicine, may also have explicitly stated ethical codes and guidelines that may be more or less in line with the underlying moral culture.  Nevertheless the moral culture itself is not obviated by these codes.  Indeed it underpins the existence and application of any such formally stated ethics.

The problem here is that no rule contains the principles of for its own application.   more…

Fitness to Practise Revisited

26 Jul, 13 | by Iain Brassington

***UPDATE: Important codicil at the end***

Back in March, I posted something about what I took to be a slightly odd Fitness to Practise decision by the GMC in respect of one Mohammed Al-Byati.  Via the BMJ, here’s another case that seems a bit strange:

A doctor who abducted her six year old daughter from her estranged husband nearly two years ago and took her to Pakistan has been struck off by a panel of the Medical Practitioners Tribunal Service (MPTS).

[...]

The MPTS panel, sitting in Manchester, acknowledged that Dar’s conduct did not relate to her medical practice.  But panel chairman Michael Whitehouse said that misconduct could also involve conduct “of a morally culpable or otherwise disgraceful kind,” which could prejudice the reputation of the profession.

The emphasis is mine, though it’s the stuff about the “reputation of the profession” that intrigues me.  If Dar has breached a court order, or is a kidnapping suspect, then fine – but that’s a matter for the courts.  She perhaps wouldn’t be able to practice if found guilty and imprisoned, but that’s a different matter.  It’s not obviously the GMC’s business.

Now, sometimes a profession might have an interest in disciplining people who misuse their association with it.  more…

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