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Ethics education

Making the Jump to a Medico-Legal Career

15 Jul, 15 | by BMJ

Guest Post by Daniel Sokol

On a number of occasions, I have been asked by early career ethicists about the move from ethics to law, or the wisdom of seeking a legal qualification to supplement their ethical knowledge. In the UK, this can be achieved remarkably quickly. This blog post is an answer to those questions, based only on my own experiences.

In 2008, I was a lecturer in medical ethics and law at St George’s, University of London. I had no legal training, and felt uncomfortable teaching law to medical students. Some of the graduate students were former lawyers and it must have been obvious to them that the limits of my legal knowledge extended no further than the PowerPoint slide.

That year, an old school friend, a solicitor, encouraged me to become a lawyer. “I can imagine calling you ‘My learned friend‘ in court”, he said. And so the seed was planted, and with each soul-sapping marking session, and each article published and quite unread, the seed grew until, in 2009, I resigned from my lectureship to study on the law conversion course, now called the Graduate Diploma in Law (GDL). more…

Bad Surgeons and Good Faith

10 Jul, 15 | by Iain Brassington

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear.  It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links.  It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going.  It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted atKevinMD.com, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today.  This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear.  That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble.  Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow.  I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me.  This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole.  No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

[…]

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

[…]

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment.  However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now.  I’ll also note that I can’t check the flow of the original post, because it no longer exists.  Indeed, Hope Amantine’s whole blog would seem to have been taken down.  In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more.  This is noteworthy, because, as I said, the OP has now gone.  If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone.  Where it was, there’s this message: more…

How to be a good (consequentialist) bioethicist…

6 Jul, 15 | by David Hunter

There has recently been a pattern of papers (and I am not going to identify which ones) which I take as being slightly embarrassing to academic bioethicists because they portray us in a less than flattering light because of the naive mistakes they seem to make, or the outlandish poorly argued claims they make. I have noted a trend for these to have come from relatively new, consequentialist bioethicists and being the helpful sort that I am, the aim of this blog post therefore is to help consequentialist bioethicists from falling into these pitfalls.

more…

Does religion deserve a place in secular medicine?

26 Feb, 15 | by bearp

By Brian D. Earp

The latest issue of the Journal of Medical Ethics is out, and in it, Professor Nigel Biggar—an Oxford theologian—argues that “religion” should have a place in secular medicine (click here for a link to the article).

Some people will feel a shiver go down their spines—and not only the non-religious. After all, different religions require different things, and sometimes they come to opposite conclusions. So whose religion, exactly, does Professor Biggar have in mind, and what kind of “place” is he trying to make a case for?

more…

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…

Is Medical Equipment Halal? Kosher?

23 Nov, 12 | by Iain Brassington

A recent intercalating student of mine got in touch with this query the other day:

Total parenteral nutrition is given as a replacement for nutrition where the patient cannot or should not be digesting food: it is given intravenously so bypasses digestion.  Two patients have asked my current educational supervisor if the TPN solution is halal, and no-one, including the manufacturers, seems to know. There are various parts that are derived from animals but the manufacturers can’t say where from, even which animal seemingly.

The two relevant patients have been told the ‘don’t know’ answer and have agreed to continue taking the TPN but the team is now left wondering whether to tell all patients before they commence TPN that they do not know the origin of the products used and therefore the TPN cannot be guaranteed as halal, or indeed kosher either.

A pharmacist has also pointed out that beef gelatine is also used in many tablet coatings and this is generally never discussed with patients.

There is a suggestion in this paper that we should routinely be telling all patients about gelatine in tablets and IV infusions, which is definitely what my instinctual reaction agrees with.  The authors suggest that continuing not to do so would mean modern medicine “might be thought to be following the sort of self certain, paternalistic line that doctors were accused of decades ago in relation to Jehovah’s Witnesses”. I think that sums it up quite nicely!

Another interesting question comes from a legal point of view – of the regulations surrounding labelling of food products, which I think are increasingly strict, and the information provided by manufacturers about origins of medical products and then how much of that is communicated to patients.  (I think Margot Brazier might have mentioned this issue in our regulations seminar.)

Having chatted with the student in the pub since, we agree that, ethically at least, it’s a bit of a no-brainer: since it isn’t an imposition on anyone to warn that we can’t be sure of the origin of the treatment, there’s no harm in doing so – and, for the sake of preserving patients’ control over what goes into their bodies, we ought.

The legal question is potentially quite interesting here.  Going off on one a bit, could there be a negligence issue here – on the grounds that it’s reasonable to suppose that at least some patients might want to know the information, even if they don’t expressly say they would (because it never crosses their mind)?  Not to warn could be a serious omission here – and I’m wondering whether it might make a difference to consent.  I genuinely don’t know: were someone to make a case that they should have been warned and would not have consented had they known, would there be legal mileage in it?

Any thoughts, anyone?

Public Lecture: Mary Midgley on Death and the Human Animal

15 Sep, 11 | by Iain Brassington

Via the Centre for Medical Humanities blog:

Royal Institute of Philosophy Public Lecture

Mary Midgley – Newcastle University

Death and the Human Animal

Wednesday 19th October 2011, 5pm – 7pm (freshments available from 5pm)
The Henry Dyson room, the college of St Hild and St Bede, Durham.

The abstract’s below the fold. more…

Philosophy on the Radio

10 Sep, 11 | by Iain Brassington

You’re all probably way ahead of me on this, but there’s a series called The Philosopher’s Arms currently enjoying a run on Radio 4.  The premise of the programme is that philosophical questions are discussed in the context of a conversation in the pub – which has, of course, been the traditional haunt of philosophers ever since Plato and his mates went out on the razz and decided to publish the transcripts of what was said.

The Practical Ethics blog currently has a survey running on Nozick’s experience machine thought-experiment.  Go and have a look.  Better yet, pour yourself another drink, and then go and have a look.

Conscientious Objection and What Makes a Medic

20 Jul, 11 | by Iain Brassington

Francesca Minerva has drawn my attention to this paper by Sophie Strickland, currently available as a pre-publication download via the JME homepage, concerning conscientious objection among UK medical students.

Students were invited to respond to a set of questions in an online poll to determine whether there were procedures to which they’d object, and in which they’d refuse to participate, and what they were.  They were also asked to identify their religious affiliation.

Respondents were asked to note if their objections to the […] 11 medical practices [mentioned] were for religious reasons, non-religious reasons or both religious and non-religious reasons.  Of all the objections raised in the study, 19.7% were for religious reasons, 44.1% were for non-religious reasons, and 36.2% were for both religious reasons and non-religious reasons.  Muslim students were more likely to report religious objections (28.4%), followed by Protestant students (27.0%) and then Roman Catholic students (23.01%).  Jewish students were the least likely to report religious objections (15.8%).  The proportion of non-religious objections ranged from 96.7% in atheist students to 21.0% in Protestant students.  The Sikh and Eastern Orthodox students have again been excluded because of their low numbers.

There’s a number of problems with online polls, of course – they’re vulnerable to impersonation and trolling, even if steps are taken to ensure that people can only respond once.  (Strickland doesn’t indicate how she dealt with these problems.)  Still: I’ll take her results at face value. more…

Pratchett and Assisted Dying: A Question of Balance?

15 Jun, 11 | by Iain Brassington

If you’ve not yet seen “Choosing to Die”, Terry Pratchett’s film about Dignitas from Monday night, I recommend that you go and watch it now.  (I don’t know if it’s available outside the UK: I’m sure it’ll appear on YouTube soon, though; or, if you’re outside th UK, get a Brit to download it and put it on a USB for you.  It’s worth it.)  It’s an astonishing piece of film-making: simultaneously gripping, heartbreaking and deeply uncomfortable.  And it raised all kinds of hard questions.  Was Peter Smedley, the man whose death was filmed, making a genuine choice?  He looked as though he was in the process of signing a contract to have his hall decorated, so calm and rational was he.  Wouldn’t you expect a bit less detachment?  A bit less bloody Englishness?  But then, how much emotion do you want?  One of my problems with the unbearable suffering criterion in Joffe’s Assisted Dying for the Terminally Ill Bill a few years ago was that the more someone’s suffering, the more it’s legitimate to worry about the clarity of their thought.  Smedley seemed very clear.

And what about Andrew Colgan?   more…

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