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Assisted Dying’s Conscience Claws

11 Sep, 15 | by Iain Brassington

Aaaaaaaand so the latest attempt to get assisted dying of some sort onto the statute books in the UK has bitten the dust.  I can’t say I’m surprised.  Watching the debate in the Commons – I didn’t watch it all, but I did watch a fair chunk of it – it was striking just how familiar the arguments produced by both sides were.  It’s hard to shake the feeling that, just as is the case with the journals, the public debate on assisted dying has become a war of attrition: noone has much new to say, and in the absence of that, it’s simply a matter of building up the numbers (or grinding down the opposition).  The Nos didn’t win today’s Parliamentary debate because of any dazzling insight; the Ayes didn’t lose it because their speakers were measurably less impressive than their opponents’.  If the law does change in the UK, I’d wager that it’ll be because of demographic brute force rather than intellectual fireworks.

(Every now and again I hear a rumour of someone having come up with a new approach to assisted dying debates… but every now and again I hear all kinds of rumours.  I live in hope/ fear: delete as applicable.)

Still, I think it’s worth spending a little time on one of the objections that’s been raised over the last couple of days to this Bill in particular; it’s an objection that was raised by Canon Peter Holliday, the Chief Executive of a hospice in Lichfield:

In an interview with the Church of England, Canon Holliday said: “If there is no possibility within the final legislation for hospices to opt out of being a part of what is effectively assisted suicide, then there is nervousness about where our funding might be found in the future. Would the public continue to support us and indeed would the NHS continue to give us grants under contract?”

Canon Holliday said the Assisted Dying Bill also contains no opt out for organisations opposed to assisted suicide in spite of high levels of opposition to a change in the law amongst palliative care doctors. Where hospices did permit assisted suicide the potential frictions amongst staff could be ‘enormous’ with possible difficulties in recruiting doctors willing to participate, he said.

“The National Health Service requires us, in our contracts, to comply with the requirements of the NHS. Now if the NHS is going to be required to offer assisted dying there is of course the possibility that it would require us or an organisation contracting with the NHS also to offer assisted dying. If we as an organisation were able, and at the moment under the terms of the bill there is no indication we would be able, but if we were able to say that assisted dying was not something that would happen on our premises, would that prejudice our funding from the NHS ?”

Is this worry well-founded? more…

On the other hand…

20 Jul, 15 | by Iain Brassington

… the phenomenon of apologising for the wrong thing comes alongside people taking umbrage at the wrong thing.  Last week, the BMJ ran a head-to-head feature on the “question” of whether doctors should recommend homeopathy.  This was the latest in a series of articles in which a question is posed, apparently strictly on the understanding that it’ll accommodate a polarised debate, and one person is invited to give a “yea” response, and another to give “nay”.  I won’t bother here with a screed about homeopathy: Edzard Ernst does a good job in the BMJ piece, as have many others across the blogosphere.  (You could do worse, for example, than to have a wander through the Anomalous Distraction blog, which is written by an ex-schoolmate of mine, and which also has lots of pretty pictures of proteins and things.)  Since it’s a nice day, and I’m in a reasonably good mood, I’ll even admit that when Hahnemann was working, something like homeopathy was probably as good a punt as anything else that medicine had to offer.  But… y’know.

Aaaaaanyway…  A rather angry letter appeared.  I think it’s worth examining, because it makes a number of normative and value claims; and if norms and values aren’t the meat and veg of an ethicist’s life, then we might as well go home. more…

The Death of Sidaway: Values, Judgments and Informed Consent

15 Mar, 15 | by BMJ

Guest post by Kirsty Keywood (University of Manchester)

On 11th March Nadine Montgomery won her case before the UK Supreme Court to gain compensation for the failure of her obstetrician to warn her of risks associated with the vaginal delivery of a large infant – a risk which she would have averted by requesting a caesarean section.[1] Shortly after his birth, her son was diagnosed with cerebral palsy and a brachial plexus injury, resulting from the occlusion of the placenta during a “very stressful” vaginal delivery.

Nadine Montgomery had diabetes, which increased her chances of giving birth to a larger than average-sized baby. This, in conjunction with her small stature (she was 5 feet tall), indicated a risk that a natural delivery would bring with it a 9-10% chance of shoulder dystocia. Were dystocia to occur, attempts to dislodge the infant’s shoulders through mechanical manoeuvres would generate a risk of occlusion of the umbilical cord resulting in death or cerebral palsy of 0.1%. According to the obstetrician, Dr McLellan, the risk of shoulder dystocia did not merit specific mention in discussions with diabetic patients, because the risk of an adverse event associated with shoulder dystocia was very small indeed.

Mrs Montgomery’s case before the UK Supreme Court hinged on the question of the nature of the obstetrician’s duty to the patient. more…

Once More unto the Breach of Covenant?

31 Oct, 14 | by Iain Brassington

The “Military Covenant” is in the news again:

The government is failing to abide by its military covenant, medical experts who treat injured soldiers have said.

Leading professors in psychology and orthopaedics say the healthcare system is not providing veterans with the service they have been promised. […]

The moral obligation to treat veterans should not stop when service ends, the covenant states, saying veterans should receive priority healthcare from the NHS when they are being treated for a condition dating from their time in the armed forces.

The Covenant is set out here; most of it is pretty vague, and what isn’t vague is largely predictable in its tone.  In respect of healthcare, the relevant part is on p 6:

The Armed Forces Community should enjoy the same standard of, and access to, healthcare as that received by any other UK citizen in the area they live. […]  Veterans receive their healthcare from the NHS, and should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need.

This, at first glance, seems to be saying that members of the forces, and ex-members, should be treated in the same way as everyone else, except that they shouldn’t.  (There’s a fuller version of the statement here.)  The Government repeats this confusing attitude elsewhere: its own website explains that

[i]t’s not about getting special treatment that ordinary citizens wouldn’t receive, or getting a better result. For those that have given the most, such as the injured and the bereaved, we do make an exception

But maybe that’s just a terminological infelicity.

The Covenant itself does not have the status of law (and even if it did, that wouldn’t make any moral difference, unless you happen to think that all law is de facto good law).  However, the Armed Forces Act (2011) does state that the Secretary of State must prepare and present before Parliament every year a report on the covenant; and, according to §343A(3), more…

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…?


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…

Welcome to Britain.

30 Dec, 13 | by Iain Brassington

It having been a long time since my last post, and this being the season of good-will, I wasn’t going to comment on the government’s new policy of charging migrants for A&E services.  Noone needs that kind of spleen on a dreich Monday; besides: I’ve got a PhD thesis that needs assessing, and a bathroom floor that I’ve been meaning to re-lay all year – all manner of better uses of my time.

Still, there’s a couple of things that merit comment.  First, there’s this, from the Government’s press-release:

We know that some people are abusing the system by coming into the country early enough to have one or more antenatal appointments before giving birth on the NHS – without the intention to pay.

I love a good vague statistic.  “Some” people.  There’s nothing offered about how many that amounts to.  Presumably, it’s more than one, but fewer than everyone.  Beyond that, though… well…  The phrase “some” just isn’t very useful when it comes to making judgements about anything – as waitresses (and diners) can attest.  But still, I’m willing to concede that “some” indicates a positive integer, and that there is therefore some measurable impact on expenditure arising from such people.  This doesn’t tell us whether it’s expenditure at a level that should bother us.  The DoH press release offers some illumination on this point: more…

Conference: Compassion Fatigue: Changing Culture in the NHS

18 Apr, 13 | by Iain Brassington

26-28 June, Woodbrooke Quaker Study Centre, Birmingham

(via Andrew Edgar)

Can the language of compassion capture the moral problems confronted by the NHS, or might it obfuscate and distract us from more subtle and demanding issues?

Through a series of plenary addresses, workshops, panels and shared opportunities for discussion, “Compassion Fatigue” will provide an opportunity to explore the language of compassion, and the impact that it has on the practice of health care provision.

More details below the fold. more…

Torture and Fitness to Practise

12 Mar, 13 | by Iain Brassington

I’m running a bit late with this, but the BMJ reported last week that Mohammed Al-Byati had been suspended from the medical register for 12 months for complicity in torture.  So far, the decision hasn’t been uploaded to the list of Fitness to Practise decisions, but the outline of the case is available here, on the “upcoming hearings” calendar:

The Panel will inquire into the allegation that between December 1992 and March 1994, Dr Al-Byati visited camps and prisons in his capacity as a doctor in Iraq.  It is alleged that during these visits and whilst administering treatment, Dr Al-Byati knew that some prisoners he treated had sustained injuries as a result of torture, and it was likely that the prisoners would be tortured again.  It is also alleged that as a consequence of Dr Al-Byati’s engagement in these events, he was complicit in acts of torture.

The BMJ report relates that

the panel decided not to end his career by erasing him from the medical register, after accepting that he played no part in the torture and had effectively no choice but to carry out orders.  He told the panel that he had been “terrified” of what would happen to him and his family if he did not do as he was told.   The panel’s chairman, Michael Whitehouse, said, “He was a junior doctor whose behaviour was being controlled by a dictatorial, totalitarian regime which used systematic, widespread, and extremely grave violations of human rights to control the population.  Dissent from orders was not tolerated.

There’s a couple of things that’re perplexing about this.

The first is that it’s not clear how close to the torture process Al-Byati actually was.  The FtP outline simply alleges that he knew the people he was treating had been tortured, and that they probably would be again.  The BMJ repeats this.  Al-Byati appears to have denied knowing it, but it’s not clear to me that it’d’ve mattered if he had known: treating someone in those circumstances doesn’t amount to endorsement of the torture.

I mean: imagine that you’re working in A&E and someone is admitted whom you suspect strongly (strongly enough for it to count as knowledge in the common-or-garden sense) to have been injured as a result of domestic violence.  You patch up the patient, who then goes home – to face, you suspect almost as strongly, more violence.  It’d be nuts to suppose that you could be criticised as complicit in or even supportive of that violence, though, or that there might be something problematic about treating the patient in the knowledge of what had happened and may happen again.  At most, you might be criticised for not contacting the police or social servives; but that’s a question of confidentiality, and of a totally different stripe – and, anyway, to whom would Al-Byati have reported his concerns?

The other thing that’s perplexing is that noone claims that Al-Byati had any real choice in the matter.  It doesn’t seem unreasonable for a twentysomething medic to agree to provide medical treatment to those who need it, especially when it’s at the request of the state and that state is Ba’athist Iraq.  Maybe he could have refused in principle – but in practice, that kind of refusal may well have been heroic, and it’s odd to criticise someone for not being sufficiently heroic.

In both cases, consider the alternative.  The alternative for the patient is not being treated.  The alternative for the doctor is… well, who can say?  I doubt that there was much scope for conscientious objection.  And remember that the complaint is not that he assisted in the torture, but that he knew about it.

So why apply sanction?  Here’s Michael Whitehouse, the panel chairman, quoted in the BMJ:

He said that the suspension, for the maximum period allowed, was necessary “to demonstrate clearly to him, the profession, and the public that even though his involvement as an accessory to torture was outside his control, such conduct is unacceptable.”

Ummm… Really?  The emphasis is mine, because this is a very, very odd thing to say.  Treating people for the effects of torture is not to be an accessory in any meaningful sense – especially if you didn’t have a realistic choice.  And the pour encourager les autres claim in this context stinks.  I mean, as a principle of justice, my inclination is to think that it’s iffy at best in any circumstance.  But it’s not really as if anyone needs to have it demonstrated that state-sponsored torture is a bad thing to begin with.  And if, mirabile dictu, someone does need to be reminded of that, it’s not clear that they’re going to be swayed by demonstrations of foot-stamping like this.

Note that this case seems to raise questions similar to those raised in respect of medical involvement in capital or corporal punishment.  However, it’s also significantly different from what I can tell.  For one thing, in regimes in which capital or corporal punishment is used and the presence of a medic is mandated as an integral part of that process (for example, if the law demands that a lethal injection be administered by a medical professional), it seems to me that it’d be conceivable that minimally decent doctors would refuse participation, thereby bringing the whole process to a halt.  One might even imagine doctors refusing to be involved as a means of bringing the process to a halt – though you could, alternatively, make a rule-of-law case to insist that medics ought not to aim to undermine valid laws from valid sources, and draw a distinction between conscientious objection that makes the execution of a sentence (and a prisoner) impossible as a side-effect, and more activistic attempts to exert moral pressure on a notionally unjust law.

Whatever.  There’s a debate to be had there, but it doesn’t really speak to this case, because Ba’athist Iraq was not a rule-of-law regime, and (perhaps more importantly) non-participation wouldn’t – on the face of it – have made any real difference, because from the way the story is reported, the presence of a medic like Al-Byati wasn’t a part of the process.  That is: even if Iraq had been a rule-of-law regime, there’s a difference between treating someone who has been tortured and may be tortured again, and treating that person as a part of the torture framework.  There’s no reason to believe that the law required that the torture be overseen by a medic: only that he happened to be the guy closest to hand when the prisoners needed patching up.  Had he not been there, it’s all-too-easy to believe that the torture would’ve happened anyway.

Maybe I’ve missed something about the case.  But from the way it’s reported, it seems possible that the decision has been at least partially determined by the idea that Al-Byati is contaminated by association with bad people.  Either that, or because of PR concerns about the public perception of the matter should the “news”paper to which I do not link get wind of it.

I think that there’s more to be said.  There must be, mustn’t there?

Modesty, Conscience, and What it Takes to be a Doctor (with a bit of Comedy)

19 Oct, 12 | by Iain Brassington

Two apparently unrelated new and new-ish papers in the JME have caught my eye over the last few days.  One of them is this one: Salilah Saidun’s “Photographing Human Subjects in Biomedical Disciplines: An Islamic Perspective”.  We’ll come to the other in a little while.

There’s a couple of puzzling things about the paper.  One is that I’m not sure what the tone is supposed to be.

It could be a descriptive piece, along the lines of “Look, here’s what Muslims might think about medical photography, and if you’re going to take or use medical photographs, you might want to keep it in mind.”  Of course, it’s by no means certain that all Muslims think alike, or that if (mirabile dictu) they do, it has anything much to do with Islam – but we’ll put that to one side.  Similarly, the fact that some people do think this won’t tell us much about what practical implications there ought to be, beyond keeping it in mind.  It won’t tell us that we ought to adhere to those opinions.  Islamic rules might provide a reason to behave in a certain way; but there might be other reasons to behave in a certain other way – and they might sometimes be more compelling.  I’ll put that to one side, too, though.  As a descriptive paper, it might very well be the sort of thing that’s useful on the wards.

But a descriptive reading won’t explain the passages that appear to have a more normative dimension: more…

What can we Learn from “The Exorcist”?

15 Nov, 11 | by Iain Brassington

When John Sentamu stood up in the House of Lords a couple of weeks ago and spoke about the need for the NHS to concern itself with “spiritual” needs – and illustrated his claim with an anecdote about something resembling an exorcism – the response from a lot of the blogosphere was, at its friendliest, one of pointing and laughing.  It’s very easy to see why.  Not only is it slightly embarrassing that in the UK you can be made a Member of Parliament for being good at believing in the right kind of god in the right kind of way, but the NHS – and healthcare generally – is successful when and because its clinical procedures are based on science and reason, not spooky ghosty stuff.  (In fact, I struggle to see what Sentamu actually meant.  He was empatic that the spiritual is not the same as the psychological, but this just prompts a question: what, then, is it – if anything?  If you remove the psychological from the spiritual, does anything remain?  And if it does, how do we know?)

Anyway: I was prepared to go along with the pointing and laughing.  But then, on Saturday, I saw a DVD of The Exorcist for a couple of quid and impulse bought it; and, that evening, I turned off the lights and watched it.*  You’ll have to bear with me on this, but it made me wonder if there might be something interesting about the idea of “spiritual” care on the NHS.  Not that I believe for a moment that there’s such a thing as demonic possession, or such a thing as a soul or spirit.  Of course there isn’t.  But it doesn’t follow from that that such terms have no place in respect of some forms of care. more…

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