News

IME National Student Debate Competition 2020

We are pleased to announce this popular event is back and we are accepting video auditions! 

The audition closing date is 19th December 2019 and the final will take place at the IME Student Conference on Saturday 8th February 2020, Leeds Medical School.

The topic for the video audition is: Competent minors should have the legal right to refuse as well as consent to treatment.

 

CLICK HERE for more information

If you have any questions, please email Phil Greenwood: philg@instituteofmedicalethics.org.



Alexa Warnes, a medical student at Brighton & Sussex Medical School received an IME Bursary for her elective in May 2019. Read the report of her project below

End of Life Choices – Reflections from a medical elective placement in Oregon, USA

As a trainee doctor, death and dying is something that I will inevitably be dealing with during my professional life. And caring for people who are dying can be one of the most dramatic things that doctors will come across. Yet, it still isn't something we are practiced in talking about. I wanted more experience in how to look after the dying person, and decided to organise my medical elective in end-of-life care. I chose Oregon, USA, as a destination because they have an interesting model of palliative care alongside Medical Aid in Dying (MAID). MAID came out of the Death with Dignity law – a law passed in Oregon over twenty years ago, which allows people at the end of life with a six-month prognosis (or less) to take a medication to assist in their death.

Prior to my arrival in Oregon, I was expecting that MAID - a legal choice at the end of life - would be brought up in consultation as readily as, for example, a new drug regimen for pain management, or an appropriate antiemetic to help with nausea. This is not to say that the discussion would be a simple one, but more that it would be easily accessible to the dying person as a part of a wider conversation about end-of-life choices. I soon realised I was naïve in this expectation, as the reality is actually that MAID was never something that would be 'offered' to the patient in consultation with a healthcare professional. It became clear, from what I saw and heard, that the few people who were eligible and then opted for MAID were all people who had very decidedly made this decision for themselves, independently of their doctor. MAID was never something I saw initiated by the doctor. And when I asked doctors about how the conversation with a patient came up, it was apparent – even by those advocating for MAID as a choice – that it would be inappropriate to initiate discussions for fear of it being interpreted as coercion.

Alongside thinking about the fear of being coercive, I also became interested in how a doctor's individual belief system may affect how a patient accesses MAID, as the moral application of MAID continues to cause divisions. I have always been very curious about the power of an individual's personal beliefs, and how these beliefs reveal themselves during professional life. Personal beliefs shape what we think to be right and wrong, and it does not strike me as surprising that when it comes to life and death, people feel very strongly about how these events should play out. In a similar vein to anti-abortion arguments, there are groups of people who believe in the preservation of life, and thus do not believe in MAID. Whilst this is not a piece of writing arguing the bioethics of whether MAID is morally right or wrong, it does invite a consideration of when personal beliefs may overtake, for example, a doctors professional integrity and duty to their patient.

I began thinking about this early in my trip after I met Dr Grey*, a family doctor with many years of experience working as an advocate for MAID. As a doctor, his thoughts were that there is a paramount duty to use professional integrity to guide clinical practice towards what best serves the beliefs and wishes of the patient. This is very different, he says, to using one's own personal belief system to guide what one might think as best for their patient. And Dr Grey explains that where some doctors may resist conversations about MAID because of personal beliefs, he sees it as his professional duty to talk to a patient openly and honestly about all the options of how to die. Thus, in order to do this, it may be appropriate for a doctor to be the first initiator of a conversation about MAID.

Dr Grey's approach stuck with me during my time in Oregon, and I slowly realised that he was in fact rather maverick in his outlook. As the first days of my clinical placement in the hospice went by, conversations between healthcare workers and their patients began gathering in my brain. I found myself often waiting for MAID to be offered to the dying patient, yet this offer was never made. Realising this, I stopped waiting, and instead focused on how different words were delivered about common themes of prognosis, the "dying" process, and then death itself. And I began to see that to be an advocate for MAID, this did not necessarily have to equate with the healthcare worker initiating the conversation with the patient. But it could do – and as Dr Grey explained, for him it was actually part of his professional duty. For most, however, supporting the option of MAID as an end-of-life choice meant responding to a patient's request and guiding them towards necessary next steps.

My reflections on MAID in Oregon have focused on this aspect of "how to have the conversation" because it seems to be one of the main areas that both doctors and patients have difficulty – and thus something that may come up here in the UK should we ever pass a similar law. There are of course many practical issues that go alongside bringing in new healthcare legislation such as ensuring appropriate safeguarding measures, organisation of policy frameworks, and medication issues. But as an ethical question, I did notice myself continually returning to how these initial conversations about MAID actually came about. I am not yet decided on what I consider to be the "best" approach – whether it is the duty of the doctor to initiate the discussion – or instead whether it should always come first from the patient. I see the logic of the latter, but I am compelled by Dr Grey's "professional integrity" and the duty he places on himself to discuss all end-of-life options (including MAID) with his patients. Perhaps there is no 'best' way at all, and as is often the case, it will depend on each individual patient. But it is an interesting thought, and one that will require a doctors scrutiny here in the UK, should they ever find themselves in these consultations in the future.

*Pseudonym



IME Annual Seminar Competition 2019/2020

IME Annual Seminar Competition 2019/2020

 

The Research Committee of the IME is inviting submissions for its annual seminar competition (2019/2020). The closing date for applications is Monday 2nd December at 5pm. Applicants will be notified of the outcome of their submission by Friday 31st January 2020. All funds must be spent by 30th December 2020.

 

What We Offer

We fund projects in the region of £2,500-£3,500, and we expect to make approximately 3-4 awards per year. All costs need to be carefully justified, so we encourage applicants to consider value for money when costing their proposal. Applications will not be considered where the amount of support required from the IME is less than £500, or where the event is targeted at staff or students from a single institution.

 

Eligibility

Applications will only be accepted from IME members, but no restrictions are placed on the professional background of this lead applicant (e.g. academia, research, clinical practice). Whilst early career researchers are encouraged to apply, applications led by, or aimed at postgraduate (including doctoral) students are not permitted via this scheme. Postgraduate students may be listed as co-applicants for this scheme, but are otherwise encouraged to contact the IME’s Postgraduate Committee for alternative funding opportunities.

 

What We Fund

The money can be used to support the delivery of an individual seminar, workshop or short conference, or to support a series of events. Provided that applicants can show relevance to the aims and objectives of the IME, there are no restrictions concerning the subject matter, although applicants should be able to demonstrate clear benefits of the proposed activity to the wider biomedical ethics community (for example through the identification of new areas for inter-disciplinary scholarship, developments in methodology or theory, or through broader research/scholarship capacity building activities). Innovation in activity content and design, as well as collaboration with clinical practitioners is encouraged. Participants must also be able to demonstrate wide-reaching dissemination plans for the outcomes of their event in order to maximise the impact and benefit for the biomedical ethics community. 

 

Please apply using this form ensuring that you take a note of the application rules.

If you have any queries, contact Phil Greenwood philg@instituteofmedicalethics.org



Craig Tilley, a medical student at Brighton & Sussex Medical School, received an IME Scholarship for his BSc Bioethics intercalated degree at University of Bristol, Sept 2017. The report of his project is below

Understanding Dignity: A Fundamental Concept in the Assisted Dying Debate

Background

Dignity is a concept that is intrinsically linked to the assisted dying debate, yet it is considered a murky notion that lacks the clarity to bring anything meaningful to bioethical discourse. This project had three parts. First, to provide an overview of end of life law in the UK. Second, to explore the variety philosophical concepts of dignity and settle on a definition. Third, to apply my defined concept of dignity to the end of life debate.

Part 1

I started my examination of the legal landscape in the United Kingdom (UK) at the end of life with a comparison between the cases of R v Cox[1]  and Airedale NHS Trust v Bland.[2] This provided the perfect springboard for the debate, as it highlights the critical difference between act and omission that UK law has long relied upon. The withdrawal of life sustaining treatments is seen as an omission at law. Therefore, it is not an act that hastens death and is not akin to euthanasia. These cases, in combination with the Suicide Act 1961 provide the basis for the UK's legal principles at the end of life. These are as follows: Assisted dying, be that active euthanasia or assisted suicide is illegal. Whereas passive euthanasia, such as the withdrawal of life sustaining treatments is legal.

With this foundation laid, I move on to discuss the cases that have challenged the UK's current stance. Starting with the cases of Pretty[3] and Purdy[4]. The former leading to the European Court of Human Rights recognising that the UK's current law breached Ms Pretty's right to self-determination under Article 8 of the Human Rights Act 1998. However, this right was sacrificed in order to protect the wider population. Ms Purdy's case lead to the publishing of a policy that brought clarity to prosecution of offenses under the law surrounding assisted suicide.

Finally, I explored the arguments in the case of Nicklinson.[5] Despite this case being unsuccessful, in their judgments the majority supreme court justices appeared to sympathise with the claim that existing law was incompatible with Article 8 of the Human Rights Act 1998. Further to which, it is argued that their statements suggest that Parliament must satisfactorily address this issue. Commentators, such as Hobson argued that in this context, these statements were tantamount to a change to law.[6] The Assisted Dying Bills that followed did not pass. Later, when Noel Conway challenged, many predicted that the declaration of incompatibly would arrive. Ultimately, this did not come to fruition.

Part 2

Macklin argues that without any meaningful definition it is a useless concept that can be removed from bioethical discourse without loss of content.[7] In order to salvage dignity I look to historical uses of the term, before looking to more recent discussion.

This began with an exploration of Immanuel Kant's use of dignity. Kant saw dignity as the intrinsic value that all human beings possess due to their capacity for autonomous action.[8] However, he failed to appreciate that not all human beings have a capacity for autonomous action, such as those in a coma, yet we still see them as having dignity that can be affronted. Therefore, I abandoned the Kantian approach for a modernistic account by Neal.[9]

Neal sees universal vulnerability as the organising idea of dignity. The value of dignity is its positive valuation of the things that make all humans vulnerable to harms. I failed to find flaw's in Neal's claims, but felt her account lacked the clarity to be a useful concept. I decided to combine her account, with its basis of vulnerability with Foster's Aristotelian account of dignity. Foster's account sees dignity as a way of "being", which I argue can be seen as "being vulnerable" as all humans are. This model for application of dignity uses a consequentialist transaction in which all stakeholders in a decision have their dignity accounted for.  Ultimately, the transaction aims to protect dignity by promoting the views of the most vulnerable and maximising the thriving of stakeholders as a whole.

Part 3

Next, I needed to perform an audit of the dignity interests of all stakeholders. I considered three stakeholders; the patient, 'at risk' groups and doctors.

In the case of the patient, whom I considered to be the most vulnerable group, I concluded that only in a very specific set of circumstances would an assisted death promote dignity. These are that the patient is in a state of such permanent ill-health that they lack the capacity to thrive and are only moving away from thriving and towards greater vulnerability. Only in these circumstances will assisted dying protect the dignity of patients.

Next, we consider 'at risk' groups such as the old, disabled and psychologically distressed. It can be argued that individuals belonging to these groups will be considered as lacking in the capacity to thrive at all times. I found this issue difficult to overcome and brought to light the need to individualise thriving which makes my model of dignity less useful as a general concept.

When considering the dignity of the doctor, I considered a thriving doctor to be one who practices within on the goals of medicine and professional integrity. Many argue that preservation of life is the most critical goal of medicine. However, in response I argue that once a patient is recognised as dying, this is no longer the critical goal and is replaced by a focus on comfort. Therefore, a doctor who aids a patient with a terminal illness and a voluntary request for an assisted death does not contradict the doctors thriving.

Conclusion

From my three sections I arrive at three conclusions. One, a hidden majority of supreme court justices see current law as incompatible with human rights. Two, the murky notion of dignity can find footing in intrinsic human vulnerability. Three, auditing the dignity of all stakeholders I arrive with a result in support of assisted dying for terminally ill individuals who lack the capacity to thrive.

[1] [1992] 12 BMLR 38.

[1] [1993] AC 789 (HL).

[1] R (Pretty) v Director of Public Prosecutions [2001] EWHC Admin 788.

[1] R (Purdy) v Director of Public Prosecutions [2008] EWHC 2565 (Admin), [2009] HRLR 7.

[1] R (Nicklinson) v Ministry of Justice; R (AM) v Director of Public Prosecutions [2014] UKSC 38, [2015] AC 657.

[1] Clark Hobson, 'Is it now institutionally appropriate for the courts to consider whether he assisted dying ban is human rights compatible? Conway v Secretary of state for Justice.' (2017) Medical Law Review accessed 8 April 2018.

[1] Ruth Macklin, 'Dignity is a useless concept.' (2003) 327 British Medical Journal 1419.

[1] Immanuel Kant, Groundwork for the metaphysics of morals (JW Ellington trans, 2nd ed, Hackett, 1994) 40.

[1] Mary Neal '"Not gods but animals": Human dignity and vulnerable subjecthood' (2012) 33 Liverpool Law Rev 177.



Sara Khalid, a medical student at University of Exeter received an IME Scholarship for her intercalated BA in Medical Humanities with Ethics, Sept 2018. Read the report of her project below

'To treat or not to treat'- the modern's physician's dilemma in the discussion of paediatric end of life care

Background

Paediatric end of life care is becoming an increasingly prevalent conundrum for doctors. With an increase in premature neonatal survival, a new population is arising1. End of life care now includes babies who have beaten their statistical survival probability odds, bringing new ethical considerations. Highly publicised cases of Charlie Gard and Alfie Evans have caused public uproar, presidential involvement and professionals receiving death threats3-5. The courts often become involved, a traumatic experience for both doctors and parents. Could perhaps the answer in the best way to manage such cases lie in returning to ethical theory and principles? Furthermore, could revisiting ethical theory shed some light on the reason as to why the courts are often seen backing the doctors' decisions rather than the parents desires?

Due to word constraints, this summary only describes main discussions. Others investigations have not been covered but are mentioned in the conclusion.

Methodology

Information was obtained through literary searches and databases. Modules taken in Medical Ethics and Law and Disability in Society, provided skills and knowledge in interpreting, understanding and criticising end of life law and ethics.

Key ethical principles

It has been suggested that a thorough understanding of ethics will aid decision-making6. However, as ethical principles are explored, more clashes between them are found. Identifying clashes illustrates inconsistencies in end of life reasoning that is currently used as justification in paediatric end of life decision-making.

Autonomy

Autonomy is the foundation on which patient desired passive euthanasia (PPE) is built on, as seen in Re B7. However, autonomy is not respected in active euthanasia (AE) or assisted suicide (AS) as seen in the case of Tony Nicklinson8. Therefore, the discussion surrounding autonomy is complex and inconsistent enough without the consideration of paediatric patients who are unable to voice their autonomy, with Gillick's competence also being of no use in the neonate population.

To overcome this, English Law requires parents and clinicians to agree on a 'best interests' decision on behalf of the child with the courts making the decision if disagreement, as was seen with Alfie Evans, occurs. However, 'best interests' is vague and difficult to gauge and gives rise to a standoff between the parents' and doctor's autonomy. Patient autonomy is not absolute, with patients not able to demand treatment. AE and AS requires a substance to be administered whereas patient requested PE declines treatment and is therefore covered by autonomy. This concept could be extrapolated to parents, perhaps offering a solution to when disagreement occurs. Parents' autonomy by proxy can decline treatment but not demand it. However, this is also not clear-cut as doctors can also override parent's decisions in refusing treatment, if they believe it not to be in the child's best interests e.g. blood transfusions in Jehovah's Witnesses.

Sanctity of life

Sanctity of life is often cited why AS and AE cannot be legalised. However, this argument is often criticised, due to its religious origins having no place in secular state9, but also as it is of no concern when treatment is withdrawn.

Dworkin argues sanctity of life coexists with quality of life. If a person has a poor quality of life, its value diminishes and therefore no longer protected by the principle9. However, Dworkin's reasoning is problematic as it justifies terminating individuals' life with social/mental issues who believe their life has no value when other methods to remedy that belief are available. Furthermore, in paediatric cases it is arguably impossible to make a judgment about the kind of life a baby will have. Clinicians can attempt to predict but they cannot say for definite, seen in the ongoing debate surrounding Down syndrome and terminations10,11. Furthermore, value comes from more than just health. Those considered 'healthy' for numerous social reasons lead lives with seemingly no value. However, suggesting a neonate's life not be protected for either having a disability or being born into difficult social situations e.g. as an addict due to maternal drug use would be absurd, rendering sanctity of life also useless in this discussion.

Intention verses foresight

A loophole to explain why AE and AS are illegal, yet doctor dictated PE is not, is that the latter foresees death but does not intend it. This can therefore be used to understand previous paediatric end of life decisions. Keown argues that a distinction exists between intended consequences of an act and foreseen consequences of act, as certain12. A surgeon knows that surgery will cause post-operative pain. This differs from the surgeon, who operates in order to induce pain. Furthermore, the pain is not the means by which the operation will succeed, therefore foreseeing death is different to intending and knowing a side effect of an action does not prove causation. However, the law can only work when consequences of an action are assessed over the act itself13. Therefore, in the case of Indirect Euthanasia, the purpose of an act could reasonably be pain relief, however PE has no similar purpose that doctors could cite apart from death.

As foreshadowing arguments are unconvincing, there appears no reason why AS and AE are illegal. This complicates Paediatric end of life decision making, as what is often portrayed as beneficent terminating of suffering, is through studying ethical theory, technically no different to illegal and condemned acts of AE and AS.

Conclusion

End of life decisions are an ethical maze. The law is not morally consistent, with study of ethical principles showing inconsistencies. Furthermore, such discussion usually centres on adult patients, with little discussion on paediatrics. This summary only touches upon some of the issues in this argument, with topics of omission verses act, personhood, dignity and the weight placed on medical opinion by the courts all further areas that should be considered. What is clear is that although an increased understanding of ethical theory is useful for one's own understanding, it does little to help the physician faced with a difficult paediatric end of life decision, as the more one delves into the theory, the more inconstancies and questions arise.

References

Santhakumaran S, Statnikov Y, Gray D, et al Survival of very preterm infants admitted to neonatal care in England 2008–2014: time trends and regional variation Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 07 September 2017. doi: 10.1136/archdischild-2017-312748

Dyer C. Doctors and parents agree care plan for toddler with terminal condition.

Robert Mendick. [Internet] The Telegraph: Charlie Gard court case: Parents have just 48 hours to prove untested, experimental technique works. July 2017, Accessed December 2019. Available from: https://www.telegraph.co.uk/news/2017/07/10/charlie-gards-parents-stressed-hopeful-ahead-new-court-hearing/

Mary MacLeod. [Internet] Great Ormond Street: Statement from Chairman of Great Ormond Street Hospital, 22 July 2017. July 2017. Accessed December 2019. Available from: http://www.gosh.nhs.uk/news/latest-press-releases/statement-chairman-great-ormond-street-hospital-22-july-2017

Dyer C. Doctors can withdraw treatment from child on life support, says judge. BMJ: British Medical Journal (Online). 2018 Feb 21;360.

Tripp J, McGregor D. Withholding and withdrawing of life sustaining treatment in the newborn. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2006 Jan 1;91(1):F67-71

Re B (Adult: Refusal of Medical Treatment) [2002] EWHC 429.

R (Nicklinson) v Ministry of Justice [2014] UKSC 38.

Jonathan Herring, Medical Law and Ethics, (5th edn, Oxford University Press, 2014) 528

BBC Radio 4. Disability. Beyond Belief. 10/9/18. Available from: https://www.bbc.co.uk/programmes/b0bh431j [Accessed on 25/2/19]

A world without Down's syndrome? 2016.

Jonathan Herring, Medical Law and Ethics, (5th edn, Oxford University Press, 2014) 520

Andrew McGee, "Finding a way through the ethical and legal maze: withdrawal of medical treatment and euthanasia" [2005] 357, 373.



In memory of The Very Rev'd Edward Shotter, Hon Vice-President, Institute of Medical Ethics

Ted Shotter

(29 June 1933 – 3 July 2019)

We are deeply saddened to inform you of the recent passing of Ted Shotter, Hon Vice-President, IME. Ted was a true pioneer in the field of medical ethics and leaves behind an outstanding legacy, both in the UK and worldwide. Prof Raanan Gillon, President of the IME, has written a tribute which he delivered at Ted's funeral service at Blythburgh Church ('the cathedral of the marshes') in Suffolk on 29 July, and which will give you a flavour of Ted's life and achievements...

Edward Shotter - a true innovator for medical ethics

I was introduced to Ted in the very early 1970s by the Dean for postgraduate students at University College Hospital London, Gerald Stern, who knew I had an interest in medical ethics. 'Ted Shotter is the man you need to meet' – and how right he was. However at that first meeting I told Ted- who had previously been a Student Christian Movement chaplain to medical students- that I very much doubted that I, an atheist Jew- albeit educated at Christ's Hospital- could be much help in his very Christian– as I then perceived it to be- London Medical Group. He smiled- he might even have winked. 'If you'll forgive my saying so Dr Gillon I think you're a Godsend'. Ted had in fact been assiduously extending the teaching of medical ethics to medical students of all faiths and none. Well we were friends ever since and I was appointed another of his 'Assistant Directors' of the London Medical Group. The LMG as it was known, along with the similar student-led groups that arose in every UK medical school, was the first of Ted Shotter's three major contributions to medical ethics both in the UK and internationally, for it introduced outside experts into the teaching of medical ethics to medical students, and about subjects chosen by the students themselves. Since Hippocratic times medical ethics had been a zealously guarded doctors-only zone but Ted changed all that!

His second major contribution was the invention of the Institute of Medical Ethics, at first somewhat laboriously named the Society for the Study of Medical Ethics. That Institute is these days a significant UK charity promoting teaching, research and publication in medical ethics, and providing grants for doing so, thanks in large measure to its co-ownership- with the British Medical Association- of the very successful Journal of Medical Ethics. That journal is Ted's third major contribution to the development of national and international medical ethics, for it is now one of the world's leading bioethics journals. Again Ted's encouragement was hardly a hindrance to my application back in 1980, to be, after Alastair Campbell, the JME's second editor- a post I somewhat greedily held for twenty years.

I was so pleased to have very recently been able to pass on slightly belated birthday greetings from his IME colleagues, friends and admirers and to reminisce with him about the achievements I've just mentioned; and also to recall his honorary Fellowship of the Royal College of Physicians, as well as his international recognition by the American Hastings Center in bestowing its prestigious Henry Knowles Beecher Award for life time contributions to bioethics. The occasion was lunch at Westhall, nobly prepared for the two of us by Jane before she retired to her own sick bed. Ted was in wonderful form and several times said what a fortunate man he was in so many ways, and especially in his lovely and loving wife and family.

It was a terrible shock to learn that he had died the following day- but it remains my strong impression that he died a truly happy man.

Prof Raanan Gillon
President, Institute of Medical Ethics



Dr Abidemi Otaiku, FY1, received an IME conference grant to present a poster at the Neuroethics Network meeting, Paris, June 2019. Read his report below

The Neuroethics of Dreaming? Ethical & Psychological Implications of Lucid Dream 'Immorality'

I recently had the opportunity to attend the Neuroethics Network 2019 Meeting which was held at the Brain and Spine Institute in Paris, an internationally recognised neuroscience research foundation, located on the grounds of the world famous Salpêtrière hospital. 

This was an intimate three day meeting that brought together early career researchers and established academics from around the world working in neurology, psychiatry, philosophy, ethics and neuroscience, to present and discuss the latest research findings in Neuroethics - the academic discipline concerned with the ethical, societal and legal implications raised by advances in neuroscience and neurotechnology.

Over the three days of the meeting, there were seven 'Athenaeum Seminars', which were essentially three to four themed talks grouped together in the programme, each covering a key topic in neuroethics. These ranged from highly pragmatic talks focused on ethical issues arising from treating complex psychiatric patients, in the 'Psychiatric Illness' seminar, all the way to the more esoteric and philosophical, but still fascinating talks, regarding machine consciousness and 'machine moral responsibility' in the 'Other Minds' seminar. Other seminars had a more interdisciplinary nature such as the seminar 'Forensic Psychiatry and Neurolaw' which explored how neuroscience may affect how we determine the legal culpability of offenders, and also, how neuroscience based interventions – such as so-called 'moral bioenhancement' may one day be used to prevent offenders from committing further crimes.

In addition to the talks included in the Athenaeum Seminars, there were also a number of e-poster presentations that were displayed throughout the meeting. I had the privilege of having an abstract for my research on the ethical and psychological implications of "immoral" lucid dream behaviour, accepted for an e-poster presentation at the meeting. I received some very helpful and interesting feedback from the delegates who had read my poster and had come to find me during breaks in the programme to discuss my work further. I am hoping to write up this research for submission to a medical ethics or neuroethics journal in the coming weeks, and I will most certainly be integrated some of the constructive feedback that I received throughout this meeting to improve the final manuscript.

Overall this was a very enjoyable and intellectually stimulating meeting, which introduced me to new areas of neuroethics and also increased my knowledge of areas that I had already been familiar with. Having this opportunity to present my work at an international conference at such an early stage in my career was a greatly informative experience, and has given me the confidence to submit my work to other international medical ethics or neuroethics conferences in the future.

I am very grateful to the IME for awarding me with a Postgraduate Conference Grant, which enabled me to attend and present my work at the Neuroethics Network Meeting, which I highly enjoyed, and which has also deepened my knowledge of the fascinating field of neuroethics.



Sarah Kelly, a medical student at University of Edinburgh received an IME Scholarship for her Master of Bioethics intercalated degree at Harvard University, August 2017. Read the report of her project below:

Handling Medical Error: Lessons to be learned from the US?

Medical error is a leading cause of death in Western nations.1 To address this problem, there have been recent public policy and legal reforms in the UK, including a statutory duty of candour and emphasis on institutional support and responsibility.2 These aim to engender a culture of openness and transparency in order to better prevent, address and learn from medical errors. However, there have been limited concurrent educational or institutional changes to support these statutory and professional obligations. Current practices around institutional handling of medical error continues to fall short of these professed policy and legal standards, as was borne out in the case of Dr. Hadiza Bawa-Garba.3 This case reignited debate around medical errors in the UK and how they ought to be handled and the medical community expressed outrage and fear over the decisions of the Court and General Medical Council.3 It highlighted the tension between the legal tendency to pinpoint blame and the professed aim of the medical community to acknowledge collective responsibility. In particular, many called for new ways to consider how institutions can better support individuals involved in instances of medical error.

Medical practice in the US has gained a reputation for its litigious culture and many individual hospitals are taking steps to avoid medical errors in order to reduce litigation and improve patient care.4 As part of the Masters of Bioethics programme at the Center for Bioethics, Harvard Medical School I interned with the Ethics Committee at Beth Israel Deaconess Medical Center. As part of this I assisted in ethics consultations requested by patients and clinicians and I took particular interest in their proactive approach to handling medical errors. This report considers some of the steps taken by BIDMC to address and reduce “preventable harm” and how they might be applicable to UK medical practice.

One method by which BIDMC aims to promote collective responsibility around medical error is by publishing quarterly reports of “Preventable Harm” online.5 On their publicly available website, the hospital lists the number of reported errors across many contexts, including surgical site infections, falls resulting in injury and disrespectful communication. This allows for ready identification of common errors, which has led to review and improvement in areas such as infection control. It aims to destigmatise error and share responsibility for improving practice between clinicians and management. By encouraging open dialogue around errors, the hospital aims to demonstrate to patients and families that they are actively identifying important contexts where mistakes commonly occur and proactively addressing them. This approach to transparency is relatively unique among Massachusetts hospitals and I could find no record of UK Health Boards doing anything similar. Given that data around numbers of incidents of medical error are commonly recorded by hospital management, it would be feasible to create comparable documentation in the UK—whether available online to the public, to clinicians only, or available upon request. Tracking such numbers might provide the institutions with a certain accountability to ensure that areas of common mistakes are acknowledged and could identify specific areas that require additional support.

Secondly, BIDMC (along with other Massachusetts hospitals) have introduced a Communication, Apology and Resolution (or “CARe”) initiative.6 Clinical staff are provided with training to encourage timely communication with patients and families.5 The “CARe” initiative is offered as means of encouraging collaboration between involved parties to prevent future errors. Meetings between parties following difficult events can provide valuable time for personal and team reflections on the surrounding circumstances and emotions and what might be done in future to improve practice. Decisions regarding whether to pursue litigation are complex and multifactorial but the provision of an alternative, non-adversarial but official pathway for dealing with mistakes is thought to reduce rates of legal action. Data tracking practice since 2001 at the University of Michigan has demonstrated that such a programme as led to a reduction in the number of patient injuries claims, system improvements following investigation of claims, shorter time to claim resolution, and significantly decreased costs for both the claimants and the hospital involved.4 Given that the cost of legal claims is known to be rising around the UK, such a system would not only encourage valuable (and confidential) individual reflection but also serve as a means of allowing funds to be spent on improving care rather than costly compensation.

 

Thirdly, BIDMC Ethics Committee provide consultations at any point of patients’ journeys. They can provide support, guidance and mediation around complex decisions, reducing harms like disrespectful communication. They also offer discussions and debriefs with patients, families, and clinicians after difficult events to ensure all perspectives are considered to improve practice. Ethics committees who provide such contemporaneous advice, actively meet with all stakeholders, and provide care-guiding advice remain rare in the UK;7 in the US, almost every hospital now has some form of committee providing such consultations.8 My experience demonstrated the role of committee members (with appropriate training in communication) being involved early in discussions with the medical teams after an error to advise on the most suitable methods and circumstances to discuss the errors with patient and family. They often worked in conjunction with the hospital legal team to counsel on how to broach the subject with honesty and integrity, while assuaging clinicians’ commonly-held fears around litigation.


In conclusion, medical error is a complex but important issue that must be acknowledged and addressed. My experience with BIDMC Ethics Committee has demonstrated some ways in which mistakes can be identified, tackled and prevented. Transparent record-keeping of numbers and patterns of incidents, explicit programmes to encourage communication and collaboration around medical error, and ethics committees to provide guidance and mediation are all examples of some methods that could be used to improve practice.

 

REFERENCES

 

  1. Makary, M, and Daniel, M. 2016. "Medical Error—The Third Leading Cause of Death in the US". BMJ, p.i2139.
  2. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  3. Cohen, D. 2017. "Back to Blame: The Bawa-Garba Case and the Patient Safety Agenda". BMJ, j5534.

4.Michigan Medicine. University of Michigan (2019). The Michigan Model: Medical Malpractice and Patient Safety at Michigan Medicine. [online] University of Michigan. Available at: https://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs [Accessed 16 June 2019].

 

  1. BIDMC. Eliminating Preventable Harm at BIDMC. https://www.bidmc.org/about-bidmc/quality-and-safety/efforts-to-improve-quality-of-care/eliminating-preventable-harm-at-bidmc. [Accessed 16 June 2019]

 

6.Massachusetts Alliance for Communication and Resolution following Medical Injury (2019). MACRMI: About CARe. [online] Available at: https://www.macrmi.info/about-macrmi/about-dao/ [Accessed 16 Jun. 2019].

 

7.  Sokol, D. 2014. "Renewing the Call for Clinical Ethicists". BMJ 349. 2: g5342-g5342.

 

8. Aulisio, M. (2016). “Why Did Hospital Ethics Committees Emerge in the US?”. The AMA Journal of Ethics, 18(5), pp.546-553.

 

REFERENCES

  1. Makary, M, and Daniel, M. 2016. "Medical Error—The Third Leading Cause of Death in the US". BMJ, p.i2139.
  2. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  3. Cohen, D. 2017. "Back to Blame: The Bawa-Garba Case and the Patient Safety Agenda". BMJ, j5534.

4.      Michigan Medicine. University of Michigan (2019). The Michigan Model: Medical Malpractice and Patient Safety at Michigan Medicine. [online] University of Michigan. Available at: https://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs [Accessed 16 June 2019].

  1. BIDMC. Eliminating Preventable Harm at BIDMC. https://www.bidmc.org/about-bidmc/quality-and-safety/efforts-to-improve-quality-of-care/eliminating-preventable-harm-at-bidmc. [Accessed 16 June 2019]

6.      Massachusetts Alliance for Communication and Resolution following Medical Injury (2019). MACRMI: About CARe. [online] Available at: https://www.macrmi.info/about-macrmi/about-dao/ [Accessed 16 Jun. 2019].

7.      Sokol, D. 2014. "Renewing the Call for Clinical Ethicists". BMJ 349. 2: g5342-g5342.

8.      Aulisio, M. (2016). “Why Did Hospital Ethics Committees Emerge in the US?”. The AMA Journal of Ethics, 18(5), pp.546-553.



Lydia Daniels, a medical student at Imperial College London received an IME Scholarship for her intercalated BSc in Medical Sciences with Humanities, Philosophy & Law, Sept 2018. Read the report of her project below

Should doctors be the arbiters in decisions to withdraw artificial nutrition and hydration from minimally conscious and vegetative patients?

My project focuses upon the decision to withdrawal artificial nutrition and hydration from patients in a vegetative or minimally conscious state. More specifically, I respond to the ruling in An NHS Trust v Y (2018) (hereafter, NHS v Y), by asking, should doctors be the ultimate arbiters of these decisions, according to the nature of the decision and the doctor's role?

The landmark case of Airedale NHS Trust v Bland (1993) (hereafter, Bland) ruled that indefinitely prolonging a life in a vegetative or minimally conscious state may not always be in the patient's best interests and hence that withdrawing ANH can be legal. The question of 'who decides' was granted legal clarity in NHS v Y, a Supreme Court ruling which confirmed that doctors can withdraw ANH from patients in permanent vegetative and minimally conscious states (PVS and MCS) without recourse to the courts, providing there is agreement between the doctor and the family that this is in the patient's best interests.

Making this decision in the clinical setting has clear practical and economic benefits. Halliday et al. (2015) states that NHS economists estimate the average court referral process costs around £122,000, and Holland et al. (2014) highlight the emotional distress that delays in withdrawal can cause families.

Beyond its practical implications, the ruling in NHS v Y prompts us to reflect on the critical question of whether doctors should be entrusted with decision-making power in these cases. Wicks (2019) claims this ruling threatens the patient's right to life by removing a neutral advocate in the court, and Foster (2018) argues the ruling could lead to paternalistic decision-making orientated around biomedical need rather than patient wishes. However, in order to make a more robust evaluation of this ruling we must take a broader view. As Lord Browne-Wilkinson states in Bland, 'behind the questions of law lie moral, ethical, medical and practical issues of fundamental importance to society' (p877). These issues need to be evaluated in order to test whether the ruling in NHS v Y reflects a fair balance of perspectives. My project uses a multidisciplinary approach by looking at the sociological background, legal context and professional implications of the ruling in NHS v Y to assess whether doctors are well-placed as arbiters of these decisions.

Firstly, I track the court's deference to the medical profession, particularly following the shift towards greater respect for patient autonomy demonstrated in the Mental Capacity Act (2005). Looking forward to NHS v Y, I have identified the element of deference in the ruling's assertion of doctors as arbiters of these decisions and its reliance upon professional regulation. However, I argue that this deference can be dissociated from traditional, paternalistic notions of the term, in light of how the profession and its guidance has evolved to become more patient-centred, as suggested by Devaney and Holm (2018).

I also investigate the nature of the decision doctors are being asked to make: firstly how the concept of best interests has evolved to become more holistic, and secondly whether withdrawal of ANH from PVS/MCS cases ought be to categorised as 'special cases'. My project considers that viewing PVS/MCS patients as deserving of a higher safeguarding standard than other patients is unjustified, and that the technicalities of diagnosis should not overshadow consideration of the patient's wishes. NHS v Y has rightly aligned these decisions with other life and death best interest decisions, however the significance of ANH and its withdrawal for families should be taken into account by doctors and discussed with sensitivity.

I then focus on whether clinical decision-making in the present day lends itself to withdrawal decisions, including discussion of the broader role of ethical decisions in medicine. Contrary to the concern that this ruling will incite paternalistic decision-making, empowering doctors to be arbiters of these particular decisions allows timely withdrawal of ANH when it is agreed to no longer be in the patient's best interests. I argue, therefore, that this model may demonstrate greater respect for the patient's wishes.

Paternalistic or idiosyncratic decision-making is mitigated against by the rigour of the professional guidance. I have considered that the measures which have been put in place within the guidance have created sufficient safeguards for the patient's right to life: consultation with those concerned for the patient's welfare, the expert 'second opinion' and the option to consult the courts.

My project concludes that the ruling in NHS v Y represents a positive step forward, asserting the doctor as the arbiter of these withdrawal decisions and recognising their ability to develop and exercise sound ethical decision-making, for the ultimate benefit of the profession and its patients.

Although this project has advocated doctors as the appropriate decision-maker in these sensitive and important scenarios, this must correspond with standards in clinical training. I recommend that medical schools ensure that they facilitate the development of sound ethical reflection and knowledge of the law to equip future doctors to face such scenarios. Incorporating this into a broader study of medical humanities would give students an appreciation of the profession's historical and sociological context as well as the narratives brought forwards by patients. This would encourage future doctors to properly evaluate their assumptions alongside patients' personal, religious and cultural values.

With heaviness of heart I recognise that the voices of PVS and MCS patients cannot contribute to this debate. Unless we are able to establish communication with these patients, the decision-maker must rely on second-hand accounts of previously-expressed feelings and values. It has been deeply moving to consider the impact of the decision-making process on the family, many of whom see withdrawing ANH as an impossibly difficult decision, but at the present time, the only feasible option to allow their relatives to die. This project also illuminates the need to encourage patients to draft advance decisions to refuse treatment where appropriate, ensuring these are properly documented and respected by healthcare teams.

I am incredibly grateful for the opportunity to explore this topic and extend particular gratitude to the IME for their financial support.

References

Airedale NHS Trust v Bland (1993) House of Lords, AC 789 (House of Lords)

An NHS Trust & Ors v Y & Anor (2018) Supreme Court, UKSC 46 (Supreme Court)

Mental Capacity Act (2005) (c.9) United Kingdom. London: HMSO. Available at: https://www.legislation.gov.uk/ukpga/2005/9/contents

Devaney, S. & Holm, S., 2018. The Transmutation of Deference in Medicine: An Ethico-Legal Perspective. Medical Law Review, 1 5, 26(2), pp. 202-224.

Foster, C., 2019. The rebirth of medical paternalism: An NHS Trust v Y. Journal of medical ethics, 1 1, 45(1), pp. 3-7.

Halliday, S., Formby, A. & Cookson, R., 2015. An assessment of the court's role in the withdrawal of clinically assisted nutrition and hydration from patients in the permanent vegetative state. Medical Law Review, 23(4), pp. 556-587.

Holland, S., Kitzinger, C. & Kitzinger, J., 2014. Death, treatment decisions and the permanent vegetative state: evidence from families and experts. Medicine, health care, and philosophy, 8, 17(3), pp. 413-23.

Wicks, E., 2019. An NHS Trust and others v Y and another (2018) UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal. Medical Law Review, 15 1



Rachel Burnley, a student at University of Bristol Medical School, recently received an IME Institutional Grant to help fund the BSc Bioethics student-led conference 'Personal Beliefs within Medicine' held March 2019.

Click HERE to read the report which highlights an excellent example of a university involving students from local schools and colleges in ethics conferences as part of their widening participation scheme.



The Nuffield Council on Bioethics has published a bioethics briefing note on disagreements in the care and treatment of critically ill babies and young children.

The briefing note outlines the possible causes of disagreements between parents and healthcare staff, and highlights areas of action for healthcare policy-makers and NHS leaders that could help to prevent prolonged and damaging disagreements developing in future, or to resolve them more quickly.

 

Overall, they suggest the aim should be:

  • good communication between families and staff and an understanding of differing perspectives

  • appropriate involvement of parents in discussions and decisions about the care and treatment of their child

  • timely use of resolution interventions, such as mediation, in cases of disagreement

  • attention to the profound psychological effects that disagreements can have for families and staff.

     

    The briefing note is available at: http://nuffieldbioethics.org/project/disagreements-care-critically-ill-children. 

    Please do not hesitate to get in touch with Nuffield Council on Bioethics if you would like to discuss any aspects of the briefing note:

    020 7681 9622 |

     

T: +44 (0) 20 7681 9622 | E: sgriffiths@nuffieldbioethics.org



Financial support for carers. Had an abstract accepted for the IME Conference 2019?

If you have had an accepted accepted for the IME Conference on 24-26 June 2019 at Cardiff Metropolitan University, you might be eligible for financial support for carers.

The IME recognises that for those of you with caring responsibilities, attending events such as the IME Conference is an important part of developing and maintaining your career.  The IME also understands that attending such events can cause an additional financial burden if you need to make alternative care arrangements.

To help alleviate some of this burden, we are introducing a scheme which may entitle you to a small grant of up to £250 (maximum fund of £2,000) if you have caring responsibilities.  In order to qualify for the grant you must have an abstract accepted for the conference. *Abstract Submissions are now closed*

The grant can be used to fund additional/alternative care arrangements for your dependent* to either stay at home while you travel, or to fund travel and associated care costs allowing the dependant to travel with you.

Note:
A dependant is a partner, child or parent, or someone who lives with you as part of your family. This could be, for example, an elderly aunt or grandparent. It does not include tenants or boarders who may be living in your family home.

You may make an application for this grant if the following conditions apply:

·You have caring responsibilities and nobody else at your home can provide the care.

·No alternative source of funding is available, e.g. from the conference/training etc. organiser or by other means, such as from research grant funding.  Where relevant it is your responsibility to provide evidence that no alternative source of funding is available.

·The grant is to cover costs outside of the routine everyday care costs you normally incur.

The funds will be paid on receipt of an invoice/receipt detailing the costs incurred. Please note that any impact on benefits or HMRC impacts are the responsibility of the applicant.

Click here for an application form.

Click here for guidelines.

 



National Student Debate Final 2019

Winners! The Keele team

Winners! The team from Keele

Congratulations to the team from Keele University who took on the reigning champions Queen's University Belfast at the 2019 National Student Debate Final in Manchester on Saturday 9 March. Queen's won both the 2017 and 2018 finals & proved to be tough opponents during the 2019 final but, in the end, Keele triumphed.The motion was Law & professional guidance should abandon the 'best interests' test in favour of the 'serious harm' test when deciding whether to override the decisions of parents about treatment for their children.

Congratulations once agan to Keele and commiserations to tough opponents Queen's.

Thank you to all the teams who entered, in particular those who reached the final: Keele University - Queen's University Belfast - University of Liverpool - University of Exeter - University of Sheffield - University of Cambridge - University of Cambridge - University of Birmingham.

Thank you also to our guest speaker, Dr Joe Brierley (Consultant Paediatric Intensive Care & Director of Bioethics), Great Ormond Street Hospital who spoke to the students about Paediatric Bioethics, and also to our panel of judges: Georgia Testa, Dr Richard Knox, Dr Joe Brierley, Miss Lorraine Corfield, Dr Vivienne Crawford, Dr Simon Deery, Julie Stone, Jordan Parsons and Dr Daniel Tigard.

Details of next year's competition will be announced later this year.

Runners up Queen's Dr Joe Brierley Runners up Queen's and

Dr Joe Brierley, Great Ormond St Hospital




Calling Medical Undergraduates! The IME Student Council are recruiting!

Click here for details and how to apply.

Join us & help promote interest & awareness of medical ethics.

Deadline for applications: midnight, Sunday 2 June 2019



IME Student Conference 2019: Medical Ethics in a Technologically Advancing World

Click here to read a conference review, by Charlotte Galvin, intercalating medical student, Keele University and IME Student Conference Vice Chair.
 



Dr Richard Shoulder was awarded a full elective bursary 2017/18 for his project entitled 'Elective Ethical Toolkit - an essential for medical students working abroad' whilst in his final year at University of Bristol.

Richard is also the 2018 winner of The Mark Brennan Poster Prize (bursary category) for his poster of the project. Congratulations Richard!

To read Richard's elective report (which includes the Elective Ethical Toolkit), click here.



Progress Educational Trust Annual Conference - Institutional Grant Report

PET conference_2018The IME was pleased to be able to award an Institutional Grant to PET to fund the attendance of eight medical students at their annual conference Make Do or Amend: Should We Update UK Fertility and Embryo Law? on 5 December 2018.

Read their report below ...

The Progress Educational Trust (PET) is an independent registered charity founded in 1992 to advance public understanding of ethics, law and science in the fields of human genetics, assisted reproduction and embryo/stem cell research.

PET works to improve choices for people affected by infertility and genetic conditions, and to promote the responsible application of science through education and debate.

PET's discussion conference Make Do or Amend: Should We Update UK Fertility and Embryo Law?, which was held at Amnesty International in London, on 5 December 2018, explored law and regulation governing fertility treatment and embryo research.

In the PET tradition, following introductory presentations the bulk of each session's running time was devoted to soliciting questions and comments from the audience.

Conference sessions included:

The Human Fertilisation and Embryology Act: Is It Broke and Should We Fix It?

Society Marches On: Key Social Changes

Science Marches On: Key Scientific Developments

New Science, New Families, Old Law: Is the Human Fertilisation and Embryology Act Fit for Purpose?

A Patchwork of Policies: Assisted Conception and Embryo Research in Europe

The Future of Fertility Law: What Must Change and When?

How the Institute of Medical Ethics made a difference

By funding places for eight medical students to attend the conference free of charge, the Institute of Medical Ethics (IME) made the event substantially more accessible. The medical students who made use of these places, contributing to the 220-strong audience, were from the Universities of Birmingham, Sheffield and Liverpool and from Manchester Metropolitan University. One student also attended from Australia's Monash University, currently a visiting student at the Oxford Uehiro Centre for Practical Ethics.

Thanks to the IME, it was possible for these students to participate in an event whose cost would otherwise have been prohibitive – especially when combined with the cost of travel.

Furthermore, association with a body such as the IME gives an imprimatur of quality to the event. Prospective delegates who are unfamiliar with PET's work in bioethics are given confidence that the conference will be of a high standard.

Feedback from attendees:

220 people attended the PET conference, of the attendees who completed feedback forms, 100 per cent rated the conference as either excellent or good overall, and 97 per cent said they were better informed as a result of attending.

Several of the students who received sponsored places gave specific feedback:

Charlotte McDowell (University of Sheffield):

'I'm a third-year medical student planning to intercalate in medical ethics and law next year. I find the topic of surrogacy to be particularly interesting, and I went to the event in the hopes of getting a better understanding of the current ethical and legal issues. The event was very engaging, and I really enjoyed it. All of the speakers were interesting and well selected. The talks given only furthered my interest in intercalating in medical ethics and law. I also have to write an essay for my applications for intercalated degrees, and I decided as a result of the event to write about the ethical issues surrounding commercial surrogacy. I would like to thank the IME for kindly subsidising places, as I could not have attended without this.'

Lucy Benham Whyte (Manchester Metropolitan University and University Hospital Coventry):

'I am extremely grateful for the subsidised place that was available to me, since I would not have been able to afford to come to London on the student budget alone. This particular event was extremely relevant to my studies as a trainee embryologist, and I feel my level of knowledge in regard to embryo and fertility law is much more advanced as a result. I hope I will be able to attend many PET conferences in the future.'

Lydia di Stefano (Monash University):

'I found the conference really interesting and helpful to complement the biomedical perspectives I have heard about assisted reproductive technologies at medical school. I would not have been able to attend the conference without being sponsored.'

Sam Calmonson (University of Birmingham):

'I was able to attend the Progress Educational Trust conference thanks to the IME. It was fantastic opportunity to increase my knowledge about the topic. All the speakers gave an interesting insight into their views, and the short presentations helped to keep the conference moving, whilst generating debate and conversation. As a medical student, this was an interesting day away from the main course that I would highly recommend to anyone interested in ethics.'



Gemma Skilton, a final year medical student at the University of Birmingham, received an IME grant to present her paper at the 13th World Conference on Bioethics, Medical Ethics & Health Law, Jerusalem, Nov 2018

Read her report below as an example of the IME enabling students to participate in an international conference & to hear diverse views on important topics.

In November of this year, I received a conference grant from the IME that allowed me to travel to Jerusalem in order to present my research at the 13th World Conference on Bioethics, Medical Ethics and Health Law. This was a 3-day conference that took place from the 27-29th November 2018. As a medical student at the University of Birmingham I had previously completed an intercalated degree in Healthcare Ethics and Law. It was during this degree that I conducted the research which I was then able to deliver during my oral presentation at this conference. Thus, as a medical student with an intercalated degree in this field, I was incredibly excited and grateful for this opportunity not only to present my own work but also to learn from many other like-minded people presenting their own research on varied topics within the field of healthcare ethics and law.

This conference offered over 500 presentations across more than 60 topics and subtopics, with presenters coming from 63 different countries. The sheer size, variety and international nature of the conference made for an amazing and unique experience. Never before had I had the opportunity to hear from such a diverse group of people about the many different ethical and legal issues affecting them in all different parts of the world. As just one example, the ethics of psychiatric assessment to possess firearms is an ethical issue that seldom requires reflection in the UK, however the application of these issues in the USA was a novel consideration for me. Particularly poignant was the phrase coined by the presenter, a psychiatrist working in the USA, “I cannot take your guns away from you, but I can take you away from your guns”. The enriching opportunity to consider different international perspectives on medical ethics and law served to further my already great interest in this field. Not only this, the conference also presented the opportunity to consider ethical issues within other fields than medical ethics such as immigration ethics and the ethical responsibilities within migration policies.

 

As outlined, this conference really opened my eyes to a diverse range of ethical issues which I had not previously reflected upon. However, given that I was also there to present my own research, my experience of the conference in relation to this cannot go without reflection. The topic of my research was based upon the informed consent process for the implantation of implantable cardioverter defibrillators (ICDs) and whether discussing deactivation ought to make up a part of this. Consequently, I found several of the informed consent themed sessions incredibly engaging and thought provoking in relation to the background of my own research. For example, one delegate delivered her legal analysis of “the hidden paternalism in Montgomery” which was particularly interesting to reflect upon given that an analysis of UK case law on informed consent made up a section of my own research. I was very lucky to have been accepted not only to give an oral presentation but also to co-chair the session in which I was presenting, both of which were new experiences to me. I was one of five presenters in my session themed around informed consent. Two delegates, both from Israel, presented on the topic of the readability standards of informed consent and health literacy level. Another delegate, from South Africa, presented his research regarding informed consent for Biobank research. Finally, the fourth delegate, also from University of Birmingham, presented the ethical issues around gaining informed consent for complex procedures. This experience has been valuable firstly, in assisting the development of my presentation skills. Secondly, in allowing me to share my research with international experts and to hear about their research in turn, using this exposure to further refine my ideas and ethical understanding of the different concepts and issues around informed consent.

The sheer size and variety of this conference made for a truly unforgettable experience. Whilst at times its size and diversity felt a little overwhelming, this was only because there were so many talks to visit that one wished that they could somehow be in several places at once! It was a real inspiration and privilege to be amongst such a wide array of people all so passionate about medical ethics and law and I would thoroughly recommend this conference to all medical students with such an interest like myself. I am incredibly grateful to the IME for the support they have given me which allowed me to do this.

 

 

 



Sam Calmonson, a final year medical student at University of Birmingham, received an IME conference grant to give an oral presentation at the 13th World Conference on Bioethics, Medical Ethics & Health Law, Jerusalem, November 2018. Read his report below

Thanks to the Institute of Medical Ethics Conference Grant programme, I had the opportunity to attend the 13th World Conference on Bioethics, Medical Ethics and Health Law, organised by the UNESCO Chair in Bioethics. The conference took place in the Ramada Hotel in Jerusalem and ran across three days, with over 800 participants discussing more than 60 topics in bioethics and law.

Each day was split into sessions, with the vast majority of each sessions having five 15 minute presentations under a common theme, leaving a short amount of time for general questions at the end. Some operated as a round table discussion between experts in a topic, followed by a generalised discussion involving the audience afterward. Outside these scheduled hours, the set-up of the hotel allowed for fruitful discussion about the ethical topics, as well as an opportunity to ask more detailed questions of the presenters and their work. This is something with which I actively engaged, finding their comments on my own work very helpful. The sheer variety of opportunities to learn about new and developing research was astounding.

Of the topics available, I particularly enjoyed session relating to the ethics of informed consent, ethics in Jewish law, ethical decision-making in psychiatric patients and the other presentations in my own session on 'Death and Dying: Life's Beginning'. In the session about informed consent, there was research published by surgeons describing the ethical implications of consenting patients to surgery carried out by trainees and the degree to which consent for this needed to be gained. This sparked debate about the 'minimally good samaritan' and whether there exists a collective societal obligation to be treated by trainee doctors for the good of the society. This was followed by a philosopher's approach to using the informed consent principle as an argument for euthanasia. The session about Jewish law discussed arguments about abortion based upon the debate between two famous biblical scholars, as well as looking at the religious interpretations about genome editing - something important for future healthcare practices in Israel. After my own presentation about the ethics of withholding resuscitation from extremely premature neonates, there was a presentation about extending Canada's Medical Assistance in Dying (MAiD) programme to those who are under 18 years of age, using case studies of teenage cancer patients who have reached palliative stages but not the age above which MAiD was available. This extended into a wider debate about assisted dying in general. Similarly, a psychiatrist from Harvard Medical School talked the topic of assisted dying in psychiatry the following morning. These topics tended to generate the most conversation during the questions and answer sessions. Another presentation that I found particularly interesting was the question of administering contraception to migrants in expectation of rape. The question posed by the presenter was whether this was ethically justified by preventing pregnancy or complicit by not preventing rape. The consequentialist argument found that contraception was a net good and therefore ethical, but the topic raised the wider topic of migrants from other countries, something that has taken a back seat in the wider news today.

I thoroughly enjoyed the opportunity to present my own research to an audience of about 50 people. It was a new experience, involving dealing with people who vehemently disagreed with my content during my presentation as well as those who actively engaged with my work and sought me out after to continue the discussion. I have been able improve my own work and find helpful people to consult in the future. None of this could have been possible with the generous grant from the Institute of Medical Ethics and it is to them that I am most grateful for allowing me this enriching opportunity.



Paolo Corsico, PhD student, University of Manchester School of Law, received an IME conference grant to present at the American Society for Bioethics & Humanities conf, & the International Neuroethics Society annual meeting 2018. Read his report below

Report on American Society for Bioethics and Humanities (ASBH) annual conference and International Neuroethics Society (INS) annual meeting

California, October – November 2018

Last October, I received an IME conference grant to go to California and attend two of the most important bioethics conferences worldwide. Thanks to the generous support of IME, I was able to take part in the American Society for Bioethics and Humanities (ASBH) annual conference in Anaheim, on October 18-21, 2018. Ten days later, I took part in the annual meeting of the International Neuroethics Society (INS) in San Diego. As a European postgraduate student in bioethics, I was eager to learn about trends, priorities, and novel challenges in medical ethics as they are experienced by colleagues in North America.

It is hard to describe how vast, inclusive, and far-reaching was the array of issues addressed by more than 600 presentations during the four-day ASBH conference. You need a mobile app to navigate the programme at ASBH. Still, it is difficult to decide which sessions to attend. The keynote speakers addressed what I believe to be two overarching themes of the conference: new 'epidemics' and global health challenges, and the relevance of health humanities in contemporary culture and clinical education.

The first keynote speaker Jonathan Metzl, professor of sociology and psychiatry at Vanderbilt University, Tennessee reflected on the relationships between mass shootings and mental illness. In his inspiring lecture, Metzl noted that:

The US gun violence epidemic is made worse by polarized debates, which are fuelled by stereotypes around mental illness and race.

Three stereotypes characterize the problematic narrative according to which 'mental illness is the problem in mass shootings': 1) the mentally ill are disproportionately violent, 2) psychiatric expertise can predict gun violence, and 3) gun violence is the result of 'dangerous loners' or 'violent cultures'.

The way in which we build narratives around mental illness and gun violence is stigmatizing. We must challenge such stereotypes, give up polarized debates, and start working together to build a safer society.

With reference to the health humanities, Despina Kakoudaki, director of the Humanities Lab at the American University in Washington DC engaged the ASBH audience with a fascinating overview of Mary Shelley's Frankenstein. Her keynote shed light on the cultural understanding of artificial bodies and robots. Kakoudaki argued that the discourse on artificial bodies has been ongoing for centuries. This discourse includes the ancient ideas of 'artificial birth' and 'mechanical body', as well as the modern idea of 'mechanical slaves' and that of 'existential cyborgs'. Two key points of her lecture were that:

Real robots are now changing our world. However, real robots are sometimes non-recognizable in everyday life, as embodiment and location of artificial agents influence the perception of their agency.

If robots become self-aware, like Frankenstein, they might demand rights and liberty. This is a real political issue that we ought to address.

The INS annual meeting, entitled "Cutting Edge Neuroscience, Cutting Edge Neuroethics" was held at San Diego Central Library on November 1-2, 2018. Smaller than ASBH, but by no means less engaging, the meeting aimed at rethinking the role of neuroethics for the occasion of the 10th annual conference. Central themes were the growing expansion of digital neuro-technologies in health care domains, and the impact of neuro-technology on individuals' identities and public policies.

I particularly appreciated the opening keynote address, delivered by the president of Mindstrong Health, Tom Insel. Dr Insel highlighted the disruptive potential of digital phenotyping—that is, the measurement of individual cognition, emotion, and behaviour by using data from smartphones and wearables—to address 'disorders of behaviour'. The key messages of his keynote were that:

Digital phenotyping has the potential to revolutionize the way we manage disorders of behaviour, by giving us access to data that are objective, continuous, ecological, and passive.

Ethical challenges emerge within two domains: 1) issues of value, which include the efficacy of novel tools and user engagement, and 2) issues of trust, which include transparency, agency, and responsibility.

Emily Postan from the University of Edinburgh then gave an engaging 'rising star plenary lecture'. Postan argued that access to neuro-information has the potential to affect our identities and that our primary concern should not be with the abuse of neuro-information by others, but with the use that we ourselves make of it. Postan's central claim was that beliefs about the brain and the mind influence our self-narratives in positive and negative ways. We should ensure that access to neuro-information benefits the construction of our self-narratives and the development of our personal identities.

I believe that any student in bioethics and medical humanities would greatly benefit from attending ASBH and INS. Not only for the opportunity to network with fellow ethicists from all over the world, nor for the conferences' cutting-edge approach to ethics and policy debates. Most importantly, I think that early career bioethicists should attend the ASBH and INS annual conferences because they are outstanding opportunities for personal and professional development. I am deeply grateful to the IME for having supported me.

Paolo Corsico, PhD candidate in Bioethics and Medical Jurisprudence, CSEP, School of Law, the University of Manchester

Below: American Society for Bioethics & Humanities Conference, Anaheim

ASBH, Anaheim



IME Intercalated Scholarships available - apply now!

UK medical undergraduates .. Apply here for an IME Intercalated Scholarship 2018/19 - available now! Up to £2,000 each available to support your intercalated degree.

Closing date: 23.59 on 31 March 2019. 

 

 



Call for Papers - 2019 IME Conference

Concept, Classroom and Clinic

24th - 26th June 2019 Cardiff Metropolitan University, Llandaff Campus, Western Avenue, Cardiff, CF2 2YB

The Institute of Medical Ethics invites abstracts for its forthcoming conference in Cardiff, 24th – 26th June 2019. The conference is designed to give opportunities for researchers, educators, clinicians, and students involved in medical ethics, medical law and medical humanities to present their academic work. The conference organisers welcome submissions from a range of disciplines relevant to medical ethics, including bioethics, medicine, healthcare, philosophy, social sciences, law, public policy and the medical humanities.

In addition to submissions from established academics, early career researchers and healthcare professionals, we also encourage submissions from postgraduate and undergraduate students. Contributions to the 2019 conference can take the form of posters, oral presentations, lightning talks or panels. Oral presentations last 20 minutes followed by questions and discussion. Panels will run forÂÂÂÂÂ 90 minutes and should consist of two or three papers with sufficient time for audience discussion. Lightning talks last five minutes.

In addition there is the Fringe focusing on performance art/stories/live medical humanities and a session where participants can make a pitch for funding a research proposal to an expert panel. The abstract submission process is online and open at https://bit.ly/2j41IP0

There are six categories of abstract. Please indicate the categories for which you have submitted your abstract.

Oral presentations: 20 minutes, followed by ten minutes’ discussion to explore the implications for research, teaching clinical practice and critical humanities (to submit under this category please select 'Oral' from the Presentation Format dropdown box and whenÂÂÂÂÂ inputting text in the Abstract Content box please type ORAL).

Poster presentations: there will be a prize for the best poster (to submit under this category please select 'Poster' from the Presentation Format dropdown box).

Panel sessions: 90 minutes: two or three speakers related to a single topic with audience discussion. Abstracts should include a proposed timetable for the session (to submit under this category please select 'Panel' from the Presentation Format dropdown box).

Lightning talks: 5 minutes: a chance to share work in progress on a project – anything from a Master’s dissertation, a PhD, an educational development, a challenging clinical event or a piece of critical research (to submit under this category please select 'Oral' from the Presentation Format dropdown box and whenÂÂÂÂÂ inputting text in the Abstract Content box please type LIGHTNING).

Fringe: 15 minutes (maybe negotiable): something different, imaginative, perhaps provocative: performance, creativity, audience interaction (to submit under this category please select 'Oral' from the Presentation Format dropdown box and whenÂÂÂÂÂ inputting text in the Abstract Content box please type FRINGE).

(Red*) Dragon’s Den: This is a UK version of the popular US show Shark Tank based on a Japanese programme called Money Tigers: an opportunity to pitch an imaginative idea for funding a project or piece of research. Adapted for IME, this will offer constructive criticism to those making a pitch and will avoid the brutal humiliation sometimes associated with these shows (to submit under this category please select 'Oral' from the Presentation Format dropdown box and whenÂÂÂÂÂ inputting text in the Abstract Content box please type DRAGON).

*The Red Dragon is a symbol of Wales and appears on the Welsh flag.

You may submit more than one abstract to this conference. Submissions should be submitted by midnight: 31st January 2019



IME National Student Debate Competition 2019

Student information

The event will take place on Saturday 9th March 2019

 

 

 

The debate final will be held in the City of Manchester. As well as the actual ‘debates’, there will also be a keynote speaker of interest to finalists.

Purpose of the debates

  1. a)Promote engagement on a national level with medical ethics
  2. b)Foster a community of interest in medical ethics
  3. c)To provide new learning opportunities
  4. d)To allow students to enjoy medical ethics and have fun

Recruiting students

Students are responsible for organising their own debate teams. It is likely that you will have an ethics lead in your School but they may not have the time to be involved. Putting the onus on students to organise their teams means that you can still enter the national competition even if your ethics lead is unable to be involved.

Although this event has been primarily organised with medical students in mind, you have the option to include students of allied healthcare professions in your team if you wish, such as nurses or physician associates. At least half of the team members must be medical students. Given the purpose of the debates, you should endeavour to include students who are interested in medical ethics rather than simply debating. This event is part of the IME’s endeavour to engage students in medical ethics and foster a community of interest. While many students are competitive and want to win, the stress should be on taking part, meeting like-minded students, learning and enjoyment. It is the taking part that matters.

Entering the competition

There will be a limit of eight teams that can participate in the final in Manchester, and only one team per Medical School. As there may be more than eight teams interested in taking part, there will be a video-audition process to decide which eight teams will qualify to take part on the 9th March. If there are many interested students in your medical school, it is possible for more than one team to upload an entry for the video audition.

All teams wishing to compete are required to upload a video of themselves undertaking a 10 minute debate which will then be judged by a panel to select the eight finalists.

Teams participating in the national final can have up to six members. But when preparing the video, only four people take part: two on each side of the debate.

The topic for the video audition is:

Too much importance is placed on autonomy in medicine today

Each side should spend five minutes presenting their side of the debate. Format is as follows:

First speaker For the motion: 2 minutes

First speaker Against the motion: 2 minutes

Second speaker For the motion: 2 minutes

Second speaker Against the motion: 2 minutes

For the motion (summing up): 1 minute

Against the motion (summing up): 1 minute

*The person summing up can be either of the two speakers. 

Deadline for videos to be uploaded is 10th December 2018

Please upload to YouTube. You will need to create a channel if you don’t already have one. Upload your video as ‘Unlisted’ which is a drop down option in the centre of the screen at the start of the upload process on https://www.youtube.com/upload

This will ensure that the video won’t be findable by the general public even if they know the name of it.

Then email the URL of your video to Phil Greenwood of the IME philg@instituteofmedicalethics.org; copying in contact@instituteofmedicalethics.org 

Please note: If you do not receive a confirmation of submission email from us within one week of emailing the URL of your video, please telephone us on 01925-299733.




Toni Saad, final year student at Cardiff University, was the recipient of a 2018 IME Elective Bursary. Read his report below ...

Conscientious Objection in Healthcare

April 2018, Anscombe Bioethics Centre, Oxford, UK

For two weeks of my medical elective, after completing six weeks in Neurology, I was the Anscombe Bioethics Centre's Visiting Research Fellow, working on the current controversy of conscientious objection in healthcare. My time consisted of preparing a paper for a half-day symposium on the subject and planning a joint seminar between the Uehiro Centre and the Anscombe Centre.

The seminar took place at the Oxford Martin School and consisted of a discussion of the Consensus Statement on Conscientious Objection (published on the University of Oxford's Practical Ethics blog) and Prof. David Oderberg's Declaration on Conscientious Objection. The merits of these were debated and their implications explored. The overriding goal was for parties to gain a better understanding of the core disagreement(s) about conscientious objection. One of the attendees drafted a dozen points upon which disagreement was agreed, and these were summarised at the end. After the event, the discussion was continued by email. We are hoping to draft some of the work which has come out of the seminar for submission for publication. The value of this exercise was to locate precisely the points of disagreement which underly the respective positions on conscientious objection in healthcare, as well as points upon which parties agreed.

The second major event was the half-day symposium on conscientious objection in law and medicine at which I presented a paper. Dr Mary Neal spoke about some of the legal aspects of conscientious objection in healthcare, while my talk considered the ethical and medical aspects. I argued that some common arguments raised against conscientious objection do no withstand logical scrutiny: arguments about the requirements of autonomy fail to recognise the real difference between positive and negative autonomy; arguments about the duty of a healthcare professionals typically do not consider the goals of medicine or the nature of clinical judgement; and arguments about the inappropottaeness of values in clinical decision-making ignore the ineluctably moral character of healthcare and the inevitability of making clinical decision on the basis of conscience. The second part of the paper explored the question of why hostility to conscientious objection has come about in recent times. I argued that the hostility is not towards conscience per se, although that is often how arguments are presented, but it is to do with concerns over controversial issues relating to sex and reproduction. If these issues were different, I speculated that there would not be such a hostile literature towards conscientious objection. After delivering the paper, I heard Dr Andrew Papanikitas' response to it, and took questions from the attendees. This last part was most challenging, as I was forced to answer questions which I had not previously considered. However, the event was undoubtedly useful for my own learning.

My time in Oxford highlighted the need to continually refine my thinking about conscientious objection in healthcare. Interacting face-to-face with those who take a view opposed to my own showed me that I had misunderstood some of the concerns of those opposed to conscientious objection and failed to answer these adequately. Moreover, I realised that previous work I had done in defence of conscientious objection needed revision in light of very helpful conversations with Prof. David Albert Jones. I had previously argued in a paper in Clinical Ethics that conscientious objection should only be permitted with respect to procedures which do not conform to the goal of medicine defined as healing. In this category I included abortion, contraception, euthanasia and ritual circumcision etc. What I realised is, if medicine really is a moral endeavour which requires conscience to make any clinical decision, then it does not make sense to shut down from the outset conscientious objection to things which are not part of a pre-agreed list of controversial procedures. It is too narrow to talk about conscientious objection only in terms of ends, and not also in terms of means. These two can be distinguished, and doing so shows that, even when there is no conflict about the morality of ends, there can be conflict over means. Hence, thought a cardiologist may not be opposed to treating heart disease with a given drug in principle, he may refuse to do so in practice if he deems it would be ineffective or disproportionally harmful. This is a decision of conscience as much as typical examples, though it is about means rather than ends. This is an area which remains uncharted in the debate over conscientious objection. I now believe the discussion needs to move beyond its focus on lists of controversial procedures and view healthcare holistically as a moral endeavour: conscience is not only for the dilemma and controversy, but for every act where one aims to do good.

I am very grateful to the IME for its generous grant for this medical elective, and would like to thank them for making it possible. I would also like to thank Prof. David Jones of the Anscombe Bioethics Centre for the honour of making me the centre's Visiting Research Fellow and guiding my work in preparation for my elective. I look forward to studying further this surprisingly complex subject.

Toni Saad holds an MA in medical ethics and is the book reviews editor for The New Bioethics.



Below is a report from Lydia Daniels, third year medical student at Imperial College London, who was given an IME grant to attend our Spring Conference: Rights, Access & Entitlement to Healthcare on 9 March 2018

 

daniels finalI was given the opportunity to attend the 12th Annual IME Spring (Education) Conference entitled Rights, Access, and Entitlement to Healthcare, held in Manchester on the 9th March, thanks to support from the IME conference grant. I arrived eager to uncover lesser-known truths about inequalities within our NHS. There is no doubt that I came away from the conference with a heightened awareness of access disparities between UK communities and the existence of stigma and prejudice within our healthcare system, alongside both the ethical tensions and the opportunities that this creates.

One of the most striking sessions of the day was delivered by Anna Miller on the topic of healthcare provision for migrants, refugees and trafficked people, with reference to her policy and advocacy work with Doctors of the World. We focused on the many barriers facing undocumented migrants who need to access healthcare, and the complex of loops undocumented migrants must jump through before they can receive NHS services. Hospitals do not follow this process as closely as it is described within the law, yet a true enforcement would create a huge resource burden. Measuring this beside the comparatively small proportion of NHS money that is spent on undocumented migrants, some would argue the charging process is somewhat futile especially as this group are unable to secure legal, well paid employment.

The current guidelines from NHS England make it clear that no lack of ID or immigration status disclosure should prevent a person from full registration with a GP practice, however when Doctors of the World have made attempts to register migrants on their behalf, only 2 in 5 applicants were successful - the others were rejected on the aforementioned grounds. These statistics were appalling revelations, and show a discrepancy between guidelines and reality.

We were also made aware of migrants' reluctance to access healthcare due to fear that they will be detained and forced to leave the country. Anna described a 2017 agreement (the Memorandum of Understanding) that allows NHS digital to pass information to the Home Office for immigration law enforcement purposes. We were caused to ponder upon the ethical unease this creates, including the obvious impact on trust in the doctor-patient relationship. A reluctance towards full disclosure means clinicians are neither able to safeguard effectively nor pursue a full holistic approach. Migrants are some of the most vulnerable people living in our country, and it is next to impossible for them to freely access healthcare. Therefore, we must ask: what message does this send about the values of our NHS, and does this come into moral conflict with its founding principles?

Fascinating insights into incorporating homeless people into healthcare were delivered by Dr Shaun Jackson, a GP at Urban Village Medical Practice in Manchester and innovator of "needs-led" homeless healthcare clinics. Shaun began his talk by giving us some hard-hitting statistics. Homeless people have a significantly lower average life expectancy than the general population, and many die from treatable conditions – this group, with some of the greatest health needs, often falls outside the NHS's field of vision. Shaun's clinics consist of fully integrated, multidisciplinary services, including mental health support, tissue viability, and drug assessment and treatment, tied together under the concept of 'inclusion health'.

Conference attendees were encouraged to reach out to this group, with Shaun's assurance that homeless people are, in his experience, greatly concerned for their health. Therefore, they are often surprisingly capable of engaging with health interventions. This translates into a clear opportunity for health professionals to expand their services to reach out to those in great need, to more faithfully implement the principle of universal provision: proportional healthcare access for marginalised people. Ingrained attitudes towards people experiencing homelessness were emphasised as a constraining factor, and it was suggested that a lack of exposure within training could hold responsibility for this.

This report is merely a glimpse into the insights that were shared on this day. I, like many others, left the conference better informed, and inspired to join the fight to better serve the health needs of those on the fringes of society.

Lydia Daniels, 3rd Year Medical Student, Imperial College London



Briefing Note: Nuffield Council on Bioethics: Ethical challenges in bioscience and health policy for the UK Parliament

 

This briefing document sets out four key ethical challenges in bioscience and health policy for the UK Parliament and suggests how these challenges can be addressed.

Four challenges, explored in greater detail in this document, include:

 

  1. Build and maintain trust in medical research and the life sciences

  2. Ensure research and innovation address the needs of society

  3. Promote responsible health policy and research

  4. Promote international leadership in bioethics

 

These challenges draw on current and previous projects including their work on genome editing, cosmetic procedures, non-invasive prenatal testing, biological and health data, the culture of scientific research, children and clinical research, donor conception, emerging biotechnologies, mitochondrial DNA disorders, solidarity, naturalness, organ donation, biofuels, personalised healthcare, dementia, public health and forensic bioinformation.

 

The briefing document, along with short summaries of the Council’s recent reports, policy briefing papers and responses to policy consultations are available here.

 

 

 

 

 



NEW BOOK: D. Jones, C. Gastmans, C. MacKellar (Eds.) Euthanasia and Assisted Suicide: Lessons from Belgium. Cambridge University Press. 2017

 

 

 

Euthanasia in Belgium – one of the only five countries where euthanasia is practiced legally – is the subject of a large body of empirical research. However, until the present volume no study has sought to draw this research together into a coherent narrative and present it to an English-speaking readership. The book includes fourteen contributions from academics and clinicians in Belgium and six from international academics. Looking at the implications of legalized euthanasia and assisted suicide from an international and interdisciplinary perspective, this panel of experts has written an in-depth analysis of the ethical aspects of this complex area, appealing to law, philosophy and medical disciplines. The discussion forms a foundation for informed debate about assisted dying and provides a useful guide to similar choices faced by other jurisdictions.

 

 

 

Click here for more information

 



PET Report: Basic Understanding of Genome Editing

 

The Progress Educational Trust has just published their report entitled Basic Understanding of Genome Editing. The report summarises the findings of a project they carried out with their fellow charity Genetic Alliance UK, funded by the Wellcome Trust. The project explored what patients and laypeople think and know about genome editing and its implications, and developed recommendations for how best to discuss genome editing in public.

Click here

 



Speaker slides & delegate handbook now available to view: Ethics Education after Medical School 5 June 2017, St Catherine's College, Oxford

Click on Resource centre to view.



Undergraduate conference report by IME grant recipient, Simrit Kudhail

KUDHAIL Image_presentationSimrit is a 4th year student at University of Birmingham who was awarded IME funding to enable him to attend & present at the UNESCO 12th World Conference in Bioethics on 21-23 March in Limassol, Cyprus

The UNESCO Bioethics conference was established to provide academics and healthcare professionals from a wide range of fields with a forum to discuss prevalent and emergent issues of bioethics, healthcare ethics and medical law. Conference attendees represented many different countries and professions, allowing cross-disciplinary and cross-cultural presentations and discussions of these issues, with the aims of raising awareness and presenting novel ideas or possible solutions to a range of ethical issues.

I attended the conference to present the research I conducted during my Healthcare Ethics and Law intercalation year at the University of Birmingham, in which I discussed whether religious patients should be considered autonomous in their decision-making. I hoped that by discussing my research with experts in the field, I would gain a valuable insight into the strengths and limitations of my work, allowing me to develop it further before aiming for a publication. I also hoped to hear others' research on autonomy and see whether my notions of autonomy were similar that of the other presenters, and also whether my research was applicable to their presentations. In this report I reflect on the presentations concerning patients' autonomy and their implications on my own research.

My main area of reflection concerned the difference in the use of autonomy between myself and the other presenters; where my research intended to provide a theoretical revision of autonomy as a rational concept, others' presentations concerned autonomy as a practical principle that all patients ought to have. One such presentation by a Sudanese doctor discussed the rights of adolescents in decision-making in Sudan (Ebtihal Eltyeb, Saudi Arabia). Her presentation eluded to the use of something similar to Gillick-Fraser competence, but it was interesting to hear her attempts to establish a criteria by which adolescents could be given the right to their own healthcare decisions whilst also managing complex cultural traditions (for example examination by doctors of the opposite sex). Another presentation by a British academic discussed the use of a new toolkit (the Mental Capacity Assessment Support Tool, M Jayes, University of Sheffield) which allows healthcare professionals to ensure patients have the capacity to make their decisions. Once again this used autonomy as a practical principle, using Beauchamp and Childress' concept of autonomy as freedom from external influence, achievable through capacity and informed consent.

In this respect, my research was significantly different. I felt a to think theoretically to determine if religious and cultural beliefs were philosophically compatible with autonomy by critiquing whether philosophical accounts of autonomy allowed external influences on decision-making. To do this, I had to move away from the use of autonomy as freedom from external influence, as religion and cultural traditions are themselves external influences. All of these accounts suggested autonomy needed some rational aspect in the decision-making process, whether it is hierarchical desires, coherence with other beliefs, or normative competency. Therefore my research concluded that theoretically, religious or cultural beliefs that have undergone some rational critique can be considered autonomous – a process which I called rational consideration. Thus my presentation was theoretical instead of practical, and concerned autonomy itself rather than the practicalities of decision-making.

The difference in definition was made clear after my presentation, as the first questioner asked "but is autonomy actually rational?" To me, this made it clear that many people do not see autonomy as a property in its philosophical sense, and instead use the word autonomy as a synonym for the patient's own choice which does not necessarily involve a rational component. Thus my reply to the question had to make it clear that I felt our current view of autonomy has moved too far from its philosophical origin, as autonomy is necessarily rational, and I therefore felt non-rational decision-making cannot be considered autonomous. Replying to this question sensitively was one of the hardest aspects of the presentation, and this stressed the importance of making this ethical distinction clearer in my development of this research.

Alongside talks on autonomy, I also attended the sessions run on medical ethics education, disaster ethics, and ethical implications of end of life treatment. One of these presentations - 'Mediating Religious Objections to End-Of-Life Care' (Kartina Choong, University of Central Lancashire) - explored the use of mediation between families and medics as a way to overcome possible conflicts between the religious beliefs of the patient or the patient's family and the medical team. Interestingly this research reached a similar conclusion to my own, in suggesting accepting dissent of treatment on the grounds of their perceptions of their religious belief is not necessarily the right option. Instead, the process of mediation allows the medical team and the patient's family to explore the beliefs in question, and discuss the best outcomes for the patient. This process is in essence similar to the process of rational consideration which I suggested was necessary to ensure decision-making based on religious influence can be considered autonomous; the difference being that the rational process in Choong's research is done by a group on behalf of an individual, whereas rational consideration as I described it is done by the individual themselves.

Whilst this report focuses on autonomy and religious belief, it was inspiring to see a wide range of people discussing a variety of topics concerning medical ethics. Attending a conference with the primary aim of exploring issues in bioethics, healthcare ethics and law across the world has made it clear that medical ethics is incredibly relevant in today's society, and it is becoming more significant globally Yet the cultural diversity we see means that one solution for a given problem isn't always possible, and cultural beliefs and practices affect the ethical issues we will face. Thus it is important we discuss these issues globally in an attempt to find the best solutions possible at that time, and plan for future developments in medical ethics.



Postgraduate conference report by IME grant recipient, Helen Smith

Helen is a PhD student, University of Bristol, who was awarded IME funding to enable her to attend CEPE/ETHICOMP 2017: Values in Emerging Science & Technology on 5-8 June in Turin, Italy

Ethicomp is a series of conferences which consider computer ethics conceived broadly to include philosophical, professional, and practical aspects. It has held conferences since 1995 in Europe and Asia. CEPE (Computer Ethics and Philosophical Enquiry) has been running since 1997 and is more narrowly focussed on the philosophical aspects of computer and information ethics. The CEPE/Ethicomp 2017 was the third joint event which they have held, this time kindly hosted by the Department of Law at the University of Turin, Italy, from 5-8 June 2017.

Around 100 delegates attended; I met professionals, students and academics from Europe, Asia, Australia and North America. The interdisciplinary ethos meant that there were contributions brought from a variety of sectors such as computer scientists, policy makers, lawyers, ethicists, philosophers, social scientists, gaming as well as health technology. The warm, friendly and supportive attitude within the attending community encouraged space for constructive feedback after presentation of each contributor's paper.

Those presentations which were specifically relevant to the medical ethics community included:

Katleen Gabriel's presentation "Between 'Entertainment Medicine' and Professionalization of Healthcare: An Interview Study of Belgian Doctors" identified the rise in enhanced selfcare utilising new technology e.g. blood pressure monitoring, blood sugar monitoring. Her study asked Belgian GPs and Cardiologists how they'd felt about the rise of the use of digital tracking. Patients wanted more dialogue with their doctors and did not wish for the technology to surpass their physician's expertise. Unreliable tech had made one cardiologist angry as it was taking his time away from people who had genuine needs. Drs did not feel that they were losing their authority to tech, but were afraid of the data overload and loss of context. Overall, with data gathered, one can have a clear and more accurate conversation with patients. But the time saved will probably get used to see extra patients rather than spending more time with the individual patient.

Frances Shaw's presentation of "Ethics in the design, research, and evaluation of mHealth and eHealth solutions for mental health: a qualitative study of a research institute" reported on the ethical development she has been doing for the Socialize App (a smartphone app which associates changes in social networks over days/weeks may indicate mental health problems developing) which is in early prototyping. There is concern for the maintenance of privacy as GPS data discloses the home and workplace of individuals and that this data creation is passive and opposite to the act of active and willing disclosure of illness; that disclosure is made on behalf of the individual rather than by the individual which interferes with the person's agency. She identified that Big Data is shaping our state of being and that we should anticipate the development and then theorise the ethics before application rather. For example; there is no identification of the responsibility of initiating the intervention for the person who has been identified as being at risk of being mentally unwell- who should respond once the app has raised the alarm?

David Krep's and Oliver Burmeister's presentation of "I am a Person" spoke of how we are both radically contingent and unique, that in age related cognitive decline the physical motor accompaniment to our mental and emotional lives begins to deteriorate. Value Sensitive Design (VSD) seeks to explicitly support human values in assistive technologies. Through this, power can be identified in an intentional way which will help with the realisation of a society in which technology is a force for empowerment rather than for domination.

I would like to take this opportunity to thank the Institute of Medical Ethics for making it possible for me to attend this event.



Posters by Titilopemi Oladosu, King's College London

Titi is a past recipient of an IME Elective Bursary which enabled her to travel to Nigeria in 2013 for her project entitled: Ethico-Legal Issues and Nigeria's Mental Health Act: Health Workers' Perspectives. This was a qualitative study focusing on health workers' perspectives of the 'lunacy act' in Nigeria, and the ethico-legal issues which arising from implementation (or lack) of the act. Titi's work involved one-to-one interviews with members of the Ministry of Public Health, health practitioners, and NGOs focusing on mental health.

Take a look at her excellent posters below highlighting the project. 

Titi orally presented at The World Psychiatry Association International Congress, November 2016 in Cape Town, South Africa.

In poster form, her work has been presented at the Royal College of Psychiatry International Conference 2014 and the Royal College of General Practitioners National Conference 2016.

Pathway to Care - Exploring Accessibility & Delivery of Mental Healthcare in South West Nigeria

Mental Health Ethics & Law in South West Nigeria

 



Elective Report by Laura Shorthouse, 4th Year Medical Student, University of Liverpool

Below is Laura's report following her recent IME elective in Zambia earlier this year ......

A personal reflection of ethical dilemmas encountered, and the cost-benefit analysis to Livingstone Central Hospital in Zambia for hosting my elective in maternal, neonatal and child health.

During my five-week elective I gained hands-on experience in maternal, neonatal and child health at Livingstone Central Hospital, and in three local community districts served by the hospital - Linda, Maramba and Mwandi. Working days contained rich and varied learning opportunities to accomplish my goals and professionally develop, but also, provided powerful ethical dilemmas and lessons in people, life and myself, forever shaping my future medical career and character.

Ethical dilemmas

I was introduced to the labour ward on my first day, which was an unforgettable first impression. From the initial ethical 'horror' I felt and not wanting to return to the ward, to the in-depth personal and professional thinking it evoked, to finally overcoming it- it was a life changing experience in growing as a future doctor and person. In a large curtain-less room three women were giving birth in silence and shouted at when they made a noise. The first delivery I witnessed in Africa was stillborn twins.

They were left for over five minutes unwrapped on their mother's lap while the midwives cleaned the floor. They were then disposed, without any opportunity to say goodbye. I wanted to comfort the mother but felt it an inappropriate first impression. Instead, I stood there shocked holding back tears.  I found this opening hour to 'obstetrics in Africa' cruel, insensitive, detached and degrading with no patient empowerment. I did not want to go back and play any further part.

As the initial shock of witnessing a different cultural and geographical approach to labour eased, I shamefully realised I was being judgemental. I was impinging my ideology of ethical practice onto others, disregarding their culture and traditions as though the ' west' approach was best. I was determined to overcome this dilemma by returning to the ward and learning more about their culture and ideology. I came to understand that Zambian women have adopted a tough 'carry on' exterior because sadly losing a baby is more of the 'norm' in their culture than mine, as well as them feeing grateful to still be alive post childbirth- to them it is the best way of moving forward. They prefer silence because it is important for them to introduce their baby into a calm environment. Being silent is their personal, empowering and autonomous choice, rather than the oppressive, degrading and paternalistic one I wrongly assumed. Subsequently whilst this was foreign to me, I had chosen to work here and believed it important to respect their wishes and culture moving forward. I therefore felt I was subconsciously empowering my patients and respecting their autonomy thus providing good medical practice; albeit in a very different way to home.

The English language, whilst the official language of Zambia and that of medicine, was predominately limited to wealthy well-educated families, or young children benefiting from international volunteering projects teaching English. Consequently there were several occasions, notably obstetrics and gynaecology, where I needed translators. These were not third party impartial translators like in the UK, but either other doctors, the patient's family or their own children.  Where possible I would have preferred doctors, however I did not want to ethically burden my overworked and understaffed host, so relied mostly on the latter two.  Taking obstetric and gynaecology histories involve asking many sensitive, intimate and personal questions, which I found not only uncomfortable asking others but took longer. I overcame this discomfort by remembering it was necessary to gather information to treat effectively. In paediatrics, I tried to obtain the history from the child which given their good level of English was more possible and I preferred.

Zambian doctors rarely introduced themselves to the patient, asked how the woman or child was, or sought consent appropriately.  No curtains separated the beds and handwritten patient notes were left on makeshift tables often next to the wrong person visible for all to see. Doctors would discuss patients loudly for others to hear and examine them in full view on the ward. Whilst I could not change this practice, I conducted myself in the manner I would back home with some improvisation where necessary. I always introduced myself especially explaining why I was working in the hospital, spoke quietly so only the patient could hear, and asked a colleague to hold a sheet up around the patient's bed when I wanted to examine them privately.

Medical tourism: cost-benefit analysis

I believe my elective benefited the hospital and population it served. Livingstone Central is adjusting to a significant time in its history and facing added pressures that come with a tertiary status. I was an enthusiastic and highly active team player getting involved, and providing teaching opportunities for clinicians to undergo professional development especially on ward rounds. I also impacted my knowledge and experience, which having just completed and passed my medical school finals was of a high standard, and therefore, I believe I facilitated a mutual learning environment. I worked within my competency independently clerking and monitoring patients with minor complaints, so senior clinicians could attend to major complaints and emergencies. I therefore crucially alleviated staffing problems safely without compromising reputations or the work of other staff members.

However, despite only asking the doctors to translate when no-one could speak English I felt guilty for creating extra work for them. Subsequently, if patients could speak some English I preferred to spend longer taking a history than asking the doctors. I would advise medical students to act this way, learn some local/ tribal language where possible, and be acquainted with a place's culture/ customs before arriving.

Conclusion

A complex relationship exists between medical ethics and external influences. Successfully navigating cross-cultural medical ethics requires sensitivity, non-judgemental attitude, and enhanced communication and clinical skills. Through a rich and enjoyable personal elective experience, this study supports the evidence-base 8-10 that electives in developing countries can be beneficial to all.

Word count (997- excluding title, acknowledgement, references)

Acknowledgement

Thank you to the 'Institute of Medical Ethics' for a Medical Elective Bursary.

References

The CIA world fact book (2016) 'Zambia' https://www.cia.gov/library/publications/the-world-factbook/geos/za.html. (Accessed 26th August 2016)

World Health Organisation (2012) 'Country cooperation strategy at a glance: Zambia'. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_zmb_en.pdf (Accessed 26th August 2016)

World Health Organisation (2016) ' Zambia' http://www.who.int/countries/zmb/en/ (Accessed 26th August 2016)

World Health Organisation (2015) 'Zambia: WHO statistical profile' http://www.who.int/gho/countries/zmb.pdf?ua=1 (Accessed 26th August 2016)

Unicef (2016) ' Zambia: HIV and Aids' http://www.unicef.org/zambia/5109_8459.html (Accessed 26th August 2016)

Our Africa (2016) 'Poverty and Healthcare' http://www.our-africa.org/zambia/poverty-healthcare (Accessed 26th August 2016)

Post Zambia ( 2015) 'L/stone hospital starts operating as tertiary medical institution' http://www.postzambia.com/print.php?id=3441 (Accessed 10th November 2015)

Ackerman LK. The ethics of short-term international health electives in developing countries. Ann Behav Sci Med Educ2010;16:40–3

Hanson L, Harms S, Plamondon K. Undergraduate international medical electives: some ethical and pedagogical considerations. J Stud Int Educ 2011;15 (2):171–85.

Banerjee A et al, Medical student electives: potential for global health?Lancet 2011;377 (9765):555.



Report of Intercalated Project by Toni Saad, MA in Bioethics and Medical Law, St Mary's University, Twickenham

I am grateful to the IME for their awarding me the intercalated degree grant for my research project into euthanasia in Belgium. Below is a summary of my dissertation, which, I am pleased to report, received the highest mark ever awarded a dissertation on the MA programme at St Mary's (91%).

THE PATH OF LEAST RESISTANCE? HISTORICAL, POLITICAL AND PHILOSOPHICAL CONTEXT OF THE BELGIAN EUTHANASIA EXPERIENCE

Abstract

Following the Netherlands by a few months, Belgium is the second nation worldwide to decriminalise voluntary euthanasia. It did so in 2002 with the passing of the Act on Euthanasia, though euthanasia was relatively widely practiced in Belgium beforehand. Moreover, the Act did not put an end to illegal practices in regard to euthanasia: much euthanasia remains unreported, and non-voluntary euthanasia and physician-assisted suicide, both of which are illegal, continue to occur. Chapter One of this dissertation considers the state of affairs concerning euthanasia prior to and after the 2002 Act, and traces its development and influences. It shows that the process which preceded the decriminalisation of euthanasia was expedited by political motive, and that the Act itself suffers from conceptual flaws. Chapter Two places this Belgian euthanasia experience in its historical-philosophical and political context. It begins by outlining one influential ethical tradition, Aristotelian-Thomism, and describing how departure from it has radically changed the nature of moral philosophy, and, consequently, the fabric of moral debate. Furthermore, it argues that in the social context of political liberalism, the Belgian euthanasia experience and similar phenomena are somewhat inevitable developments. Analysis of the changing nature of moral debate confirms that, though it is very difficult to achieve moral consensus today, trends in moral philosophical thought nevertheless run in definite directions. It is concluded, therefore, that the Belgian euthanasia experience is a single symptom of broad and powerful changes in moral and political philosophy.

Chapter One: The Belgian Euthanasia Experience: Historical and Political Review of a Law unto Itself

In this first chapter I considered the historical and political development of the Belgian law on euthanasia, beginning with the practice of euthanasia before the 2002 law was passed. I examined this law in detail, and traced its evolution, and compared euthanasia practiced before and after its passing into law. Here is a quote from my conclusion of chapter one:  "The 2002 Act on Euthanasia was a rushed and deficient piece of legislation which served to justify a pre-existent practice. In a sense, it was a mere formality, though one strongly influenced by the political climate, rather than interested parties. The Act suffers from conceptual and practical shortcomings and remains significantly under-enforced—only half of all cases of euthanasia are reported. The later amendments it has undergone, particularly that of 2014 concerning the repeal of an age restriction on access to euthanasia, reflect the existence of a strong political will to liberalise euthanasia. And, as in 2002, calls to amend the law did not come from interested parties. At present, euthanasia in Belgium remains a concern because physicians do not abide by the law in terms of reporting euthanasia, continue to practise physician-assisted suicide and, most worryingly, non-voluntary euthanasia."

Chapter Two: The Moral and Political Context of the Metamorphosis of Bioethics

The second chapter takes a broader look at the phenomenon of the Belgian euthanasia experience (BEE), and sets it in its philosophical context. I consider one significant ethical tradition (that embodied by Aristotle, Thomas Aquinas and John Finnis) and describe how departure from it leads almost inevitably to the multiplication of phenomena like the BEE. I consider thin theories of good in the light of this, and explain them in the context of a concurrent evolution in political theory. These changes are then considered in terms of how they bear on contemporary bioethical discourse and debate.

Here is the conclusion to which I come: "the BEE is not an isolated or even a surprising phenomenon. It is the product of an anaemic moral philosophy which has abandoned a substantive notion of human goods. Into the resulting vacuum has entered a conceptually-thin formally rational debate, coupled with shifts in political ideology which seek to place morality in the hands of individuals rather than the State. Ethical discourse is changed unrecognisably as a result...The fact that euthanasia was relatively widely practised before it became legal, and before any significant public debate occurred on the subject, is evidence of the psychological influence of this moral evolution. It is only a society with a very narrowly redefined axiology which can tolerate such widespread transgression of the basic good of life. And it is only a formally rational terrain of debate which can allow such actions to be rationalised in law in order to maximise individual autonomy. That euthanasia continues to go unreported in Belgium, and that there was such a strong political will for its passing into law, is additional evidence of Belgian society's desire for something which was once unthinkable. And the decision to extend the scope of euthanasia to include children is due to the projection of paper-thin axiological values onto the youngest and most vulnerable members of society..."



Conference Report: Centre for Ethics in Medicine, University of Bristol

Below is a post-conference report by two recent Institutional Grant recipients, Rachel Gallagher & Charlotte Mills, University of Bristol, following their Bioethics Conference on 13 April 2016. 

Well worth a read as it focusses on a very interesting topic which is not often discussed.

Centre for Ethics in Medicine, School of Social and Community Medicine

University of Bristol

Bioethics conference 2016:  Gender, Relationships and Equality

Report for the Institute of Medical Ethics

The conference 'Gender, Relationships and Equality' was an exploration of how medical and social notions of gender affect our relationships. The topic covered a broad range of areas: intersex, fatherhood, prenatal testing, surrogacy and the future of medicine. The audience was mostly students, including bioethics students from the University of Bristol and University of Birmingham, and nursing students from the University of West England.

Dr Sorcha Ui Chonnachtaigh (Keele) presented the first talk on 'the parent-child relationship and decision-making regarding surgeries on intersex children.' This taught us to modernise our conception of gender, as we learnt that it is not a binary notion. This increased our awareness of related issues, and gave us insight into how to address such situations that may arise in our future careers with sensitivity.

Next, Dr Jonathan Ives (Bristol) gave a presentation on 'fathers and reproduction: rights, interests and relevance.' He discussed the different approaches taken by different European countries with regards to abortion and reproductive technologies, and highlighted some key issues about potential inequalities. This encouraged us to analyse the current healthcare approach to pregnancy with more consideration of the father.

Dr Sandi Dheensa (Southampton) continued with the theme of the role of the father, speaking on 'men's involvement in prenatal genetic/genomic testing.' This highlighted conflicts between a need to include fathers in prenatal healthcare, and protection of mothers in instances with potential domestic abuse. Interestingly, 30% of domestic violence starts during pregnancy.

Our final speaker was Dr Katherine Wade (King's College London) who discussed 'improving the surrogacy framework in the UK: a children's rights perspective.' This was especially interesting as it provided an alternative perspective on a topic that the majority of the audience had been studying throughout this year. Dr Wade highlighted how the current law on surrogacy is ineffective as it conflicts with the best interests of the potential children that are brought about in this way.

To finish we were joined by Professor Lois Bibbings (Bristol), for a panel discussion on why bioethics should be concerned about gender, chaired by Dr Zuzana Deans (University of Bristol). Discussion focused on feminist approaches to bioethics, and how these could shed light on issues around gender that may arise in our future careers as doctors and nurses. There was active participation from the audience, including group discussion, which raised some key issues about gendered pay structures and (in)equality of opportunities.

Overall, the discussions throughout the day displayed diverse opinions and disciplinary perspectives on a variety of issues regarding 'Gender, Relationships, and Equality.' The conference was thoroughly enjoyable, and beneficial to all. We would like to express our gratitude to the Institute of Medical Ethics for making this valuable learning opportunity possible.

Rachel Gallagher and Charlotte Mills

Student Representatives, Bristol BSc Bioethics programme



The Messiness of Medicine by Daniel Sokol

Written with medical ethics educators in mind, this BMJ blog piece by Daniel Sokol, Barrister & Medical Ethicist, can be found in our Resource centre.



IME Education Conference 11 March 2016 Speaker Presentations

Presentation slides by Dr David Molyneux & Prof Susan Bewley are available in our Resource Centre.  Please do not use or copy without author attribution.



100 Cases in Clinical Ethics and Law, Second Edition

 

  

Carolyn Johnston, Penelope Bradbury

Available from 14 January 2016: Paperback £22.99   eBook £16.09   eBook Rental £10.00

Summary

A 30-year-old Polish lady is admitted in labour. This is her first pregnancy and she is full term. She is in a lot of pain, her liquor is stained with meconium and the trace of her baby's heart is classified as pathological. Her grasp of English is limited. You have been asked to obtain her consent for a caesarean section…

 

100 Cases in Clinical Ethics and Law explores legal and ethical dilemmas through 100 clinical scenarios typical of those encountered by medical students and junior doctors in the emergency or outpatient department, on the ward or in a community setting. Covering issues such as consent, capacity, withdrawal of treatment, confidentiality and whistle-blowing, each scenario has a practical problem-solving element, encouraging readers to explore their own beliefs and values including those that arise as a result of differing cultural and religious backgrounds. Answer pages highlight key points in each case, providing advice on how to deal with the emotive issues that occur when practising medicine and guidance on appropriate behaviour.

  • Covers all the topics of the IME core content of learning (2010)

  • Contains input from consultants, lawyers, religious leaders and healthcare professionals

http://www.amazon.co.uk/Cases-Clinical-Ethics-Second-Edition/dp/1498739334