News

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. 

 

 



IME Elective Bursaries available - apply now!

UK medical undergraduates - apply now for an IME Elective Bursary. Up to £800 available to support your elective.

Closing date: 18 November 2018

 

https://bit.ly/2eWhZTt



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