News

IME Student Competition: Medical Ethics in the Life Experiences of the Developing Professional

Organised by the IME Student Council, this new competition aims to encourage reflection and expand engagement with medical ethics. The competition comprises two categories and entrants can submit to either:

Category 1: Essay submission

or

Category 2: Creative Arts/Humanities submission

The competition is open to medical students currently enrolled at a medical school within England, Wales, Northern Ireland, and Scotland. This includes students in their final year of study who will have graduated by the closing date. Submissions from students undertaking an intercalation year will be also be accepted. Only one submission per person is permitted, and one author/artist per submission.

The closing date is 15th October 2020. Click here.



Assessing Medical Ethics and Law Meaningfully

 

10th September 14.00-16.00

The purpose of this virtual meeting is to share good practice in the assessment of medical ethics and law; as well as to explore the challenges and potential innovations to make medical ethics and law assessment more meaningful.

This is a FREE event. You will require an appropriate space to participate in the virtual meeting and a computer or device with audio and video that allows you to join the meeting.

A weblink will be circulated to those who express interest to attend by emailing:philg@instituteofmedicalethics.org 

Provisional Agenda (2 hours)

1. Introductions
2. 1-2 minute sharing of an issue/innovation relevant to medical ethics and law assessment (can be poster slide, picture, verbal or any other form you feel is effective to communicate your point)
3. Discussions on Key Themes
4. Conclusions and Next Steps



20 tips for online teaching of medical ethics

This short guide for educators during the pandemic is available in the IME Resource Centre. Click HERE.



Save the Date - IME 2021 conference

The IME 2021 conference will take place at Austin Court, Birmingham on 1st and 2nd July. Abstracts accepted to the cancelled 2020 conference will be accepted at the 2021 event and those presenters have been contacted about this. A call for papers will take place towards the end of 2020 to fill slots that have not been taken.



The IME Student Council are recruiting!

The IME Student Council is a team of 16 medical students from around the UK working to promote interest and raise awareness of medical ethics. Eight places are currently available to replace outgoing members and the term of office is 2020-2022. Applications from students who are studying healthcare degrees other than medicine are also welcome to apply.

For more information and how to apply, click HERE.

Closing date: midnight Sunday 2nd August 2020



It didn't have to be this way

For a first-hand reflection on life under lockdown in the northern Italian city of Forli, along with some of the ethical challenges and consequences the pandemic brings to the region, you might want to take time to read Dr Silvia Camporesi's essay here. Silvia is Senior Lecturer in Bioethics and Society at King's College London where she directs the master's programme in Bioethics and Society. She is interested in everything related to emerging biotechnologies, genetics, ethics, gender and sport. Silvia also sits on the IME Research Committee



COVID-19 Ethics Guidance

COVID-19 Ethics Guidance

Current guidance published in the last few days or weeks on ethical decision making during COVID-19 pandemic.

UK Clinical Ethics Network COVID-19 Dedicated page

http://www.ukcen.net/main

BMA Ethics Guidance for COVID-19 related Decisions

https://www.bma.org.uk/news-and-opinion/bma-publishes-ethics-guidance-for-doctors-making-difficult-covid-19-decisions-on-the-front-line

Ethical Guidance published by the Royal College of Physicians

https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic

Covid-19 ethics resources published by the Nuffield Council on Bioethics

https://www.nuffieldbioethics.org/publications/covid-19/covid-19-ethics-resources

Ethics Resources on the Coronavirus (COVID-19) published by the Hastings Center

https://www.thehastingscenter.org/ethics-resources-on-the-coronavirus/

The New England Journal of Medicine - Fair Allocation of Scarce Medical Resources in the Time of Covid-19

https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_coronavirus

The New England Journal of Medicine – Facing Covid-19 in Italy – Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line

https://www.nejm.org/doialull/10.1056/NEJMp2005492?query=featured_coronavirus

The BMJ - Ethical Roadmap through the Covid-19 pandemic

https://www.bmj.com/content/369/bmj.m2033

Department of Health Northern Ireland - COVID-19 Guidance: Ethical Advice and Support Framework

https://www.health-ni.gov.uk/sites/default/files/publications/health/COVID-19-Guidance-Ethical-Advice-and-Support%20Framework.pdf

Managing the Burden of Covid-19 Burnout: What clinicians need to know - David Goodman, John Hopkins School of Medicine

https://ime2.peervoice.com/340COVID2/340COVID2_p1/p1s1?MemberID=101476009

 

Palliative Care for patients with severe Covd-19  - The BMJ

 

 

https://www.bmj.com/content/370/bmj.m2710




The Building Bridges in Medical Science Society, University of Cambridge, received an IME grant for their conference, Mar '20. Their report (below) highlights the challenges they faced following their decision to convert to a virtual event due to Covid-19

The Next Decade of Medical Innovation

Cambridge, 13th March 2020

The Building Bridges in Medical Science (BBMS) society recognises the need for interdisciplinary approaches to tackle the biomedical and global health challenges of the 21st century. This year our committee, a group of motivated medical and graduate students at the University of Cambridge, elected to take the opportunity in the 12th annual BBMS conference to examine the next decade of medical innovation. We invited experts from research, medicine, industry and policy to speak to early researchers and medical students about their own experience of medical innovation. A particular aim of the committee for this year's conference was to highlight the ethical implications of advancing artificial intelligence and technological devices. We wanted to extend the BBMS platform further and use it to encourage and help attendees to begin questioning how we champion and discuss the forefront of medical research. With the increased spread of coronavirus days before the conference's due date, the committee itself had its own ethical dilemma to weigh up and had to innovate to deliver a conference virtually in only a day.

The Speakers

The format of the digital conference was a series of lectures streamed online to our delegates with questions encouraged through the chat function available. The day was split into sessions addressing different elements of innovation.

In our session on medical devices, we featured speakers who had recognised problems that could be solved by developing technological tools. We began in the lab where Professor Tuomas Knowles had developed an innovative approach to his research on protein folding diseases. Dr Nick Skaer shared his biomaterial innovations and their implications for the future of orthopaedics, raising issues around cost-effectiveness in the NHS and developing a product that gives an improvement that is significant enough to justify the extra cost that it may incur. David Fried, who has developed a virtual rehabilitation tool for stroke patients, highlighted the current need for improved continuity of care and help in the community for patients and the potential and limitations of using digital solutions for this purpose. Dr Martina Di Simplicio, a consultant psychiatrist, spoke about her experience developing an app that provides episodic stimulation-based self-harm reduction. In particular, she spoke about the reaction of the medical world to such a suggestion and the balance of using a tool as an adjunct and not to replace good quality medical care.

Our next session focused on the use of artificial intelligence in healthcare. Dr Michael Thornton has a start-up developing an artificial neural interface and Dr Dafydd Loughran has developed a digital consent platform using AI that aims to reduce errors in the process. In particular, consent is a fundamental ethical pillar in medicine and it raised an interesting issue of using AI to ensure that information that is appropriate to the situation can be easily found but in addition the requirement that this information is unbiased and complete enough for a sufficient and self-determined decision to be made.

Additional interesting talks were delivered by Araceli Camargo and Dr Julian Huppert. Araceli took a unique angle, thinking about how our habitat impacts upon our health for example in depression and diabetes and how these considerations should factor into the construction of cities. Julian has substantial experience campaigning for science in politics and provided an insight into how decisions are made at policy level and the process and implications of developing regulations.

Our Audience

Our delegates came from a wide variety of backgrounds including PhD students, post-graduates, undergraduates, medical students and practising doctors. Across the course of the conference speakers had a changing audience of between 40-60 delegates with different individuals attending throughout the day. A strong aim of the conference was to engage and inspire our audience. The committee organised a poster presentation session during the conference to enable early-career researchers to have an opportunity to summarise their own research in the field and be able to present to an engaged audience. With the advent of a digital conference and a chat function we found that we actually received a greater number of questions and people felt more able to engage with our speakers as evidenced from responses in our post-conference feedback.

Going digital during the coronavirus pandemic

One of the unique challenges of organising the BBMS conference this year was converting from a physical to a virtual conference in less than a day. In the beginning days of March, the number of people infected by SARS-CoV-2 (Coronavirus) was increasing and both the university and the government were considering its approach. Though no official guidance dissuading against large gatherings was in place, the implication was that it would be imminently and even without an imposed regulation the committee was faced with an ethical dilemma as to whether we, in hosting a physical conference, would put a large group of individuals and their loved ones at risk.

In making a decision about the future of the conference we had to take several things into consideration. Firstly, and most importantly, we assessed the risk to the safety of our delegates and speakers. At the time of early March there had been coronavirus infections in the UK, however only a couple had occurred in the Cambridgeshire area and the majority were focused in London. We knew our audience itself to be mostly young individuals, who were not in the at-risk demographic then reported. The committee thoroughly investigated the ways we could minimise risk of spread at the conference including liaising with our hosting college to produce a plan of the steps to isolate a conference-attendee who exhibited symptoms and further ordering the constituents of hand-sanitiser for our chemistry PhD committee members to bulk make for the day (innovating in light of the hand sanitizer shortage.)

However, though it was early days in what was to become a pandemic, we already had knowledge of asymptomatic spread and the potential of indirectly putting our delegates' contacts at risk. Our COVID questionnaire, that had been sent out to all speakers and delegates, revealed a high number of individuals who had been recently abroad. Our speaker profile had been in constant flux in the days before as speakers pulled out for coronavirus related emergency meetings or their own personal situations. Indeed, at least one of our speakers, although still wishing to attend, had an immunocompromised family member and was depending on government guidance updating. In light of the knowledge that some our speakers deemed the risk to be too high and our own reservations, we had to consider whether hosting a physical conference was an inappropriate endorsement and whether falling back on the free-choice of our attendees to make the risk assessment for themselves was sufficient for an activity that we were responsible and accountable for. As a result of these reflections, we realised that for us hosting a physical conference was no longer acceptable.

Our second dilemma was what was the alternative to a physical conference? We discounted cancelling the conference as we felt like we had an important and unique message to deliver and by cancelling at this stage we would be letting down our audience who had wished to attend and undermining the hard work of the committee in the prior year. However, postponing seemed impossible due to the degree of uncertainty about the length of time till it would be possible to host a physical gathering and if our speakers would be able to come together again at the same time. Hosting a virtual conference was at first a joking suggestion- the committee taking our own small step towards medical innovation. However, we then seriously considered the advantages of our speakers and delegates being able to present and listen from anywhere, without risk of added risk of infection against the drawbacks of the huge practical effort for us and access to the conference becoming dependent on having a computer and WiFi which are luxuries.

On the day before the conference, the committee made the difficult to decision to host the event virtually. The majority of our prior arrangements had to be disregarded and the change required extensive communications with our speakers as well as a new publicity drive. On the day itself we experienced technical issues for the first hour which threw into doubt whether we should continue with the conference at all. However, instead of abandoning the day we preserved, changed our online platform, overcame the challenges and delivered a conference we are proud of.

The current coronavirus pandemic is an exceedingly difficult time for all. It has changed our daily lives and put much medical research and education on hold and yet it is also a time where there is a need to continue to have informed ethical discussions and a need to continue to pursue medical innovation, albeit requiring a very rapid adjustment to new digital platforms in order to do so.

Appendix:

The BBMS 2020 webinar can be found online here.

 

Or via our website.

 



Nicole Lamb, a medical student at the University of Sheffield, received an IME bursary for her elective from Jan-Mar 2020. Her project report (below) highlights the different cultural values held by the people of the island she visited.

An insight into the health care in Vanuatu

I carried out my elective on an island called Espiritu Santo in Vanuatu, an archipelago of 82 islands in the South Pacific. The reason I chose Vanuatu was because I knew nothing about the place and neither did anyone else. After some research into the islands my flights were booked and bags were packed. I had no idea what to expect and now I know nothing would have prepared me for the experience I was about to have. 

The first day at the hospital seemed all too familiar, medical student looking lost looking for help for about half an hour. A nurse quickly recognised my lost face and introduced me to the Doctor I would be shadowing to start with. The friendly culture amongst all of the Ni van people was extraordinary, they were always willing to help and had the warmest of welcomes. I started on the medical ward for the first two weeks which was an eye opener for what was to come. Conditions and illnesses I had never seen or heard of before. No imaging machines apart from an ultrasound machine. No blood tests available apart from a full blood count. No cancer treatment.

We started the ward round and throughout I could hear weeping and screaming. I didn't say anything or ask any questions whilst shadowing the doctor as I didn't want to offend anyone asking what was going on as I wasn't aware of their culture as of yet. The doctor later told me that this is how the families mourn after a death. Little did I know that this would become a common occurrence during my elective. In England as medical students we rarely witness death as the health service provided by the NHS is exceptional and the treatment available makes the majority of people better. To witness death occurring every day in young and old was shocking. It quickly dawned on me the lack of resources and facilities was a serious problem here.

I then spent the next few weeks on the women's health ward. Here I assisted in clinics and with births. The time I spent on this ward allowed me to gain an understanding for the research project I set out to do, investigating the ethical position women have with regard to their own healthcare. It quickly became clear the answers to some of my questions as a husband was handed a consent form for his wife's caesarean section in front of me. I spent time in a family planning clinic for a few days which involved women attending to get contraception which their husband had approved. There were several women who opted for a depot contraceptive injection which would cover their contraception from their husband. I found it very difficult to comprehend how it must have felt to not have the choice and say over your own body. Women that didn't comply to their husband's rules were threatened, shunned and often experienced domestic violence. This was proven by the stack of folders standing on the shelf behind the nurse stacked above a post it saying 'domestic violence'. It was the highest stack.

lamb image_1 Left: A bed in the labour ward at the NPH.

Below: A room on the maternity ward

Lamb 2nd_image_3

It was difficult trying to understand their cultural beliefs. Doctors are seen to be like the devil and people will only resort to hospital if there is no other herbal medicine or remedy to try. Patients mostly presented at very late stages of easily treated diseases. One of the biggest problems was asthma. Due to families having indoor fires for cooking and the lack of compliance and technique to use inhalers this resulted in a lot of exacerbations. To make matters worse the hospital was running out of medication for these patients as they relied on drug donations and imports from other islands which could take weeks. Diabetic patients didn't comply with medication which led to serious problems and more deaths. The patients also lacked an education into their health problems, more often than not they didn't understand why they were taking a medication. This was proven with heart failure and high blood pressure patients not getting further prescriptions as they didn't know they would have to take lifelong medication.

I met four brothers on the medical ward which were being treated for reactive arthritis which was thought to have been triggered from a contaminated water source in the south of the island. The brothers remained on the ward for 4 weeks with one of them having to lie on the floor as he was in so much pain. The brothers were slowly discharged one by one. I decided I wanted to see the difference in hospitals between the government one I was currently in compared to the charity run hospital down the road. I introduced myself and was able to sit in on clinics. The first clinic I was in I instantly recognised one of the patients, it was one of the brothers. His reactive arthritis was still there and was getting worse again. He later explained that he was discharged without the medication required as the hospital had totally ran out and his brothers were worse too. Luckily the charity run hospital had some of the medication he required and he was able to return home with medication for them all.

The time I spent in Vanuatu will be truly unforgettable, the most rewarding part of my medical career so far. It has taught me many unforgettable lessons and most importantly it gave me a massive appreciation for what we have here within the United Kingdom. I know the NHS is taken for granted by most people and I only wish that everyone could have the experience I was so lucky to have to be able to appreciate the reality of what we share.

An insight into the health care in Vanuatu



Announcement: IME Conference 2nd & 3rd July 2020

With the number of detected Covid-19 cases continuing to grow and uncertainty around when current restrictions are likely to be lifted, the IME Trustees have been monitoring the outbreak and government guidance towards minimising the virus spread and its impact.

Your health is the highest priority for us followed by our desire to host a quality event. In the current circumstances, we regret very much to inform you that, as a precautionary measure, the 2020 IME Conference 'Maintaining trust in medicine in a "post truth" world' scheduled for 2nd and 3rd July 2020 in Birmingham, England, is cancelled.

We sincerely apologise for any inconvenience this cancellation will cause and look forward to seeing you at a future IME event.

The IME 2021 conference will take place at Austin Court, Birmingham on 1st and 2nd July.

Should you have any questions, please do not hesitate to contact us at contact@instituteofmedicalethics.org.

 



Grants & Awards: Covid-19

Due to the ongoing Covid-19 situation, we have regrettably suspended our conference and institutional grants programme until further notice. If you need to contact us, IME staff are working from home and calls to the office (01925-299733) are being diverted. If your call goes to answerphone, please leave a message or alternatively you can email us: contact@instituteofmedicalethics.org and we will get back to you asap.



Review: IME Student Conference 2020

The IME Student Conference 'Ethical Considerations in the Pursuit of Perfection' took place on Saturday 8th February 2020 at Leeds Medical School.

Organised by the IME Student Council, the conference also included the National Student Debate Final (Leeds v Sheffield) and judging of The Mark Brennan Poster Prize. (See the Mark Brennan Prize winners here.) 

Read all about the conference here.



Georgia Scott, a final year medical student at University of Birmingham attended the PET conference 'Reality Check: A realistic look at assisted conception' December '19 after successfully applying for one of the IME-funded student places offered by PET.

Georgia has written an article summarising the conference which has been featured on the British Medical Journal's Sexual & Reproductive Health blog.

Click HERE to read Geogia's article.



Jordan Parsons, MScR student at University of Bristol received an IME Conference Grant to present orally at the Australasian Association of Bioethics & Health Law & the New Zealand Bioethics Conference, NZ, Nov 2019. Read his report below:

 Thanks to the generosity of the Institute of Medical Ethics, I was able to attend the 2019 Australasian Association of Bioethics & Health Law and New Zealand Bioethics Conference in Dunedin, New Zealand. The opportunity to present my work to an audience I would not usually find myself in front of was extremely valuable as allowed me to engage in discussion about my work from the perspective of its applicability to different jurisdictions. Whist my work primarily concerns the UK, it is interesting to consider the differences internationally and what might be learned from other countries both in terms of successes and failures. Discussions following my presentation provided this interesting perspective and I have already started to incorporate it into my work.

In addition to benefitting my own work, attending this conference gave me an insight into the research priorities in both Australia and New Zealand. I was especially keen to hear about research concerning indigenous populations as this is something that is not part of UK bioethics. One topic that received a lot of attention was voluntary assisted dying as it is very topical in Australia at the moment with the recent introduction of legislation permitting it in Victoria. As the UK euthanasia debate is relatively quite currently, it was interesting to discover how things are progressing elsewhere and in particular to hear about the sorts of patients seeking voluntary assisted dying.

Owing to the location of this conference, it was a chance for me to network with academics I would not likely have met otherwise and to catch up with those I already know in Australia. It is hugely important to develop and maintain international networks in academia and thanks to the IME I have been able to do so. I met people at the conference with similar research interests and with whom I may end up collaborating on research.

Thank you again to the Institute of Medical Ethics for such generous support. I am hugely grateful.



Elizabeth Chloe Romanis, PhD candidate in Bioethics & Medical Law, University of Manchester received an IME Conference Grant to present orally at the American Society of Bioethics & Humanities Conference, Pittsburgh, Oct 2019. Read her report below:

Thanks to support from the IME travel funds for postgraduate research students I was able to attend the American Society for Bioethics and Humanities Annual Conference this year in Pittsburgh 24th-27th October 2019. The conference was enormous with a multitude of panels and presentations to choose from as well as big name keynotes and networking meetings and receptions. It was almost overwhelming, but incredibly exciting to have so much choice. Being interested primarily in reproduction, law and ethics – I was really spoilt.

Whilst there were so many different panels on a wide range of ethical issues to attend (everything from reproethics, to anthropology in medicine, to medical education) the theme for the conference was Bioethics and Resilience, and in all of the events I participated in the adherence to the theme was notable. There was a real attempt to focus on the structural and institutional inequalities in healthcare and how bioethics and the humanities can serve social justice and contribute meaningfully to discussions about change. I learnt a lot about how the responsibility of the humanities, and of academic scholarship, in the identification of and responding to social injustice. It is so important that in our work bioethicists do not pretend that our ideas exist in a vacuum or that bioethics is entirely separate from the political spaces in which we think.

No paper at the conference made this clearer than a paper by Ariella Messing and Rachel Fabi about 'Reproductive Injustice at the Border.' This paper emphasised the importance of embedding our thinking about reproductive rights in context to expose injustice. They made a compelling argument about how there was clear evidence of reproductive oppression at the US-Mexico border and that this was part of the considered and deliberate attempt by the current US administration to deter immigration. In immigration detention centres there is routine denial of abortion care to incarcerated pregnant people. Equally, there is clear disregard of the right to have children in the denial of prenatal care to pregnant people and of the right to parent in the routine separation of families in centres. Messing and Fabi posit that such injustice demands action from bioethics. There can be no such thing as an innocent bystander in the face of such abuse.

A keynote by Margaret Battin ('Death and Sex: Using Thought Experiments with Modern Technology' was another of the main highlights of the conference for me. In this talk she considered how the thought experiment has normative force in considering the real-life implications of different conditions in real life issues, with social justice, equality and dignity at their centre. She argues that most objections to thought experiments normally come from thinking about how we get from here to there because in our current world – race, gender and class oppression are pervasive and so it is hard to imagine the subject of the thought experiment without inequality. She argues that this is the wrong way to think – thought experiments should do their normative work by seeing if we can imagine a world in which equality is realised and then work backwards to see how we can get there. She made her argument by suggesting that the world would be a better place if everyone, that is all fertile persons (whether female or male), routinely used long-acting, effective, reversible and 'forgettable' contraception all the time. She posited that in this world 'everyone would have to make a positive choice to have a baby.' I wasn't sure I was convinced, but it gave me a lot to think about.

At the conference I also presented my most recent paper 'Artificial Womb Technology and Clinical Translation' (which at the time was not yet published) on a panel about ethics in paediatric research. It was a great opportunity to get feedback from bioethicists in the US about my work because I am soon to be submitting my PhD and this paper features in my thesis.

I am really grateful to the IME for facilitating my attendance at this event.

Elizabeth Chloe Romanis, PhD candidate in Bioethics & Medical Law, University of Manchester



Dunja Begović, PhD candidate in Bioethics & Medical Jurisprudence, University of Manchester received an IME Conference Grant to present orally at the 33rd European Conference on Philosophy of Medicine & Health Care, Oslo, Aug 2019. Read her report below:

This summer I received an IME conference grant to cover the registration fees for the 2019 annual conference of the European Society for Philosophy of Medicine and Healthcare (ESPMH) 'Philosophy and Ethics at the Edge of Medicine', taking place at the University of Oslo, 7-10 August 2019. This is one of the largest European bioethics events, attracting scholars from all parts of the continent as well as the rest of the world, so as a PhD student I was honoured to have the opportunity to present at it. As the conference fee is quite high, the support of the IME was essential for my attendance.

Taking place over three days with 6-8 parallel sessions running each morning and afternoon, covering a wide range of themes from all areas of bioethics, the conference offered so many possibilities that the greatest challenge for me was to decide which talks to attend. In line with my research interests, which are primarily in reproductive ethics and particularly related to women's autonomy in pregnancy, I made sure to be there for parallel sessions like 'The limits of autonomy', 'Mothers and embryos' (in which I also presented my paper Maternal-fetal surgery: A challenge to existing notions?') and 'Genomics and reproductive medicine', where I heard some fascinating talks on issues such as obtaining informed consent electronically (Kristi Lõuk, University of Tartu), regulating surrogacy (Katarzyna Korbacz, University of Warsaw), the reification of the human embryo (Anna Smajdor, University of Oslo), and posthumous paternity (Edna Katzenelson, Tel Aviv University), among others. I also dropped into various other sessions to attend presentations on diverse subjects like epistemic injustice in clinical ethics consultation (Søren Holm, University of Manchester), self-harm and relational autonomy (Petra Gelhaus, University of Münster), body modifications for gender expression (Timothy Murphy, Hastings Center), the meaning of genetic connections and the notion of family (Daniela Cutas, Umeå University); as well as ethical commentary on cases like the He Jiankui scandal, focusing on its implications for social justice and solidarity in genetics (Darryl Gunson, University of the West of Scotland), and the Tuskegee syphilis study, shedding a light on the untold stories of the participants' wives (RayLee Otero-Bell). In general, I found all the talks I attended illuminating and relevant in different ways, and can only wonder what other interesting research I might have missed due to overlap between sessions.

Another great aspect of the ESPMH conference were the special seminars on particular topics, where invited speakers gave short presentations followed by a discussion and questions from the audience. Unfortunately, these also overlapped with the parallel sessions making the choice of what to attend even more difficult! However, I am definitely glad that I started off the conference at the special session on 'New-old ethical perspectives on the development of prenatal testing practices', as this is a topic I find highly engaging having written one of the papers in my PhD about it. It was really exciting to hear from scholars doing both empirical and theoretical work on this subject, in the context of different cultural, legal and ethical settings. Tamar Nov Klaiman of Ben Gurion University presented her research on the attitudes of parents towards non-invasive prenatal testing for Down's Syndrome in Israel, highlighting how societal views relate to parental decisions, while Stefan Reisch of the University of Lübeck gave an interesting empirically founded comparison of how women in Germany and Israel respectively perceive the issue of health insurance coverage for this kind of testing. Vardit Ravitsky of the University of Montreal discussed the future of prenatal testing in the light of the increasing transparency of the fetus, while Aviad Raz and Yael Hashiloni-Dolev presented their research on the parental and professional experiences of participating in prenatal testing. The ensuing discussion looked in more depth at the ethical implications of social context and the development of testing practices, which I found fascinating and very relevant for my own research.

I am very thankful to the IME for their generous support which allowed me to attend this conference and present my paper, as well as expand my bioethical horizons on a variety of fascinating subjects. 

Dunja Begović, PhD candidate in Bioethics and Medical Jurisprudence, Centre for Social Ethics and Policy, School of Social Sciences, University of Manchester

 



IME Student Conference 2020: 'Ethical Considerations in the Pursuit of Perfection'

Saturday 8th February 2020, University of Leeds Medical School

Keynote Speaker: Georgia Testa, Lead for Medical Ethics & Law, University of Leeds 

This conference, organised by the IME Student Council, is free-to-attend (£20 deposit required, refundable upon attendance). Students & foundation year doctors are very welcome.

Click HERE for more information and to register.

A limited number of IME Conference Grants are available for attendance at the Student Conference. Preference will be given to those presenting a paper or poster. Click here for more information about our conference grants.



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



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.

 

















































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