News

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.



Lydia Daniels, a medical student at Imperial College London received an IME Scholarship for her BSc in Medical Sciences with Humanities, Philosophy & Law intercalated degree, 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



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.



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



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



National Student Debate Final 2019

Winners! The Keele team

Winners! The team from Keele

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

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

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

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

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

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

Dr Joe Brierley, Great Ormond St Hospital




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.

 



Calling Medical Undergraduates! The IME Student Council are recruiting!

Click here for details and how to apply.

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

Deadline for applications: midnight, Sunday 2 June 2019