Andrew Grubb

Survey of British clinicians' views on management of patients in persistent vegetative state

BACKGROUNDnThe best care and management of patients in persistent vegetative state (PVS) has been the subject of sustained moral and legal debate for a number of years. However, the views of clinicians in the UK involved in caring for patients in PVS are largely unknown.nnnMETHODSnA postal questionnaire was sent to 1882 consultant members of the British Association of Orthopaedic Surgeons, the Association of British Neurologists, the Society of British Neurosurgeons, and the British Society of Rehabilitation Medicine. Their views were sought on various aspects of the management and care of PVS, in particular the appropriateness of a decision not to treat and a decision to withdraw artificial nutrition and hydration (ANH).nnnFINDINGSn1027 doctors responded (55%) of whom 558 (54%) had experience of managing patients in PVS. Over 90% of responding doctors considered that it could be appropriate not to treat acute infections and other life-threatening conditions. 65% of doctors considered that withdrawal of ANH could be appropriate. About two-thirds of doctors who thought treatment-limiting decisions could be appropriate thought that such decisions could be considered with the first 12 months of the patient being in PVS. Despite recent case law, less than half the doctors responding to the survey thought that an advance directive made by the patient should have a decisive influence in determining treatment-limiting decisions. Most doctors would like decisions about withdrawing ANH to be made in conjunction with family members and in accordance with agreed guidelines but without the need to go to court.nnnINTERPRETATIONnThere is a broad consensus among doctors that treatment-limiting decisions are sometimes appropriate for patients in PVS, irrespective of whether they have experience of the condition or of the specialty to which they belong. However, two thirds of doctors said that such decisions can be considered at a time earlier than that recommended by the British Medical Association. It is not clear why some doctors thought a decision not to treat could be appropriate while a decision to withdraw ANH would not be.

Abortion law in England: the medicalization of a crime.

n Abortion law in England has changed a great deal throughout its legal history. Starting with total prohibition in Common Law and ending up a state regulated therapeutic medical procedure. The battle over abortion rights has been as large in England as in the US; however, the battle ground has been Parliament, rather than the courts, as in the US. The reason for this stems mainly from the Sovereignty of the Parliament, which makes the English courts weaker than the US courts, which can actually over-turn legislation. In the beginning fetal rights were seen as absolute. Currently the rights of women to control their own bodies has been balanced against fetal rights. Now with some restriction and government regulation, women can seek abortion. There are still a great deal of unanswered questions concerning abortion. The legality of RU-486 and IUDs as well as selective reduction are still unresolved issues. Further, the effects of the United Kingdoms union with Europe and the change to English law that will result are still unknown. Already an English abortion case has been brought before the European Commission of Human Rights, the body that screens cases for the European Court of Human Rights. The case was rejected because the European Convention for the Protection of Human Rights and Fundamental Freedoms has several Articles which seem to apply to a womans right to bodily integrity, family determination, and physician and mental health. However, Article 2 provides that everyones right to life shall be protected. The Commission ruled that this Article applies to living people and thus not to fetuses. After European unification if completed the issue of abortion law in England will surely be settle by European Courts.n