Gordon M Stirrat

Autonomy in medical ethics after O’Neill

Following the influential Gifford and Reith lectures by Onora O’Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O’Neill in recommending a principled version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient–doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring “patient autonomy” when it is, in fact, abrogation of their duty as doctors.

Medical ethics and law for doctors of tomorrow: the 1998 Consensus Statement updated

Knowledge of the ethical and legal basis of medicine is as essential to clinical practice as an understanding of basic medical sciences. In the UK, the General Medical Council (GMC) requires that medical graduates behave according to ethical and legal principles and must know about and comply with the GMC’s ethical guidance and standards. We suggest that these standards can only be achieved when the teaching and learning of medical ethics, law and professionalism are fundamental to, and thoroughly integrated both vertically and horizontally throughout, the curricula of all medical schools as a shared obligation of all teachers. The GMC also requires that each medical school provides adequate teaching time and resources to achieve the above. We reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise. In this paper we set out an updated indicative core content of learning for medical ethics and law in UK medical schools and describe its origins and the consultative process by which it was achieved.

Management of severe pre‐eclampsia and eclampsia by UK consultants

Objective To determine the current management of severe pre‐eclampsia and eclampsia in the United Kingdom.

Abu Dhabi third stage trial: oxytocin versus Syntometrine in the active management of the third stage of labour.

OBJECTIVE To compare the effect of oxytocin and Syntometrine when used as part of active management of third stage of labour on postpartum haemorrhage, hypertension, nausea/vomiting and retained placenta. STUDY DESIGN A randomised double blind trial was conducted in the Obstetric Unit of Corniche Hospital, Abu Dhabi in the United Arab Emirates. Between 1 January 1991 and 30 June 1991, 2040 women were randomly allocated either to the oxytocin (n = 1017) or the Syntometrine (n = 1023) group. Twelve patients had to be excluded from the trial (oxytocin, 5; Syntometrine, 7) after randomisation because they no longer fulfilled the inclusion criteria. All women in the trial received either oxytocin 10 units or Syntometrine 1 ml (oxytocin 5 units+ergometrine (ergonovine) 0.5 mg) by intramuscular injection with delivery of the anterior shoulder of the baby. Relative risk with 95% confidence intervals was calculated for each variable. RESULTS Oxytocin (10 units) alone was as effective as Syntometrine (1 ml) in preventing post-partum haemorrhage without an increase in the incidence of retained placenta. Median blood loss was similar in both groups. The incidences of nausea, vomiting and headache were significantly lower in the oxytocin group, as was the occurrence of a mean rise in diastolic and systolic blood pressures of 20 and 30 mmHg or more, respectively. CONCLUSION Prophylactic administration of oxytocin 10 U in the third stage of labour, as part of active management, reduces the incidence of maternal nausea, vomiting, headache and rise in blood pressure than does Syntometrine 1 ml without adversely affecting the rate of post partum haemorrhage.

Education in ethics

Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in ones own practice and that of others; and reinforcement of best practices in clinical and research governance. Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in ones own practice and that of others; and reinforcement of best practices in clinical and research governance.

Planned trial of transcervical resection of the endometrium versus hysterectomy

Dear Sir, Let us supposc that a new drug has been dcvclopcd to trcat dysfunctional uterine bleeding (DUB) and let us call that drug TCRE. Before its general use would be permitted let alone encouraged it would have to undergo carcful and controlled. and preferably randomized, trials to compare its efficacy and side effects with other drugs currently in use lor DUB, and be approved by the Committee of Safety of Medicines. Drug therapy is only one of a series of interventions available to us as clinicians. Surgery is another. Why is it, therefore, that attitudes towards thc assessment of thesc two types of intervention are so different? Kandomized controlled trials of ncw surgical procedures vs thc alternatives are virtually unknown in gynaecology. I would suggest that this is not only unscientific but also unethical. There is an intervention called TCRE (otherwise transcervical resection of endometrium) for DUB described by D e Cherney et al. (1987) and Magos et al. (1989) and discussed by Macdonald (1990) in his useful commentary on ‘modern treatment of menorrhagia’. Although endometrial ablation is an attractive potential alternative to hysterectomy the two have never been compared. The new techniques have been developed and promoted by enthusiastic skilled surgeons without the same constraints as are imposcd on our pharmaceutical colleagues. l h e ‘gold standard’ treatment for DUB is hysterectomy and endometrial ablation needs to be compared with that in a randomized controlled trial as advocated by Magos et ul. (1Y90). The fact that it may be difficult does not lessen thc nccd for, or obligation on us to do so. Once that comparison has been carried out, various ablative techniques can be compared with each other. Macdonald (1990) calls for long-term follow-up studics. Thesc are not sufficient. Surgery must be placed under the same constraints as other interventions and tested properly. We have embarked on a randomized controlled trial of TCRE vs hysterectomy in this unit funded by the local Research Committee of the South West Regional Health Authority. We would bc delighted to widen thc study to include other centres if they would like to join

Reflections on learning and teaching medical ethics in UK medical schools

The development of learning, teaching and assessment of medical ethics and law over the last 40 years is reflected upon with particular reference to the roles of the London Medical Group, the Society for the Study of Medical Ethics, its successor Institute of Medical Ethics; the Journal of Medical Ethics and the General Medical Council. Several current issues are addressed. Although the situation seems incomparably better than it was 40 years ago, the relatively recent events in Mid Staffordshire National Health Service (NHS) Foundation Trust show we cannot be complacent. Whatever role we have in the NHS or medical education, we must all strive to make sure it never happens again.

Personal recollections of Professor Michael Hull

© 2002 The British Fertility Society 1464-7273/2002 I was deeply honoured to chair a session at this meeting. I first met Mike in a stable! Not that we belonged to the horse riding fraternity, but in the early 1970s the Department of Obstetrics and Gynaecology at St Mary’s Hospital, Praed Street, Paddington, was to be found (and still is) in the Mint Wing, formerly the stables of the Great Western Railways. Mike had just returned from 3 months in Israel working under Bruno Lunenfeld. This sojourn in the holy land literally transformed his life. This transition is seen clearly by inspection of his publications. His first eight publications from 1971 to 1975 were not related to reproductive medicine; however, after returning from Tel Aviv he joined Howard Jacobs in what was to become a quite unique team at St Mary’s. In 1976, Mike was the first author in what was a timely and important publication entitled ‘Female hypogonadism – therapy orientated diagnosis of secondary amenorrhoea’. From that time forward his publications reflected a wide interest in all aspects of human fertility. His 1979 paper with Phil Savage and Howard Jacobs on the investigation and treatment of amenorrhoea resulting in normal fertility remains a classic and is recommended reading to all interested in our subject. I still use the data when counselling couples and teaching medical students. The old and faded blue diazo slides bearing his name are a permanent reminder to me of his unique contribution to my education and to our speciality. By 1985 he had established a truly international reputation. This was further enhanced by the publication of ‘Population study of causes, treatment, and outcome of infertility’. I can do no better than summarize the main findings of the study and highlight the most important findings.

The Reproduction Revolution–A Christian Appraisal of Sexuality, Reproductive Technologies and the Family

In their preface to this book, the editors rightly state that “few social or technological developments in history have captivated peoples imagination or raised more ethical questions than todays reproduction revolution”. The authors then set that revolution in a wider context from which it is all too easily divorced today, namely the nature and meaning of sexuality and the fundamental importance of the family. As a “Christian appraisal” it is a useful apologia pro vita sua for those of us who share this credo. It also sets down a clear and consistent ethical position for all interested in the field. It never pretends that the issues are simple and straightforward. I, for example, …