Len Doyal

Informed consent in medical research: Journals should not publish research to which patients have not given fully informed consent–with three exceptions

Abstract Is the demand for informed consent absolute? In the first of this pair of articles a professor of medical ethics argues that the principle of informed consent to participate in medical research is fundamental if patients are competent volunteers. Consent is not needed when patients are incompetent to give it (young children, unconscious patients, etc); when research uses only medical records; and when stored human tissue is used. Before publishing the results of such research, however, journals must ensure that certain minimal conditions are complied with. In the second article an oncologist argues that journals should be free sometimes to publish research in which patients have not given fully informed consent. He points to the practical difficulties of obtaining fully informed consent from all patients and, because of this, poor recruitment into trials. He suggests that a helpful approach would be to obtain “blanket” approval at the outset of treatment for inclusion in studies that might be in progress during the patients illness–accepting that the doctor would always act in good faith and be prepared to explain treatments at any time.

The rationing debate: Rationing within the NHS should be explicit: The case for

Much recent discussion has revolved around whether the rationing of health care that is occurring within the NHS should be explicit or implicit.1 Many commentators argue in favour of implicit rationing, for a range of reasons. Opinion appears to be divided between those who claim that implicit rationing will ( a ) be inevitable since there are no clear criteria on which to base explicit rationing, ( b ) make patients and providers happier, ( c ) make the administrative and political processes of healthcare provision run more smoothly. I provide reasons for rejecting each of these contentions, arguing instead that explicit rationing is vital for the moral management of health care. The creation of an internal market in the NHS appeared to place explicit rationing on the agenda of healthcare providers. Rationing had always occurred within the service but previously it had been camouflaged under clinical judgment. Now purchasers were to draw up plans showing how much was to be allocated to what type of care and why. Providers were to audit clinical staff to ensure that their work conformed to agreed criteria of effectiveness and all was to be open to public scrutiny. The expected transparency has not occurred. Health authorities have generally not come clean about their inability to meet demand and have awarded block contracts primarily on the basis of past expenditure, with shortfalls shared between existing clinical services. As a result, the realities of rationing within the NHS have remained where they always were–with clinicians making decisions on the basis of varied and conflicting criteria, often dressed in the guise of clinical necessity.2 These developments have led to a weary resignation that any ambition to make rationing explicit within the NHS is hopelessly optimistic. It is argued that there are no clear rules according to which rationing should occur …

Medical ethics and law as a core subject in medical education: A core curriculum offers flexibility in how it is taught—but not that it is taught

In Tomorrows Doctors Britains General Medical Council initiated a radical and needed reform of medical education. One of the less noticed, yet revolutionary, aspects of this reform is that medical ethics and law have become a core component of the curriculum. Thus all medical students, states the council, must acquire knowledge and understanding of ethical and legal issues relevant to the practice of medicine and be able “to understand and analyse ethical problems so as to enable patients, their families, society, and the doctor to have proper regard to such problems in reaching decisions.”1 Seeking to pool their expertise, most of the academics currently teaching medical ethics and law in UK medical schools—mostly cliniciansphilosophers, lawyers, and theologians—hammered out a consensus statement about what should constitute the core academic content necessary to produce “doctors who will engage in good ethically and legally informed practice.” They also agreed some minimal organisational requirements for the subject to be taught successfully. The consensus statement sees the teaching of medical ethics and law as contributing to the overall objective of medical education—“the creation of good doctors who will enhance and promote the health and medical welfare of the people they serve in ways which fairly and …

Knowing when to say “no” on the student elective: Students going on electives abroad need clinical guidelines

Personal view p 1466 The elective can be one of the most exciting components of a medical students training. When done abroad, it sometimes offers the opportunity to experience health care in a different cultural and organisational setting and to see diseases that are rarely, if ever, encountered in Great Britain. Other benefits include the maturity that comes from medico-social understanding, self-reliance, and resourcefulness that the elective experience can provide.1 Several reports describing activities on electives provide further insight into their opportunities, challenges, and benefits.2-6 The increasingly focused medical curriculum in the UK is a key reason to promote the elective. Yet despite its advantages, some concerns remain. The author of a report of his elective alludes to the discomfort felt about suddenly being expected to “see patients” (p 1466).6 Such concerns are often no different from anxieties experienced by medical students in Great Britain. …

Withholding and withdrawing life sustaining treatment from elderly people: towards formal guidelines

Clinicians often decide either to withhold or to withdraw lifesaving treatment in elderly patients. Considerable disagreement exists about the circumstances in which such actions can be defended. Debates about the scarcity of resources in the NHS add urgency to the need to resolve this disagreement. Competent elderly patients have a legal and moral right to decide whether to receive life sustaining treatment. Such treatment should not be withheld or withdrawn on the basis of a patients age alone. Principles for making decisions about life sustaining treatment in incompetent elderly patients can be defended and should exist as written guidelines.

Moral problems in the use of coercion in dealing with nonadherence in the diagnosis and treatment of tuberculosis.

Abstract: Coercion and detainment can be a morally acceptable strategy to fight the spread of tuberculosis, but these measures need to be placed into a much broader context than that of their short‐term potential effectiveness. TB should be de‐stigmatized by full acknowledgment that we all share the blame for its perpetuation. When coercion and detention are necessary, they should incorporate a strategy of optimum protection for minimum violation of autonomy. National and international health care programs should provide effective and nonthreatening treatments for TB and other related illnesses such as HIV and should develop policies to tackle the environmental causes of TB and provide support for vulnerable victims. Corporate pressures to continue world poverty must be undermined.

Mental health legislation should respect decision making capacity

New legislation should raise the moral standards of professional and personal life, but the proposed new mental health bill fails to deal with serious ethical problems in the existing act

Should the skeleton of "the Irish giant" be buried at sea?

It’s not too late to grant Charles Byrne’s wish, argue Len Doyal and Thomas Muinzer

The Moral Foundation of the Clinical Duties of Care: Needs, Duties and Human Rights

It has become fashionable to question attempts to derive internationally agreed duties of clinical care from more general theories of human rights. For example, some argue that such attempts risk moral abstraction through their neglect for the importance of culture and community in shaping moral consciousness and thus often unhelpful in the resolution of concrete moral dilemmas within medicine. Others denounce the importance of general moral principles altogether in bioethics and attempt to articulate what are claimed to be more practical approaches to resolving moral conflict. This paper challenges such arguments. It does so through arguing that: i) all humans everywhere have the same basic human needs; ii) the satisfaction of these needs varies with culture; iii) the imputation of moral duties on others entails respect for their right to basic need satisfaction, including the right to choose between presumptions about the duties and rights of patients which follow from these more general principles and v) problems of moral indeterminancy that arise from putting these principles into practice can be resolved through associated procedural policies of rational negotiation and compromise. The moral importance and practicality of respect for individual human rights within the practice of medicine is thus defended. Indeed, the paper concludes by arguing that without belief in human rights linked to a theory of basic human needs, communitarian theories of morality are incoherent.

Dignity in dying should include the legalization of non-voluntary euthanasia

often be exacerbated by the absence of any means of communicating their confusion and despair to those responsible for their care. The fact that the best interest of these patients has figured so little in debates about euthanasia is understandable. Many reflective practitioners who support the legalization of VAE have reservations about taking the lives of those who have not executed relevant advance directives and who are defenceless to protect themselves through the exercise of their autonomy. Equally, the Nazi murder of incompetent children and adults continues to cast a dark shadow over the legitimacy of non-voluntary active euthanasia (NVAE). In my view, however, this emphasis on autonomy should be reconsidered in debates about euthanasia. The interests and needs of severely incompetent humans who may also be in the grip of intolerable suffering are just as important as those patients who are competent to control the circumstances of their death and wish to do so. Therefore, I believe that NVAE should also be legalized. I have four reasons for this belief.