Power, conferred by legal authority, to control an indivdual’s affairs in relation to medical or other care.
As there is no statute de?ning the scope and limits of advance statements in the UK, their legal status depends principally on case precedents. As well as written documents, competent patients can make equally valid advance oral refusals which should be recorded in the medical notes. Some health professionals or health facilities may have a conscientious objection (see ETHICS) to the concept of withdrawing life-prolonging treatment from incompetent patients, even at the patient’s advance request. Such objections need to be made known to patients well in advance of a living will becoming eligible for implementation, so that the patient can make other arrangements. The British Medical Association has issued a code of practice on the subject; this provides widely approved guidance on various facets of drafting, storing, witnessing and implementing advance statements. It is also dealt with in the GMC document on withdrawing treatment.... living will
Medicolegal issues also include an individual’s right to die (see brain death; euthanasia; living will); the necessity for informed consent to any surgical procedure; the legal aspects of artificial insemination, in vitro fertilization, sterilization, and surrogacy; and a patient’s right to confidentiality concerning his or her illness. (For the medical aspects of criminal law, see forensic medicine.)... medicolegal
Strictly, consent is valid only if the patient has been fully informed about the purpose of the procedure, the likely outcome, and any complications and side effects.
Consent cannot be given by children or by people with serious mental disorders, but a relative may give or withhold consent on their behalf.
The patient’s consent is also needed before a doctor supplies confidential information to an insurance company, employer, or lawyer.... consent
Spontaneous abortion Often called miscarriage, this may occur at any time before 28 weeks; 85 per cent occur in the ?rst 12 weeks of pregnancy. Of all diagnosed pregnancies, 25 per cent end in spontaneous abortion.
Spontaneous abortions occurring in early pregnancy are almost always associated with chromosomal abnormalities of the fetus. Other causes are uterine shape, maternal disorders such as DIABETES MELLITUS, diseases of the thyroid gland (see under ENDOCRINE GLANDS), and problems with the immune system (see IMMUNITY). Recurrent spontaneous abortion (that is, three or more) seems to be a particular problem in women who have an abnormal response of their immune system to pregnancy. Other factors include being older, having had a lot of babies previously, cigarette smoking and spontaneous (but not therapeutic) abortions in the past.
Early ULTRASOUND scans have altered the management of spontaneous abortions. These make it possible to distinguish between threatened abortion, where a woman has had some vaginal bleeding but the fetus is alive; inevitable abortion, where the neck of the uterus has started to open up; incomplete abortion, where part of the fetus or placenta is lost but some remains inside the uterus; and complete abortion. There is no evidence that bed rest is e?ective in stopping a threatened abortion becoming inevitable.
Inevitable or incomplete abortion will usually require a gynaecologist to empty (evacuate) the uterus. (Complete miscarriage requires no treatment.) Evacuation of the uterus is carried out using local or general anaesthetic, usually gentle dilatation of the neck of the uterus (cervix), and curetting-out the remaining products of the pregnancy.
A few late abortions are associated with the cervix opening too early, abnormal structural abnormalities of the uterus, and possibly infection in the mother.
Drugs are often used to suppress uterine contractions, but evidence-based studies show that these do not generally improve fetal salvage. In proven cases of cervical incompetence, the cervix can be closed with a suture which is removed at 37 weeks’ gestation. The evidence for the value of this procedure is uncertain.
Therapeutic abortion In the UK, before an abortion procedure is legally permitted, two doctors must agree and sign a form de?ned under the 1967 Abortion Act that the continuation of the pregnancy would involve risk – greater than if the pregnancy were terminated – of injury to the physical and/or mental health of the mother or any existing child(ren).
Legislation in 1990 modi?ed the Act, which had previously stated that, at the time of the abortion, the pregnancy should not have exceeded the 24th week. Now, an abortion may legally be performed if continuing the pregnancy would risk the woman’s life, or the mental health of the woman or her existing child(ren) is at risk, or if there is a substantial risk of serious handicap to the baby. In 95 per cent of therapeutic terminations in the UK the reason is ‘risk of injury to the physical or mental health of the woman’.
There is no time limit on therapeutic abortion where the termination is done to save the mother’s life, there is substantial risk of serious fetal handicap, or of grave permanent injury to the health of the mother.
About 190,000 terminations are carried out in the UK each year and only 1–1.5 per cent are over 20 weeks’ gestation, with the vast majority of these late abortions being for severe, late-diagnosed, fetal abnormality.
The maternal mortality from therapeutic abortion is less than 1 per 100,000 women and, provided that the procedure is performed skilfully by experienced doctors before 12 weeks of pregnancy, it is very safe. There is no evidence that therapeutic abortion is associated with any reduction in future fertility, increased rates of spontaneous abortion or preterm birth in subsequent pregnancies.
Methods of abortion All abortions must be carried out in premises licensed for doing so or in NHS hospitals. The method used is either surgical or medical, with the latter being used more and the former less as time goes on. Proper consent must be obtained, signed for and witnessed. Women under 16 years of age can consent to termination provided that the doctors obtaining the consent are sure she clearly understands the procedure and its implications. Parental consent in the under-16s is not legally required, but counselling doctors have a duty to record that they have advised young people to inform their parents. However, many youngsters do not do so. The woman’s partner has no legal say in the decision to terminate her pregnancy.
MEDICAL METHODS A combination of two drugs, mifepristone and a prostaglandin (or a prostaglandin-like drug, misoprostol – see PROSTAGLANDINS), may be used to terminate a pregnancy up to 63 days’ gestation. A similar regime can be used between nine and 12 weeks but at this gestation there is a 5 per cent risk of post-treatment HAEMORRHAGE.
An ultrasound scan is ?rst done to con?rm pregnancy and gestation. The sac containing the developing placenta and fetus must be in the uterus; the woman must be under 35 years of age if she is a moderate smoker, but can be over 35 if she is a non-smoker. Reasons for not using this method include women with diseases of the ADRENAL GLANDS, on long-term CORTICOSTEROIDS, and those who have a haemorrhagic disorder or who are on ANTICOAGULANTS. The drugs cannot be used in women with severe liver or kidney disease, and caution is required in those with CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), disease of the cardiovascular system, or prosthetic heart valves (see PROSTHESIS), as well as with those who have had a CAESAREAN SECTION or an ECTOPIC PREGNANCY in the past or who are being treated for HYPERTENSION.
Some clinics use this drug combination for pregnancies older than 12 weeks. In pregnancies approaching viability (20 weeks), pretreatment fetocide (killing of the fetus) with intrauterine drug therapy may be required.
SURGICAL METHODS Vacuum curettage is a method used up to 14–15 weeks. Some very experienced gynaecologists will perform abortions surgically by dilating the cervix and evacuating the uterine contents up to 22 weeks’ gestation. The greater the size of the pregnancy, the higher the risk of haemorrhage and perforation of the uterus. In the UK, illegal abortion is rare but in other countries this is not the case. Where illegal abortions are done, the risks of infection and perforation are high and death a de?nite risk. Legal abortions are generally safe. In the USA, partial-birth abortions are spoken of but, in fact, there is no such procedure recorded in the UK medical journals.... abortion
13.
The ?rst type of damage occurs as an acute episode in which one or more severe blows leads to loss of consciousness and occasionally to death. Death in the acute phase is usually due to intracranial haemorrhage and this carries a mortality of 45 per cent even with the sophisticated surgical techniques currently available. The second type of damage develops over a much longer period and is cumulative, leading to the atrophy of the cerebral cortex and brain stem. The repair processes of the brain are very limited and even after mild concussion it may suffer a small amount of permanent structural damage. Brain-scanning techniques now enable brain damage to be detected during life, and brain damage of the type previously associated with the punch-drunk syndrome is now being detected before obvious clinical signs have developed. Evidence of cerebral atrophy has been found in relatively young boxers including amateurs and those whose careers have been considered successful. The tragedy is that brain damage can only be detected after it has occurred. Many doctors are opposed to boxing, even with the present, more stringent medical precautions taken by those responsible for running the sport. Since the Royal College’s survey in 1969, the British Medical Association and other UK medical organisations have declared their opposition to boxing on medical grounds, as have medical organisations in several other countries.
In 1998, the Dutch Health Council recommended that professional boxing should be banned unless the rules are tightened. It claimed that chronic brain damage is seen in 40–80 per cent of boxers and that one in eight amateur bouts end with a concussed participant.
There is currently no legal basis on which to ban boxing in the UK, although it has been suggested that an injured boxer might one day sue a promoter. One correspondent to the British Medical Journal in 1998 suggested that since medical cover is a legal requirement at boxing promotions, the profession should consider if its members should withdraw participation.... boxing injuries
In 1997 the ?rst mammal to be cloned from the tissue of an adult animal was born. A technique that scientists have been trying to perfect for decades, the success of the Roslin Institute, near Edinburgh, in producing ‘Dolly’, a cloned sheep, has profound implications. Already some scientists are talking of cloning humans, although this has great medical, legal and ethical consequences. The key to the scientists’ success in producing Dolly was the ability to coordinate the fusion of a donor cell (from an adult) containing all its DNA with a recipient egg from which DNA had been removed. The di?culty of the technique is shown by the fact that, out of 277 fused pairs of cells where the donor cell was from adult tissue, Dolly was the only survivor and she has developed premature arthritis. Research suggests that cloning may be accompanied by a higher than normal incidence of congenital defects.
Since Dolly was born, other animal clones have been produced and American researchers have cloned the ?rst human embryo – which grew to six cells – with the aim of providing stem cells for therapeutic use. As a result the UK government passed emergency legislation to outlaw human cloning for reproductive purposes.... cloning
Adoption declined as the availability of babies fell with the introduction of the Abortion Act 1968, improving contraceptive services and increasing acceptability of single parenthood.
However, with 10 per cent of couples suffering infertility, the demand continued, leading to the adoption of those previously perceived as di?cult to place – i.e. physically, intellectually and/or emotionally disabled children and adolescents, those with terminal illness, and children of ethnic-minority groups.
Recent controversies regarding homosexual couples as adoptive parents, adoption of children with or at high risk of HIV/AIDS, transcultural adoption, and the increasing use of intercountry adoption to ful?l the needs of childless couples have provoked urgent consideration of the ethical dilemmas of adoption and its consequences for the children, their adoptive and birth families and society generally.
Detailed statistics have been unavailable since 1984 but in general there has been a downward trend with relatively more older children being placed. Detailed reasons for adoption (i.e. interfamily, step-parent, intercountry, etc.) are not available but approximately one-third are adopted from local-authority care.
In the UK all adoptions (including interfamily and step-parent adoption) must take place through a registered adoption agency which may be local-authority-based or provided by a registered voluntary agency. All local authorities must act as agencies, the voluntary agencies often providing specialist services to promote and support the adoption of more di?cult-to-place children. Occasionally an adoption allowance will be awarded.
Adoption orders cannot be granted until a child has resided with its proposed adopters for 13 weeks. In the case of newborn infants the mother cannot give formal consent to placement until the baby is six weeks old, although informal arrangements can be made before this time.
In the UK the concept of responsibility of birth parents to their children and their rights to continued involvement after adoption are acknowledged by the Children Act 1989. However, in all discussions the child’s interests remain paramount. The Act also recognises adopted children’s need to have information regarding their origins.
BAAF – British Agencies for Adoption and Fostering – is the national organisation of adoptive agencies, both local authority and voluntary sector. The organisation promotes and provides training service, development and research; has several specialist professional subgroups (i.e. medical, legal, etc.); and produces a quarterly journal.
Adoption UK is an e?ective national support network of adoptive parents who o?er free information, a ‘listening ear’ and, to members, a quarterly newsletter.
National Organisation for Counselling Adoptees and their Parents (NORCAP) is concerned with adopted children and birth parents who wish to make contact.
The Registrar General operates an Adoption Contact Register for adopted persons and anyone related to that person by blood, half-blood or marriage. Information can be obtained from the O?ce of Population Censuses and Surveys. For the addresses of these organisations, see Appendix 2.... child adoption
The dependence that most concerns modern society is one in which individuals become dependent on or addicted to certain substances such as alcohol, drugs, tobacco (nicotine), caffeine and solvents. This is often called substance abuse. Some people become addicted to certain foods or activities: examples of the latter include gambling, computer games and use of the Internet.
The 28th report of the World Health Organisation Expert Committee on Drug Dependence in 1993 de?ned drug dependence as: ‘A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behaviour. Psychological dependence occurs when the substance abuser craves the drug’s desirable effects. Physical dependence occurs when the user has to continue taking the drug to avoid distressing withdrawal or abstinence symptoms. Thus, determinants and the problematic consequences of drug dependence may be biological, psychological or social and usually interact.’
Di?erent drugs cause di?erent rates of dependence: TOBACCO is the most common substance of addiction; HEROIN and COCAINE cause high rates of addiction; whereas ALCOHOL is much lower, and CANNABIS lower again. Smoking in the western world reached a peak after World War II with almost 80 per cent of the male population smoking. The reports on the link between smoking and cancer in the early 1960s resulted in a decline that has continued so that only around a quarter of the adult populations of the UK and USA smokes. Globally, tobacco consumption continues to grow, particularly in the developing world with multinational tobacco companies marketing their products aggressively.
Accurate ?gures for illegal drug-taking are hard to obtain, but probably approximately 4 per cent of the population is dependent on alcohol and 2 per cent on other drugs, both legal and illegal, at any one time in western countries.
How does dependence occur? More than 40 distinct theories or models of drug misuse have been put forward. One is that the individual consumes drugs to cope with personal problems or diffculties in relations with others. The other main model emphasises environmental in?uences such as drug availability, environmental pressures to consume drugs, and sociocultural in?uences such as peer pressure.
By contrast to these models of why people misuse drugs, models of compulsive drug use – where individuals have a compulsive addiction
– have been amenable to testing in the laboratory. Studies at cellular and nerve-receptor levels are attempting to identify mechanisms of tolerance and dependence for several substances. Classical behaviour theory is a key model for understanding drug dependence. This and current laboratory studies are being used to explain the reinforcing nature of dependent substances and are helping to provide an explanatory framework for dependence. Drug consumption is a learned form of behaviour. Numerous investigators have used conditioning theories to study why people misuse drugs. Laboratory studies are now locating the ‘reward pathways’ in the brain for opiates and stimulants where positive reinforcing mechanisms involve particular sectors of the brain. There is a consensus among experts in addiction that addictive behaviour is amenable to e?ective treatment, and that the extent to which an addict complies with treatment makes it possible to predict a positive outcome. But there is a long way to go before the mechanisms of drug addiction are properly understood or ways of treating it generally agreed.
Effects of drugs Cannabis, derived from the plant Cannabis sativa, is a widely used recreational drug. Its two main forms are marijuana, which comes from the dried leaves, and hashish which comes from the resin. Cannabis may be used in food and drink but is usually smoked in cigarettes to induce relaxation and a feeling of well-being. Heavy use can cause apathy and vagueness and may even cause psychosis. Whether or not cannabis leads people to using harder drugs is arguable, and a national debate is underway on whether its use should be legalised for medicinal use. Cannabis may alleviate the symptoms of some disorders – for example, MULTIPLE SCLEROSIS (MS) – and there are calls to allow the substance to be classi?ed as a prescribable drug.
About one in ten of Britain’s teenagers misuses volatile substances such as toluene at some time, but only about one in 40 does so regularly. These substances are given o? by certain glues, solvents, varnishes, and liquid fuels, all of which can be bought cheaply in shops, although their sale to children under 16 is illegal. They are often inhaled from plastic bags held over the nose and mouth. Central-nervous-system excitation, with euphoria and disinhibition, is followed by depression and lethargy. Unpleasant effects include facial rash, nausea and vomiting, tremor, dizziness, and clumsiness. Death from COMA and acute cardiac toxicity is a serious risk. Chronic heavy use can cause peripheral neuropathy and irreversible cerebellar damage. (See SOLVENT ABUSE (MISUSE).)
The hallucinogenic or psychedelic drugs include LYSERGIC ACID DIETHYLAMIDE (LSD) or acid, magic mushrooms, ecstasy (MDMA), and phencyclidine (PCP or ‘angel’ dust, mainly used in the USA). These drugs have no medicinal uses. Taken by mouth, they produce vivid ‘trips’, with heightened emotions and perceptions and sometimes with hallucinations. They are not physically addictive but can cause nightmarish bad trips during use and ?ashbacks (vivid reruns of trips) after use, and can probably trigger psychosis and even death, especially if drugs are mixed or taken with alcohol.
Stimulant drugs such as amphetamine and cocaine act like adrenaline and speed up the central nervous system, making the user feel con?dent, energetic, and powerful for several hours. They can also cause severe insomnia, anxiety, paranoia, psychosis, and even sudden death due to convulsions or tachycardia. Depression may occur on withdrawal of these drugs, and in some users this is su?ciently deterrent to cause psychological dependence. Amphetamine (‘speed’) is mainly synthesised illegally and may be eaten, sni?ed, or injected. Related drugs, such as dexamphetamine sulphate (Dexedrine), are prescribed pills that enter the black market. ECSTASY is another amphetamine derivative that has become a popular recreational drug; it may have fatal allergic effects. Cocaine and related drugs are used in medicine as local anaesthetics. Illegal supplies of cocaine (‘snow’ or ‘ice’) and its derivative, ‘crack’, come mainly from South America, where they are made from the plant Erythroxylon coca. Cocaine is usually sni?ed (‘snorted’) or rubbed into the gums; crack is burnt and inhaled.
Opiate drugs are derived from the opium poppy, Papaver somniferum. They are described as narcotic because they induce sleep. Their main medical use is as potent oral or injectable analgesics such as MORPHINE, DIAMORPHINE, PETHIDINE HYDROCHLORIDE, and CODEINE. The commonest illegal opiate is heroin, a powdered form of diamorphine that may be smoked, sni?ed, or injected to induce euphoria and drowsiness. Regular opiate misuse leads to tolerance (the need to take ever larger doses to achieve the same e?ect) and marked dependence. A less addictive oral opiate, METHADONE HYDROCHLORIDE, can be prescribed as a substitute that is easier to withdraw.
Some 75,000–150,000 Britons now misuse opiates and other drugs intravenously, and pose a huge public-health problem because injections with shared dirty needles can carry the blood-borne viruses that cause AIDS/HIV and HEPATITIS B. Many clinics now operate schemes to exchange old needles for clean ones, free of charge. Many addicts are often socially disruptive.
For help and advice see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP – National Dugs Helpline.
(See ALCOHOL and TOBACCO for detailed entries on those subjects.)... dependence
Prescriptions for drugs should be printed or written clearly in ink and signed and dated by the prescriber (computer-generated facsimile signatures do not meet legal requirements). They should include the patient’s name, address and age (obligatory for children under 12), the name of the drug to be supplied, the dose and dose frequency, and the total quantity to be supplied. Any special instructions (e.g. ‘after food’) should be stated. There are special regulations about the prescription of drugs controlled under the Misuse of Drugs Regulations 1985 (see CONTROLLED DRUGS). A pharmacist can advise about which drugs are available without prescription, and is able to recommend treatment for many minor complaints. Information about exemption from prescription charges in the NHS can be obtained from health visitors, general practitioners, or social security o?ces.... drugs
The only certain sign of death, however, is that the heart has stopped beating. To ensure that this is permanent, it is necessary to listen over the heart with a stethoscope, or directly with the ear, for at least ?ve minutes. Permanent stoppage of breathing should also be con?rmed by observing that a mirror held before the mouth shows no haze, or that a feather placed on the upper lip does not ?utter.
In the vast majority of cases there is no dif?culty in ensuring that death has occurred. The introduction of organ transplantation, however, and of more e?ective mechanical means of resuscitation, such as ventilators, whereby an individual’s heart can be kept beating almost inde?nitely, has raised diffculties in a minority of cases. To solve the problem in these cases the concept of ‘brain death’ has been introduced. In this context it has to be borne in mind that there is no legal de?nition of death. Death has traditionally been diagnosed by the irreversible cessation of respiration and heartbeat. In the Code of Practice drawn up in 1983 by a Working Party of the Health Departments of Great Britain and Northern Ireland, however, it is stated that ‘death can also be diagnosed by the irreversible cessation of brain-stem function’. This is described as ‘brain death’. The brain stem consists of the mid-brain, pons and medulla oblongata which contain the centres controlling the vital processes of the body such as consciousness, breathing and the beating of the heart (see BRAIN). This new concept of death, which has been widely accepted in medical and legal circles throughout the world, means that it is now legitimate to equate brain death with death; that the essential component of brain death is death of the brain stem; and that a dead brain stem can be reliably diagnosed at the bedside. (See GLASGOW COMA SCALE.)
Four points are important in determining the time that has elapsed since death. HYPOSTASIS, or congestion, begins to appear as livid spots on the back, often mistaken for bruises, three hours or more after death. This is due to the blood running into the vessels in the lowest parts. Loss of heat begins at once after death, and the body has become as cold as the surrounding air after 12 hours – although this is delayed by hot weather, death from ASPHYXIA, and some other causes. Rigidity, or rigor mortis, begins in six hours, takes another six to become fully established, remains for 12 hours and passes o? during the succeeding 12 hours. It comes on quickly when extreme exertion has been indulged in immediately before death; conversely it is slow in onset and slight in death from wasting diseases, and slight or absent in children. It begins in the small muscles of the eyelid and jaw and then spreads over the body. PUTREFACTION is variable in time of onset, but usually begins in 2–3 days, as a greenish tint over the abdomen.... death, signs of
The most common – Local Research Ethics Committees (LRECs) – have provided a monitoring system of research on humans since the late 1960s. Established by NHS health authorities, LRECs were primarily perceived as exercising authority over research carried out on NHS patients or on NHS premises or using NHS records. Their power and signi?cance, however, developed considerably in the 1980s and 90s when national and international guidance made approval by an ‘appropriately constituted’ ethics committee obligatory for any research project involving humans or human tissue. The work of LRECs is supplemented by so-called ‘independent’ ethics committees usually set up by pharmaceutical companies, and since 1997 by multicentre research ethics committees (MRECs). An MREC is responsible for considering all health-related research which will be conducted within ?ve or more locations. LRECs have become indispensable to the conduct of research, and are doubtless partly responsible for the lack of demand in the UK for legislation governing research. A plethora of guidelines is available, and LRECs which fail to comply with recognised standards could incur legal liability. They are increasingly governed by international standards of practice. In 1997, guidelines produced by the International Committee on Harmonisation of Good Clinical Practice (ICH-GCP) were introduced into the UK. These provide a uni?ed standard for research conducted in the European Union, Japan and United States to ensure the mutual acceptance of clinical data by the regulatory authorities in these countries.
Other categories of ethics committee include Ethics Advisory Committees, which debate dif?cult patient cases. Most are attached to specialised health facilities such as fertility clinics or children’s care facilities. The 1990s have seen a greatly increased interest in professional ethics and the establishment of many new ethics committees, including some like that of the National Council for Hospice and Specialist Palliative Care Services which cross professional boundaries. Guidance on professional and ethical standards is produced by these new bodies and by the well-established ethics committees of regulatory or representative bodies, such as the medical and nursing Royal Colleges, the General Medical Council, United Kingdom Central Council for Nursing, Midwifery and Health Visiting, British Medical Association (see APPENDIX 8: PROFESSIONAL ORGANISATIONS) and bodies representing paramedics and professions supplementary to medicine. Their guidance ranges from general codes of practice to detailed analysis of single topics such as EUTHANASIA or surrogacy.
LRECs are now supervised by a central body
– COREC (www.corec.gov.org.uk).... ethics committees
Medical ethics are embedded in cultural values which evolve. Acceptance of abortion within well-de?ned legal parameters in some jurisdictions is an example of how society in?uences the way in which perceptions about ethical obligations change. Because they are often linked to the moral views predominating in society, medical ethics cannot be seen as embodying uniform standards independent of cultural context. Some countries which permit capital punishment or female genital mutilation (FGM – see CIRCUMCISION), for example, expect doctors to carry out such procedures. Some doctors would argue that their ethical obligation to minimise pain and suffering obliges them to comply, whereas others would deem their ethical obligations to be the complete opposite. The medical community attempts to address such variations by establish-ing globally applicable ethical principles through debate within bodies such as the World Medical Association (WMA) or World Psychiatric Association (WPA). Norm-setting bodies increasingly re?ect accepted concepts of human rights and patient rights within professional ethical codes.
Practical changes within society may affect the perceived balance of power within the doctor-patient relationship, and therefore have an impact on ethics. In developed societies, for example, patients are increasingly well informed about treatment options: media such as the Internet provide them with access to specialised knowledge. Social measures such as a well-established complaints system, procedures for legal redress, and guarantees of rights such as those set out in the NHS’s Patient’s Charter appear to reduce the perceived imbalance in the relationship. Law as well as ethics emphasises the importance of informed patient consent and the often legally binding nature of informed patient refusal of treatment. Ethics re?ect the changing relationship by emphasising skills such as e?ective communication and generation of mutual trust within a doctor-patient partnership.
A widely known modern code is the WMA’s International Code of Medical Ethics which seeks to provide a modern restatement of the Hippocratic principles.
Traditionally, ethical codes have sought to establish absolutist positions. The WMA code, for example, imposes an apparently absolute duty of con?dentiality which extends beyond the patient’s death. Increasingly, however, ethics are perceived as a tool for making morally appropriate decisions in a sphere where there is rarely one ‘right’ answer. Many factors – such as current emphasis on autonomy and the individual values of patients; awareness of social and cultural diversity; and the phenomenal advance of new technology which has blurred some moral distinctions about what constitutes a ‘person’ – have contributed to the perception that ethical dilemmas have to be resolved on a case-by-case basis.
An approach adopted by American ethicists has been moral analysis of cases using four fundamental principles: autonomy, bene?cence, non-male?cence and justice. The ‘four principles’ provide a useful framework within which ethical dilemmas can be teased out, but they are criticised for their apparent simplicity in the face of complex problems and for the fact that the moral imperatives implicit in each principle often con?ict with some or all of the other three. As with any other approach to problem-solving, the ‘four principles’ require interpretation. Enduring ethical precepts such as the obligation to bene?t patients and avoid harm (bene?cence and non-male?cence) may be differently interpreted in cases where prolongation of life is contrary to a patient’s wishes or where sentience has been irrevocably lost. In such cases, treatment may be seen as constituting a ‘harm’ rather than a ‘bene?t’.
The importance accorded to ethics in daily practice has undergone considerable development in the latter half of the 20th century. From being seen mainly as a set of values passed on from experienced practitioners to their students at the bedside, medical ethics have increasingly become the domain of lawyers, academic philosophers and professional ethicists, although the role of experienced practitioners is still considered central. In the UK, law and medical ethics increasingly interact. Judges resolve cases on the basis of established medical ethical guidance, and new ethical guidance draws in turn on common-law judgements in individual cases. The rapid increase in specialised journals, conferences and postgraduate courses focused on ethics is testimony to the ever-increasing emphasis accorded to this area of study. Multidisciplinary practice has stimulated the growth of the new discipline of ‘health-care ethics’ which seeks to provide uniformity across long-established professional boundaries. The trend is to set common standards for a range of health professionals and others who may have a duty of care, such as hospital chaplains and ancillary workers. Since a primary function of ethics is to ?nd reasonable answers in situations where di?erent interests or priorities con?ict, managers and health-care purchasers are increasingly seen as potential partners in the e?ort to establish a common approach. Widely accepted ethical values are increasingly applied to the previously unacknowledged dilemmas of rationing scarce resources.
In modern debate about ethics, two important trends can be identi?ed. As a result of the increasingly high pro?le accorded to applied ethics, there is a trend for professions not previously subject to widely agreed standards of behaviour to adopt codes of ethical practice. Business ethics or the ethics of management are comparatively new. At the same time, there is some debate about whether professionals, such as doctors, traditionally subject to special ethical duties, should be seen as simply doing a job for payment like any other worker. As some doctors perceive their power and prestige eroded by health-care managers deciding on how and when to ration care and pressure for patients to exercise autonomy about treatment decisions, it is sometimes argued that realistic limits must be set on medical obligations. A logical implication of patient choice and rejection of medical paternalism would appear to be a concomitant reduction in the freedom of doctors to carry out their own ethical obligations. The concept of conscientious objection, incorporated to some extent in law (e.g. in relation to abortion) ensures that doctors are not obliged to act contrary to their own personal or professional values.... ethics
Most of the detailed information available about the practice of euthanasia comes from the Netherlands, where court rulings in the 1970s and 1980s began to permit voluntary euthanasia under certain circumstances (although both euthanasia and assisted suicide remain technically illegal). The di?culty of maintaining limits was highlighted in 1994–5 when it became clear that a small percentage of Dutch patients undergoing euthanasia had previously expressed an interest but not speci?cally requested it (involuntary euthanasia) or had no known desire for it and may have been opposed to it (non-voluntary euthanasia). The relevance of terminal illness and physical suffering was tested in Holland in 1994 when a patient received euthanasia who was not physically ill and subject to mental rather than physical suffering. Nevertheless, Dutch doctors risk prosecution if they fail to follow rules of careful conduct when carrying out euthanasia or assisted suicide. (See also ETHICS; SUICIDE.)... euthanasia
(2) A drug used to treat an individual with an illness or injury (see MEDICINES).
(3) The diagnosis and treatment of those diseases not normally requiring surgical intervention.
Defensive medicine Diagnostic or treatment procedures undertaken by practitioners in which they aim to reduce the likelihood of legal action by patients. This may result in requests for investigations that, arguably, are to provide legal cover for the doctor rather than more certain clinical diagnosis for the patient.... medicine
In the hospital service, claims for clinical negligence have risen enormously since the 1970s. In 1975 the NHS spent about £1m a year on legal claims; by 2004 the NHS faced over £2 billion in outstanding claims. In 1995 a risk-pooling Clinical Negligence Scheme for Trusts (CNST) was set up in England, and is administered by the NHS Litigation Authority. NHS trusts are expected to follow a set of risk-management standards, the ?rst being that each trust should have a written risk-management strategy with an explicit commitment to managing clinical risk (see RISK MANAGEMENT).... medical litigation
For a diagnosis of PVS to be made, the state should have continued for more than a prede?ned period, usually one month. Half of patients die within 2–6 months, but some can survive for longer with arti?cial feeding. To assess a person’s level of consciousness, a numerical marking system rated according to various functions – eye opening, motor and verbal responses – has been established called the GLASGOW COMA SCALE.
The ETHICS of keeping patients alive with arti?cial support are controversial. In the UK, a legal ruling is usually needed for arti?cial support to be withdrawn after a diagnosis of PVS has been made. The chances of regaining consciousness after one year are slim and, even if patients do recover, they are usually left with severe neurological disability.
PVS must be distinguished from conditions which appear similar. These include the ‘LOCKED-IN SYNDROME’ which is the result of damage to the brain stem (see BRAIN). Patients with this syndrome are conscious but unable to speak or move except for certain eye movements and blinking. The psychiatric state of CATATONIA is another condition in which the patient retains consciousness and will usually recover.... persistent vegetative state (pvs)
Central to an understanding of public health is recognition that public-health practitioners are concerned not just with individuals, but also with whole populations – and that improving health care plays only a part of public-health improvement. The health of populations (public health) is also dependent on many factors such as the social, economic and physical environment in which the people live and the nutrition and health care available to them.
For thousands of years, a fundamental feature of civilisations has been to seek to improve the health of the population and protect it from disease. This has led to the development of legal frameworks which di?er widely from country to country, depending on their social and political development. All are concerned to stop the spread of infectious diseases, and to maintain the safety of urban food and water supplies and waste disposal. Most are also associated with housing standards, some form of poverty relief, and basic health care. Some trading standards are often covered, at least in relation to the sale and distribution of poisons and drugs, and to controls on industrial and transport safety – for example, in relation to drinking and driving and car design. Although these varied functions protect the public health and were often originally developed to improve it, most are managerially and professionally separated from today’s public-health departments. So public-health professionals in the NHS, armed with evidence of the cause of a disease problem, must frequently act as advocates for health across many agencies where they play no formal management part. They must also seek to build alliances and add a health perspective to the policies of other services wherever possible.
Epidemiology is the principal diagnostic method of public health. It is de?ned as the study of the distribution and determinants of health-related states in speci?ed populations, and the application of this study to the control of health problems. Public-health practitioners also draw on many other skills, such as those of statisticians, sociologists, anthropologists, economists and policy analysts in identifying and trying to resolve the health problems of the societies they serve. Treatments proposed are likely to extend well beyond the clinic or hospital and may include recommendations for measures to resolve poverty, improve sanitation or housing, control pollution, change lifestyles such as smoking, improve nutrition, or change health services. At times of acute EPIDEMIC, public-health doctors have considerable legal powers granted to enable them to prevent infection from spreading. At other times their work may be more concerned with monitoring, reporting, planning and managing services, and advocating policy changes to politicians so that health is promoted.
The term ‘the public health’ can relate to the state of health of the population, and be represented by measures such as MORTALITY indices
(e.g. perinatal or infant mortality and standardised mortality rates), life expectancy, or measures of MORBIDITY (illness). These can be compared across areas and even countries. Sometimes people refer to a pubic health-care system; this is a publicly funded service, the primary aim of which is to improve health by the use of population-based measures. They may include or be separate from private health-care services for which individuals pay. The structure of these systems varies from country to country, re?ecting di?erent social composition and political priorities. There are, however, some general elements that can be identi?ed:
Surveillance The collection, collation and analysis of data to provide useful information about the distribution and causes of health and disease and related factors in populations. These activities form the basis of epidemiology, which is the diagnostic backbone of public-health practice.
Intervention The design, advocacy and implementation of policies to improve health. This may be through the provison of PREVENTIVE MEDICINE, environmental measures, in?uencing the behaviour of individuals, or the provision of appropriate services to limit disability and handicap. It will lead to advocacy for health, promoting change in many areas of policy including, for example, taxation and improved housing and employment opportunities.
Evaluation Assessment of the ?rst two steps to assess their impact in terms of e?ectiveness, e?ciency, acceptability, accessibility, value for money or other indicators of quality. This enables the programme to be reviewed and changed as necessary.
The practice of public health The situation in the United Kingdom will be described as, even though systems vary, it will give a general impression of the type of work covered. HISTORY Initially, public-health practice related to food, the urban environment and the control of infectious diseases. Early examples include rules in the Bible about avoiding certain foods. These were probably based on practical experience, had gradually been adopted as sensible behaviour, become part of culture and ?nally been incorporated into religious laws. Other examples are the regulations about quarantine for PLAGUE and LEPROSY in the Middle Ages, vaccination against SMALLPOX introduced by William Jenner, and Lind’s use of citrus fruits to prevent SCURVY at sea in the 18th century.
It was during the 19th century, in response to the health problems arising from the rapid growth of urban life, that the foundations of a public-health system were created. The ‘sanitary’ concept was fundamental to these developments. This suggested that overcrowding in insanitary conditions was the cause of most disease epidemics and that improved sanitation measures such as sewerage and clean water supplies would prevent them. Action to introduce such measures were often initiated only after epidemics spread out of the slums and into wealthier and more powerful families. Other problems such as the stench of the River Thames outside the Houses of Parliament also led to a demand for e?ective sanitary control measures. Successive public-health laws were passed by Parliament, initially about sanitation and housing, and then, as scienti?c knowledge grew, about bacterial infections.
In the middle of the 19th century the ?rst medical o?cers of health were appointed with responsibility to report regularly and advise local government about the measures needed to control disease and improve health. Their scope and responsibility widened as society changed and took on a wider welfare role. After more than a century they changed as part of the reforms of the NHS and local government in the 1960s and became more narrowly focused within the health-care system and its management. Increased recognition of the multifactorial causes, costs and limitations of treatment of conditions such as cancer and heart disease, and the emergence of new problems such as AIDS/HIV and BOVINE SPONGIFORM ENCEPHALOPATHY (BSE) have again showed the importance of prevention and a broader approach to health. With it has come recognition that, while disease may be the justi?cation for action, a narrow diseasetreatment-based approach is not always the most e?ective or economic solution. The role of the director of public health (the successor to the medical o?cer of health) is again being expanded, and in 1997 – for the ?rst time in the UK – a government Minister for Public Health was appointed. This reffects not only a greater priority for public health, but also a concern that the health effects of policy should be considered across all parts of government.
(See also ENVIRONMENT AND HEALTH.)... public health
(See also NEUROSIS; PSYCHOTHERAPY.) FORENSIC PSYCHOLOGISTS work in the
criminal and justice ?elds, applying psychological theory to aspects of legal processes in courts, criminal investigation, and understanding and treating psychological problems associated with criminal behaviour. They will have completed an accredited training course in forensic psychology. HEALTH PSYCHOLOGISTS apply psychological methods to studying behaviour relevant to health, illness and care including health promotion and education. OCCUPATIONAL PSYCHOLOGISTS are concerned with how people perform at work and how organisations function. They work in management, personnel, selection and careers advice. They have a postgraduate degee in occupational psychology and will have had to undertake three years’ supervised practice.... types of psychologist
Societies vary in the degree to which they tolerate individuals acting intentionally to cause their own death. Apart from among some native peoples, particularly the Innuit, suicide is generally viewed pejoratively in modern societies. Major religious movements, including Catholicism, Judaism and Islam, have traditionally regarded suicide as a sin. Nevertheless, it is a growing phenomenon, particularly among the young, and so has become a serious public health problem. It is estimated that suicide among young people has tripled – at least – during the past 45 years. Worldwide, suicide is the second major cause of death (after tuberculosis) for women between the ages of 15 and 44, and the fourth major killer of men in the same age-group (after tra?c accidents, tuberculosis and violence). The risk of suicide rises sharply in old age. Globally, there are estimated to be between ten and 25 suicide attempts for each completed suicide.
In the United Kingdom, suicide accounts for 20 per cent of all deaths of young people. Around 6,000 suicides are reported annually in the UK, of which approximately 75 per cent are by men. In the late 1990s the suicide rate in England, Wales and Northern Ireland fell, but increased in Scotland and the Republic of Ireland. Attempted suicide became signi?cantly more common, particularly among people under the age of 25: among adolescents in the UK, for example, it is estimated that there are about 19,000 suicide attempts annually. Follow-up studies of teenagers who attempt suicide by an overdose show that up to 11 per cent will succeed in killing themselves over the following few years. In young people, factors linked to suicide and attempted suicide include alcohol or drug abuse, unemployment, physical or sexual abuse, and the fact of being in custody. (In the mid-1990s, 20 per cent of all prison suicides were by people under 21.)
Apart from the young, those at highest risk of dying by suicide include health professionals, pharmacists, vets and farmers. Self-poisoning (see POISONS) is the common method used by health professionals for whom high stress levels, together with relatively easy access to means, are important factors. The World Health Organisation has outlined six basic steps for the prevention of suicide, focusing particularly on reducing the availability of common methods. Although suicide is not a criminal o?ence in the UK, assisting suicide is a crime carrying a potential sentence of 14 years’ imprisonment. There are several dilemmas faced by health professionals if they believe that a patient is considering suicide: one is that the provision of information to the patient may make them an accessory (see below). A dilemma after suicide is the common demand from insurers for medical information, although, ethically, the duty of con?dentiality extends beyond the patient’s death (see ETHICS). (Legally, some disclosure is permitted to those with a claim arising from the patient’s death.) Life-insurance contracts generally render invalid any claim by the heirs on the policy of an individual who commits suicide, so that disclosure by a doctor often creates tensions with the relatives. Non-disclosure of relevant medical information, however, may result in a fraudulent insurance claim being made.
Physician-assisted suicide Although controversial, a special legal exemption applies to doctors in a few countries who assist terminally ill patients to kill themselves. Oregon in the United States legalised physician-assisted suicide in 1997, where it still occurs; assisted suicide was brie?y legal in the Australian Northern Territory in 1996 but the legislation was repealed. (It is also practised, but not legally authorised, in the Netherlands and Switzerland.)
In the UK there have been unsuccessful parliamentary attempts to legalise assisted suicide, such as the 1997 Doctor Assisted Dying Bill. In law, a distinction is made between killing people with their consent (classi?ed as murder) and assisting them to commit suicide (a statutory o?ence under the Suicide Act 1961). The distinction is between acting as a perpetrator and as an accessory. Doctors may be judged to have aided and abetted a suicide if they knowingly provide the means – or even if they simply provide advice about the toxicity of medication and tell patients the lethal dosage. Some argue that the distinction between EUTHANASIA and physician-assisted suicide has no moral or practical relevance, particularly if patients are too disabled to act themselves. In theory, patients retain ultimate control in cases of assisted suicide, whereas control rests with the doctor in euthanasia. Surveys of health professionals appear to indicate a feeling by some that less responsibility or culpability attaches to assisting suicide than to euthanasia. In a recent UK court case (2002), a judge declared that a mentally alert woman on a permanent life-support regime in hospital had a right to ask for the support system to be switched o?. (See also MENTAL ILLNESS.)... suicide
Act (1983) details the rights of patients with mental illness and the grounds for detaining mentally ill people against their will. It also outlines forms of legal guardianship for such patients.
When a person is endangering his or her own or other people’s health or safety (for example, threatening harm or suicide) because of a recognized mental illness, he or she may be compulsorily taken into hospital to be given treatment.
If a person breaks the law because of a mental disorder, the courts may remand him or her to hospital.... mental health act
The pioneering success was achieved with transplantation of the kidney in the 1970s; this has been most successful when the transplanted kidney has come from an identical twin. Less successful have been live transplants from other blood relatives, while least successful have been transplants from other live donors and cadaver donors. The results, however, are steadily improving. Thus the one-year functional survival of kidneys transplanted from unrelated dead donors has risen from around 50 per cent to over 80 per cent, and survival rates of 80 per cent after three years are not uncommon. For a well-matched transplant from a live related donor, the survival rate after ?ve years is around 90 per cent. And, of course, if a transplanted kidney fails to function, the patient can always be switched on to some form of DIALYSIS. In the United Kingdom the supply of cadaveric (dead) kidneys for transplantation is only about half that necessary to meet the demand.
Other organs that have been transplanted with increasing success are the heart, the lungs, the liver, bone marrow, and the cornea of the eye. Heart, lung, liver and pancreas transplantations are now carried out in specialist centres. It is estimated that in the United Kingdom, approximately 200 patients a year between the ages of 15 and 55 would bene?t from a liver transplant if an adequate number of donors were available. More than 100 liver transplants are carried out annually in the United Kingdom and one-year-survival rates of up to 80 per cent have been achieved.
The major outstanding problem is how to prevent the recipient’s body from rejecting and destroying the transplanted organ. Such rejection is part of the normal protective mechanism of the body (see IMMUNITY). Good progress has been made in techniques of tissue-typing and immunosuppression to overcome the problem. Drugs are now available that can suppress the immune reactions of the recipient, which are responsible for the rejection of the transplanted organ. Notable among these are CICLOSPORIN A, which revolutionised the success rate, and TACROLIMUS, a macrolide immunosuppressant.
Another promising development is antilymphocytic serum (ALS), which reduces the activity of the lymphocytes (see LYMPHOCYTE) cells which play an important part in maintaining the integrity of the body against foreign bodies.
Donor cards are now available in all general practitioners’ surgeries and pharmacies but, of the millions of cards distributed since 1972, too few have been used. The reasons are complex but include the reluctance of the public and doctors to consider organ donation; poor organisation for recovery of donor kidneys; and worries about the diagnosis of death. A code of practice for procedures relating to the removal of organs for transplantation was produced in 1978, and this code has been revised in the light of further views expressed by the Conference of Medical Royal Colleges and Faculties of the United Kingdom on the Diagnosis of Brain Death. Under the Human Tissue Act 1961, only the person lawfully in possession of the body or his or her designate can authorise the removal of organs from a body. This authorisation may be given orally.
Patients who may become suitable donors after death are those who have suffered severe and irreversible brain damage – since such patients will be dependent upon arti?cial ventilation. Patients with malignant disease or systemic infection, and patients with renal disease, including chronic hypertension, are unsuitable.
If a patient carries a signed donor card or has otherwise recorded his or her wishes, there is no legal requirement to establish lack of objection on the part of relatives – although it is good practice to take account of the views of close relatives. If a relative objects, despite the known request by the patient, sta? will need to judge, according to the circumstances of the case, whether it is wise to proceed with organ removal. If a patient who has died is not known to have requested that his or her organs be removed for transplantation after death, the designated person may only authorise the removal if, having made such reasonable enquiry as may be practical, he or she has no reason to believe (a) that the deceased had expressed an objection to his or her body being so dealt with after death, or (b) that the surviving spouse or any surviving relative of the deceased objects to the body being so dealt with. Sta? will need to decide who is best quali?ed to approach the relatives. This should be someone with appropriate experience who is aware how much the relative already knows about the patient’s condition. Relatives should not normally be approached before death has occurred, but sometimes a relative approaches the hospital sta? and suggests some time in advance that the patient’s organs might be used for transplantation after death. The sta? of hospitals and organ exchange organisations must respect the wishes of the donor, the recipient and their families with respect to anonymity.
Relatives who enquire should be told that some post-mortem treatment of the donor’s body will be necessary if the organs are to be removed in good condition. It is ethical (see ETHICS) to maintain arti?cial ventilation and heartbeat until removal of organs has been completed. This is essential in the case of heart and liver transplants, and many doctors think it is desirable when removing kidneys. O?cial criteria have been issued in Britain to recognise when BRAIN-STEM DEATH has occurred. This is an important protection for patients and relatives when someone with a terminal condition
– usually as a result of an accident – is considered as a possible organ donor.... transplantation
The forensic pathologist is a doctor who specializes in the examination of bodies when circumstances suggest death was unnatural.
Forensic pathologists may also examine victims of alleged sexual assault.
Forensic scientists use laboratory methods to study body fluids (such as blood and semen) found on or near the victim and compare them with those from suspects.
They are also trained in ballistics and the identification of fibres from clothing.
In addition, forensic scientists may advise on blood groups and genetic fingerprinting in legal investigations.... forensic medicine
Full text of the document... nhs constitution for england
UK government guidance on parental responsibility... parental responsibility
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