1
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Sánchez López JD, Luque Martínez F, Peralta Cruz M, Cambil Martín J. [Lawful and bioethical reflections about Karen Quinlan case: Thirty five years after her death]. Semergen 2023; 49:101875. [PMID: 36542989 DOI: 10.1016/j.semerg.2022.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/25/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022]
Affiliation(s)
- J D Sánchez López
- Cirugía Oral y Maxilofacial, Centro de Rehabilitación y Neurotraumatología, Hospital Universitario Virgen de las Nieves, Granada, España; Comité Ético de Investigación de Granada, Granada, España.
| | - F Luque Martínez
- Comité Ético de Investigación de Granada, Granada, España; Servicio de Urgencias, Centro de Rehabilitación y Neurotraumatología, Formación del Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Peralta Cruz
- Comité Ético de Investigación de Granada, Granada, España
| | - J Cambil Martín
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, Granada, España
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2
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Beaudry JS. Death as "benefit" in the context of non-voluntary euthanasia. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:329-354. [PMID: 36227395 DOI: 10.1007/s11017-022-09597-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 06/16/2023]
Abstract
I offer a principled objection to arguments in favour of legalizing non-voluntary euthanasia on the basis of the principle of beneficence. The objection is that the status of death as a benefit to people who cannot formulate a desire to die is more problematic than pain management care. I ground this objection on epistemic and political arguments. Namely, I argue that death is relatively more unknowable, and the benefits it confers more subjectively debatable, than pain management. I am not primarily referring to the claim that it is difficult to make comparisons between live and post-mortem states, but rather to the fact that it is epistemically and metaphysically problematic to impute a "life-worse-than-death" or a state of "suffering-calling-for-death" to people who cannot subjectively wish to die, as though this kind of suffering were a medically observable fact rather than a belief- and value-laden notion. On the contrary, people enduring similar causes of pain may have different experiences of suffering and views on how it affects the worthwhileness of their existence or the desirability of death or of continuing their lives. The projection of a "suffering-calling-for-death" onto infants or people with severe intellectual disabilities may not be indefensible, but it is more controversial than judging that pain management will improve their well-being from the perspective of beneficence. My argument also relies on our society's liberal endeavour to avoid endorsing unverifiable beliefs about life and death or controversial conceptions of the good life. My goal is not to suggest we should not attend the suffering of cognitively disabled people. On the contrary, I only cast doubt on too quick an assumption that ending their lives is the best way of caring for them, when robust palliative treatments are available. Moreover, I express the concern that a lack of attention to distinctions between "pain-calling-for-relief" and "suffering-calling-for-death" may be based on ableist projections and assumptions. I conclude that it is imperative to continue research into the nature of pain and suffering experienced by individuals with mental or cognitive impairments preventing them from expressing autonomous wishes about the kind of treatment that would most benefit them.
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Affiliation(s)
- Jonas-Sébastien Beaudry
- Faculty of Law and School of Population and Global Health, McGill University, Montreal, QC, Canada.
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3
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Amiri M, Fisher PM, Raimondo F, Sidaros A, Cacic Hribljan M, Othman MH, Zibrandtsen I, Albrechtsen SS, Bergdal O, Hansen AE, Hassager C, Højgaard JLS, Jakobsen EW, Jensen HR, Møller J, Nersesjan V, Nikolic M, Olsen MH, Sigurdsson ST, Sitt JD, Sølling C, Welling KL, Willumsen LM, Hauerberg J, Larsen VA, Fabricius M, Knudsen GM, Kjaergaard J, Møller K, Kondziella D. Multimodal prediction of residual consciousness in the intensive care unit: the CONNECT-ME study. Brain 2022; 146:50-64. [PMID: 36097353 PMCID: PMC9825454 DOI: 10.1093/brain/awac335] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/25/2022] [Accepted: 08/14/2022] [Indexed: 01/15/2023] Open
Abstract
Functional MRI (fMRI) and EEG may reveal residual consciousness in patients with disorders of consciousness (DoC), as reflected by a rapidly expanding literature on chronic DoC. However, acute DoC is rarely investigated, although identifying residual consciousness is key to clinical decision-making in the intensive care unit (ICU). Therefore, the objective of the prospective, observational, tertiary centre cohort, diagnostic phase IIb study 'Consciousness in neurocritical care cohort study using EEG and fMRI' (CONNECT-ME, NCT02644265) was to assess the accuracy of fMRI and EEG to identify residual consciousness in acute DoC in the ICU. Between April 2016 and November 2020, 87 acute DoC patients with traumatic or non-traumatic brain injury were examined with repeated clinical assessments, fMRI and EEG. Resting-state EEG and EEG with external stimulations were evaluated by visual analysis, spectral band analysis and a Support Vector Machine (SVM) consciousness classifier. In addition, within- and between-network resting-state connectivity for canonical resting-state fMRI networks was assessed. Next, we used EEG and fMRI data at study enrolment in two different machine-learning algorithms (Random Forest and SVM with a linear kernel) to distinguish patients in a minimally conscious state or better (≥MCS) from those in coma or unresponsive wakefulness state (≤UWS) at time of study enrolment and at ICU discharge (or before death). Prediction performances were assessed with area under the curve (AUC). Of 87 DoC patients (mean age, 50.0 ± 18 years, 43% female), 51 (59%) were ≤UWS and 36 (41%) were ≥ MCS at study enrolment. Thirty-one (36%) patients died in the ICU, including 28 who had life-sustaining therapy withdrawn. EEG and fMRI predicted consciousness levels at study enrolment and ICU discharge, with maximum AUCs of 0.79 (95% CI 0.77-0.80) and 0.71 (95% CI 0.77-0.80), respectively. Models based on combined EEG and fMRI features predicted consciousness levels at study enrolment and ICU discharge with maximum AUCs of 0.78 (95% CI 0.71-0.86) and 0.83 (95% CI 0.75-0.89), respectively, with improved positive predictive value and sensitivity. Overall, both machine-learning algorithms (SVM and Random Forest) performed equally well. In conclusion, we suggest that acute DoC prediction models in the ICU be based on a combination of fMRI and EEG features, regardless of the machine-learning algorithm used.
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Affiliation(s)
| | | | | | - Annette Sidaros
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Melita Cacic Hribljan
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ivan Zibrandtsen
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Simon S Albrechtsen
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ove Bergdal
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joan Lilja S Højgaard
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vardan Nersesjan
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, Copenhagen, Denmark
| | - Miki Nikolic
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacobo D Sitt
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lisette M Willumsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Fabricius
- Department of Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,Department of Neuroanaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Daniel Kondziella
- Correspondence to: Daniel Kondziella, MD, MSc, PhD FEBN Department of Neurology Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100 Copenhagen E-mail:
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Cameron J, Savulescu J, Wilkinson D. Raqeeb, Haastrup, and Evans: Seeking Consistency through a Distributive Justice-Based Approach to Limitation of Treatment in the Context of Dispute. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2022; 50:169-180. [PMID: 35243998 PMCID: PMC7613734 DOI: 10.1017/jme.2022.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
When is life-sustaining treatment not in the best interests of a minimally conscious child? This is an extremely difficult question that incites seemingly intractable debate. And yet, it is the question courts in England and Wales have set out to answer in disputes about appropriate medical treatment for children.
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6
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Peterson A, Aas S, Wasserman D. What Justifies the Allocation of Health Care Resources to Patients with Disorders of Consciousness? AJOB Neurosci 2021; 12:127-139. [PMID: 33787458 DOI: 10.1080/21507740.2021.1896594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper critically engages ethical issues in the allocation of novel, and potentially costly, health care resources to patients with disorders of consciousness. First, we review potential benefits of novel health care resources for patients and their families and outline preliminary considerations to address concerns about cost. We then address two problems regarding the allocation of health care resources to patients with disorders of consciousness: (1) the problem of uncertain moral status; and (2) the problem of accurately measuring the welfare burdens these resources would relieve. We conclude by suggesting that opportunity-based frameworks might complement standard approaches for justifying resources allocation to patients with disorders of consciousness.
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Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University
| | - Sean Aas
- Kennedy Institute of Ethics, Georgetown University
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7
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Huang J, Qiu L, Lin Q, Xiao J, Huang Y, Huang H, Zhou X, Shi X, Wang F, He Y, Pan J. Hybrid asynchronous brain-computer interface for yes/no communication in patients with disorders of consciousness. J Neural Eng 2021; 18. [PMID: 33735851 DOI: 10.1088/1741-2552/abf00c] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/18/2021] [Indexed: 11/12/2022]
Abstract
Objective.For patients with disorders of consciousness (DOC), such as vegetative state (VS) and minimally conscious state (MCS), communication is challenging. Currently, the communication methods of DOC patients are limited to behavioral responses. However, DOC patients cannot provide sufficient behavioral responses due to motor impairments and limited attention. In this study, we proposed a hybrid asynchronous brain-computer interface (BCI) system that provides a new communication channel for DOC patients.Approach.Seven DOC patients (3 VS and 4 MCS) and eleven healthy subjects participated in our experiment. Each subject was instructed to focus on the square with the Chinese words 'Yes' and 'No'. Then, the BCI system determined the target square with both P300 and steady-state visual evoked potential (SSVEP) detections. For the healthy group, we tested the performance of the hybrid system and the single-modality BCI system.Main results.All healthy subjects achieved significant accuracy (range from 72% to 100%) in both the hybrid system and the single-modality system. The hybrid asynchronous BCI system outperformed the P300-only and SSVEP-only systems. Furthermore, we employed the asynchronous approach to dynamically collect the EEG signals. Compared with the synchronous system, there was a 21% reduction in the average required rounds and a reduction of 105 s in the online experiment time. This asynchronous system was applied to detect the 'yes/no' communication function of seven DOC patients, and the results showed that three of the patients (3 MCS) showed significant accuracies (67 ± 3%) in the online experiment, and their Coma Recovery Scale-Revised (CRS-R) scores were also improved compared with the scores before the experiment. This result demonstrated that 3 of 7 patients were able to communicate using our hybrid asynchronous BCI system.Significance.This hybrid asynchronous BCI system represents a useful auxiliary bedside tool for simple communication with DOC patients.
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Affiliation(s)
- Jianyong Huang
- South China Normal University, School of Software, Guangzhou, 510630, CHINA
| | - Lina Qiu
- South China Normal University, School of Software, Guangzhou, 510630, CHINA
| | - Qianmin Lin
- Guangdong Work Injury Rehabilitation Hospital, Traumatic Brain Injury Rehabilitation & Severe Rehabilitation Department, Guangzhou, Guangdong, 510400, CHINA
| | - Jun Xiao
- South China University of Technology, Center for Brain Computer Interfaces and Brain Information Processing, Guangzhou, Guangdong, 510640, CHINA
| | - Yuanqiu Huang
- Guangdong Work Injury Rehabilitation Hospital, Traumatic Brain Injury Rehabilitation & Severe Rehabilitation Department, Guangzhou, Guangdong, 510400, CHINA
| | - Haiyun Huang
- South China University of Technology, Center for Brain Computer Interfaces and Brain Information Processing, Guangzhou, Guangdong, 510640, CHINA
| | - Xinjie Zhou
- Guangdong Work Injury Rehabilitation Hospital, Traumatic Brain Injury Rehabilitation & Severe Rehabilitation Department, Guangzhou, Guangdong, 510400, CHINA
| | - Xiangyu Shi
- South China University of Technology, Center for Brain Computer Interfaces and Brain Information Processing, Guangzhou, Guangdong, 510640, CHINA
| | - Fei Wang
- South China Normal University, School of Software, Guangzhou, 510630, CHINA
| | - Yanbin He
- Guangdong Work Injury Rehabilitation Hospital, Traumatic Brain Injury Rehabilitation & Severe Rehabilitation Department, Guangzhou, Guangdong, 510400, CHINA
| | - Jiahui Pan
- South China Normal University, School of Software, Guangzhou, 510631, CHINA
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8
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Schwartz DB, Barrocas A, Annetta MG, Stratton K, McGinnis C, Hardy G, Wong T, Arenas D, Turon‐Findley MP, Kliger RG, Corkins KG, Mirtallo J, Amagai T, Guenter P. Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper. Nutr Clin Pract 2021; 36:254-267. [DOI: 10.1002/ncp.10633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Denise Baird Schwartz
- Bioethics Committee Community Member Providence Saint Joseph Medical Center Burbank California USA
| | - Albert Barrocas
- Tulane University School of Medicine New Orleans Louisiana USA
| | | | - Kathleen Stratton
- Clinical Nutrition Support Services and the Penn Lung Transplant Institute, Hospital Ethics Committee Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | | | - Gil Hardy
- Clinical Nutrition Auckland New Zealand
| | - Theodoric Wong
- Women's and Children's Hospital Birmingham United Kingdom
| | - Diego Arenas
- Direccion Medicina Functional y Nutricion Clinica Zapopan Jalisco Mexico
| | | | - Rubén Gustavo Kliger
- Nutrition Service and Nutritional Support Unit Austral University Hospital Buenos Aires Argentina
| | | | - Jay Mirtallo
- College of Pharmacy The Ohio State University Columbus Ohio USA
| | | | - Peggi Guenter
- Clinical Practice Quality and Advocacy American Society for Parenteral and Enteral Nutrition (ASPEN)
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9
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Kuek JTY, Ngiam LXL, Kamal NHA, Chia JL, Chan NPX, Abdurrahman ABHM, Ho CY, Tan LHE, Goh JL, Khoo MSQ, Ong YT, Chiam M, Chin AMC, Mason S, Krishna LKR. The impact of caring for dying patients in intensive care units on a physician's personhood: a systematic scoping review. Philos Ethics Humanit Med 2020; 15:12. [PMID: 33234133 PMCID: PMC7685911 DOI: 10.1186/s13010-020-00096-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/11/2020] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Supporting physicians in Intensive Care Units (ICU)s as they face dying patients at unprecedented levels due to the COVID-19 pandemic is critical. Amidst a dearth of such data and guided by evidence that nurses in ICUs experience personal, professional and existential issues in similar conditions, a systematic scoping review (SSR) is proposed to evaluate prevailing accounts of physicians facing dying patients in ICUs through the lens of Personhood. Such data would enhance understanding and guide the provision of better support for ICU physicians. METHODS An SSR adopts the Systematic Evidenced Based Approach (SEBA) to map prevailing accounts of caring for dying patients in ICUs. To enhance the transparency and reproducibility of this process, concurrent and independent use of tabulated summaries, thematic analysis and directed content analysis (Split Approach) is adopted. RESULTS Eight thousand three hundred fifty-eight abstracts were reviewed from four databases, 474 full-text articles were evaluated, 58 articles were included, and the Split Approach revealed six categories/themes centered around the Innate, Individual, Relational and Societal Rings of Personhood, conflicts in providing end of life care and coping mechanisms employed. CONCLUSION This SSR suggests that caring for dying patients in ICU impacts how physicians view their personhood. To resolve conflicts within individual concepts of personhood, physicians use prioritization, reframing and rely on accessible, personalized support from colleagues to steer coping strategies. An adapted form of the Ring Theory of Personhood is proposed to direct timely personalized, appropriate and holistic support.
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Affiliation(s)
- Joshua Tze Yin Kuek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lisa Xin Ling Ngiam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Nur Haidah Ahmad Kamal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jeng Long Chia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Natalie Pei Xin Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Ahmad Bin Hanifah Marican Abdurrahman
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lorraine Hui En Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jun Leng Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Michelle Shi Qing Khoo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
- Duke-NUS Graduate Medical School, Singapore, Singapore.
- Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore.
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10
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Wang DWL. Withdrawing treatment from patients with prolonged disorders of consciousness: the wrong answer is what the wrong question begets. JOURNAL OF MEDICAL ETHICS 2020; 46:561-562. [PMID: 32054775 DOI: 10.1136/medethics-2020-106063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/03/2020] [Indexed: 06/10/2023]
Abstract
In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness (PDOC) make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient's best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading cases-Bland and James-the principle of respect for autonomy creates a persuasive presumption against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an evidential presumption on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster's argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence.
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Foster C. 'Who are you today?' Problems of identity in psychiatry. BJPsych Int 2020; 17:60-62. [PMID: 34287420 PMCID: PMC8280790 DOI: 10.1192/bji.2020.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/27/2020] [Indexed: 11/23/2022] Open
Abstract
Our attributes change. Sometimes they are changed so dramatically (for instance by organic brain disease, traumatic brain injury or psychiatric disease) that it is hard to see any significant continuity with the premorbid person. Sometimes this can have important ethical and legal consequences, but the problems are often ignored. This article highlights some of the difficulties.
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Affiliation(s)
- Charles Foster
- Visiting Professor, Faculty of Law, University of Oxford, UK.
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12
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Bianchi D. Advance directives: Addressing the obligations of support as part of the right of a person with disabilities to equal recognition before the law? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 70:101561. [PMID: 32482299 DOI: 10.1016/j.ijlp.2020.101561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 06/11/2023]
Abstract
Depending upon how they are regulated in domestic law, advance directives (ADs) can enable persons to make decisions that have legal effect in the future as directed in the AD. There is some agreement in the academic literature that ADs are a legitimate way of giving effect to the obligations arising from Article 12 (3) of the United Nations Convention on the Rights of Persons with Disabilities to take appropriate measures to provide access by persons with disabilities (PWDs) to the support they may require in exercising their legal capacity. It is the purpose of this article to question when and how ADs address the obligations of support arising from Article 12 (3), concluding that it cannot and should not be assumed that ADs address those obligations only because they embody and give effect to their maker's agency. The article instead highlights the questions that must be posed to obtain legal certainty as to when and how ADs will be a form of Article 12 (3) support. The article also refutes some of the instances in the academic literature when ADs have been presented as support, while offering an account as to how the regulation of ADs should be reconsidered in order to specifically address the obligations arising from Article 12 (3) both when PWDs can and when they cannot communicate their wishes to others.
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Affiliation(s)
- Daniel Bianchi
- Faculty of Laws, University of Malta, Msida MSD 2080, Malta; School of Social Sciences, University of Manchester, Williamson Building, Oxford road, Manchester M13 9PL, United Kingdom.
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Ruck Keene ACE, Lee A. Withdrawing life-sustaining treatment: a stock-take of the legal and ethical position. JOURNAL OF MEDICAL ETHICS 2019; 45:794-799. [PMID: 31488520 DOI: 10.1136/medethics-2019-105599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
This article, prompted by an extended essay published in the Journal of Medical Ethics by Charles Foster, and the current controversy surrounding the case of Vincent Lambert, analyses the legal and ethical arguments in relation to the withdrawal of life-sustaining treatment from patients with prolonged disorders of consciousness. The article analyses the legal framework through the prism of domestic law, case-law of the European Court of Human Rights and the Convention on the Rights of Persons with Disabilities, and examines the challenge to the ethical consensus made by Foster. It concludes that the right approach remains a version of the approach that has prevailed for the last 25 years since the decision in Airedale NHS Trust v Bland[1993] AC 789, refined to reflect that that there is now, and rightly, a much more limited place for judgments made about the 'burden' of treatment or the quality of life enjoyed by the person made on the basis of assumptions about that person as a category as opposed to investigation of that person as an individual human being.
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Foster C. Deal with the real, not the notional patient, and don't ignore important uncertainties. JOURNAL OF MEDICAL ETHICS 2019; 45:800-801. [PMID: 31604833 DOI: 10.1136/medethics-2019-105857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/26/2019] [Indexed: 06/10/2023]
Abstract
There is a strong presumption in favour of the maintenance of life. Given sufficient evidence, it can be rebutted. But the epistemic uncertainties about the best interests of patients in prolonged disorders of consciousness ('PDOC') and the wishes that they should be presumed to have are such that, in most PDOC cases, the presumption cannot be rebutted. It is conventional and wrong (or at least unsupported by the evidence) to assume that PDOC patients have no interest in continued existence. Treatment withdrawal/continuation decisions should focus on the patient as he or she actually is, and should not unjustifiably assume that the premorbid patient continues to exist unchanged, and that the actual patient has the same interests as the premorbid patient and would make the same decisions in relation to treatment as the premorbid patient would have done.
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Affiliation(s)
- Charles Foster
- Faculty of Law, University of Oxford, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
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