Reflections on Charlie Gard and the Best Interests Standard From Both Sides of the Atlantic Ocean

"Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation

Introduction

Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO).

Analysis

Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed.

Discussion

Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.

An Overview of Ethical Issues Raised by Medicolegal Challenges to Death by Neurologic Criteria in the United Kingdom and a Comparison to Management of These Challenges in the USA

Although medicolegal challenges to the use of neurologic criteria to declare death in the USA have been well-described, the management of court cases in the United Kingdom about objections to the use of neurologic criteria to declare death has not been explored in the bioethics or medical literature. This article (1) reviews conceptual, medical and legal differences between death by neurologic criteria (DNC) in the United Kingdom and the rest of the world to contextualize medicolegal challenges to DNC; (2) summarizes highly publicized legal cases related to DNC in the United Kingdom, including the nuanced 2022 case of Archie Battersbee, who was transiently considered dead by neurologic criteria, but ultimately determined to be in a vegetative state/unresponsive-wakeful state; and (3) provides an overview of ethical issues raised by medicolegal challenges to DNC in the United Kingdom and a comparison to the management of these challenges in the USA.

International variability in the diagnosis and management of disorders of consciousness

This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.

An overview of Fintech applications to solve the puzzle of health care funding: state-of-the-art in medical crowdfunding

Crowdfunding is emerging as an alternative form of funding for medical purposes, with capital being raised directly from a broader and more diverse audience of investors. In this paper, we have systematically researched and reviewed the literature on medical crowdfunding to determine how crowdfunding connects with the health care industry. The health care industry has been struggling to develop sustainable research and business models for economic systems and investors alike, especially in pharmaceuticals. The research results have revealed a wealth of evidence concerning the way crowdfunding is applied in real life. Patients and caregivers utilize web platform-based campaigns all over the world to fund their medical expenses, generally on a spot basis, using donation-based or even reward-based schemes, regardless of the health care system archetype (public, private insurance-based or hybrid). Academics have also focused on funding campaigns and the predictors of success (which range from social behaviour and environment to the basic demographics of the campaigners and their diseases) and on social and regulatory concerns, including heightened social inequality and stigma. While equity crowdfunding is disrupting the way many ventures/businesses seek capital in the market, our research indicates that there are no relevant or consistent data on the practice of medical equity crowdfunding in health care, apart from a few anecdotal cases.

Resuscitation decisions in fetal myelomeningocele repair should center on parents' values: a counter analysis

In our response to, "Parental request for non-resuscitation in fetal myelomeningocele repair: an analysis of the novel ethical tensions in fetal intervention" by Wolfe and co-authors, we argue that parental authority should guide resuscitation decision-making for a fetus at risk for preterm delivery as a complication of fetal myelomeningocele (fMMC) repair. Due to the elevated morbidity and mortality risks of combined myelomeningocele, extreme prematurity, and fetal hypoxia, parents' values regarding the acceptability of possible outcomes should be elicited and their preferences honored. Ethical decision-making in these situations must also consider the broader context of the fetal-maternal dyad. Innovations in fetoscopic approaches to fMMC repair may pose additional complexity to these resuscitation decisions.

Children as voices and images for medicinal cannabis law reform

This article situates the movement for the legalisation of medicinal cannabis within the bigger picture of the impetus toward recreational cannabis legalisation. It describes the role played by children with epileptic syndromes in the medicinal cannabis law reform campaigns in the United Kingdom, and Queensland, New South Wales and Victoria in Australia. Noting the 'rule of rescue' and the prominence in media campaigns of children in Australian and English cases of parental disputation with clinicians about treatment for their children, it reviews whether paediatric epilepsy is a suitable test case for the legalisation of medicinal cannabis. Taking into account the vested commercial interests of Big Cannabis, the current medico-scientific knowledge of the efficacy of medicinal cannabis in controlling paediatric epileptic seizures, and issues of dignity, health privacy, and the enduring digital footprints of media coverage, the article commences discussion about the ethics of the media, parents, politicians and entrepreneurial doctors utilising parents' testimonials about the effects of medicinal cannabis as part of the cannabis law reform movement.