Week 3

Question 1

Withdrawal of care and futility

Answer 1

When we look at brainstem death as legal death it is the lack of prospect for recovery that has been considered as crucial
In the situation of brainstem death, withdrawal of care would be inevitable- the patient is already legally dead, no treatment can be in their best interests
No obligation to offer medical treatment that you do not believe is in the patients best interests
Treatment that is medically futile that can confer no benefit- is unlikely to be in a patients best interests

Question 2

A best interests decision

Answer 2

The patients best interests are ultimately what is in question in dilemmas around withdrawal of care
There are several things we need to think about:
-whether the treatment can benefit the patient
-what the patient would have wanted
-the nature of the treatment and the burdens inherent in it

Question 3

Futility- can this treatment provide benefit

Answer 3

Futility does not mean that successful treatment would be impossible
-if the desired outcome, although possible is overwhelmingly improbable, based on available scientific evidence
Two main arguments:
-if success is that unlikely we cannot justify putting the patient through it (eg painful procedures, insult to dignity)
-and there is no distributive justice to devoting resources to it
Futility in the context of the end for life is most often used when there is no chance of the patient being able to survive outwith an acute medical setting
However it is possible to justify withdrawing other treatments in other contexts or not offering other treatments in other contexts, on futility grounds
-futility is not just used in the context of end of life
-eg patients who are not fit for chemo, DNACPR, even antibiotics for a viral infection

Question 4

Problems with futility

Answer 4

Legal and medical scholars have argued that futility represents medical paternalism
Researchers have pointed out that doctors have used futility arguments to refuse treatments that they just didn’t want to give
Where is the line in the sand? What is overwhelming, in terms of improbability
What is the objective evidence does not exist
On the other hand:
-a lot of patients would choose to take the antibiotics even though they wouldn’t work
-isn’t deciding on whether a treatment offers benefits fundamental

Question 5

Best interests- autonomy

Answer 5

In a patient without capacity we should attempt to find out what they would have wanted: values, beliefs
In the case Archie was only 12
Need to consider whether he was competent when he made that statement
-maturity to withstand external influence
-intelligence to project into the future/anticipate consequence

Question 6

Autonomy, futility, best interests

Answer 6

Patient doesn’t give consent to a treatment that doctors consider to be in best interests
Patients does not wish for a treatment which would not be in their best interests ( here futility feeding into why it is not)
Patient wishes/did wish for a treatment which would not be in their best interests, with futility feeding in to why it is not

Question 7

Act or omissions

Answer 7

Not issuing a repeat prescription seems very different than disconnecting a ventilator or similar
One is very clearly an omission whereas the other seems more like an action
Omissions are treated differently than actions in the UK law there is no crime in not acting to protecting another (unless there was a duty to do so) whereas actively causing harm is criminal
“The difference between letting someone die and taking active steps to bring about their death has been central to the common law for centuries” Conway 2018
Reinforced in the bland case 1993 where judges ruled that the obligation to act in best interests did not necessarily mean acting to prolong life
This case also established that withdrawing treatment was an omission not an action that led to death- therefore they ruled that withdrawal of care was legal and in the patients best wishes

Question 8

Attempts to reconcile futility

Answer 8

Recent court judgements on withdrawing care have used futility arguments
-however they have taken a broader approach more patient centred idea of futility
-it is not based solely on the probability of medical success- the overwhelming improbability has been of a recovery to a quality of life that would be tolerable to the patient, based on what we know about them

Question 9

The nature of the treatment

Answer 9

In weighing Archie’s best interest, judge Hayden ruled
-the intensive ITU treatment was burdensome to Archie despite his inability to perceive pain
-the treatment was injurious to dignity
-the treatment suspended Archies autonomy

Question 10

What would be acceptable to Archie

Answer 10

Archie’s parents argued that Archie had previously said that he would want to be kept alive on a life support machine as he would not want to leave his mother
However the court appointed guardian and judge felt that when this statement was made Archie could not have anticipated the extent of the intervention or the absence of prospect of recovery
Archie was not considering this situation or the details of what it would actually entail when he made that general statement
-in any case autonomy is not held as outweighing futility or best interests

Question 11

Outside influence

Answer 11

Several recent cases have involved the same organisation giving legal advice (sometimes inaccurate) to parents- the Christian legal centre
This organisation has a religious fundamentalist position on many medicolegal issues
A judge described one of their key personnel as “fanatical and deluded” and their “malign hand” was “inconsistent with the real interests of the parents case”
Medics involved in their cases have reported that they attempt to break down the trust between relatives and the medical team

Question 12

Ceilings of care

Answer 12

Another controversial and related area is that of the ‘ceiling of care’ for example do not attempt cardiopulmonary resuscitation orders
Futility arguments are again central here- these orders are very rarely used in a situation where the likelihood of success would be high
Cardiac arrest always carries poor odds of survival and for patients who are frail or have multiple comorbidities the odds of success are very slim indeed
Again the nature of the treatment is relevant- CPR not a dignified process
However for many in the public this is again seen as a statement that someone is not worth saving
This was exacerbated in the Covid pandemic when lots of patients were made DNACPR without discussion sometimes without current clinical evaluation so the record would be present in advance should the situation arise
Legally everyone has the right to be involved in the discussion and made aware of DNACPR, they dont have to consent and cant demand CPR, right to a second opinion

Question 13

Euthanasia

Answer 13

“ the act of deliberately ending a persons life to relieve suffering”
Voluntary-competent informed patients requests
Involuntary- patient competent but not asked
Non-voluntary- patient not competent
Active- doing an act of commission that leads to death: illegal in the UK, also illegal to assist someone else to commit suicide (suicide act 1961)
Passive- doing an act of omission or withdrawal which leads to death

Question 14

The ethics of euthanasia

Answer 14

Death is normally considered the ultimate harm
However if someone existence involves suffering their life might pose a greater harm
Therefore in some contexts, ending someone’s life might be an act of beneficence
Eg terminal disease- the person is going to die imminently anyway, why protect their suffering

Question 15

The ethics of euthanasia: autonomy

Answer 15

Autonomy- self determination: we are allowed to choose how to live why should we not be allowed to choose how to die

Question 16

Ethics of euthanasia: non maleficence

Answer 16

It’s possible that if we legalised euthanasia/assisted suicide, we might cause inadvertent harms
Perhaps relatives would abuse the system to speed inheritance
People might begin to feel obliged to end their life on receiving a terminal diagnosis etc

Question 17

Ethics euthanasia justice

Answer 17

It’s unjust that those who have the physical means to end to their own life are able to do so while those whose condition prevents them from doing so are denied the choice
We euthanise animals- why are humans not given same relief
Suicide is not illegal- then why should assisting suicide be illegal

Question 18

Euthanasia ethics

Answer 18

Euthanasia has no legal status in the UK and is treated as manslaughter or murder depending on circumstances
- in UK law motive is not given weight intent is
-having a good motivation for ending someone’s life does not alter anything
-if you intended to end their life that’s all that matters
‘Physician assisted dying’

Question 19

Physician assisted dying

Answer 19

From the BMA
“Doctors involvement in measures intentionally designed to end a patients life, covering the situations below’:
-where doctors would prescribe lethal drugs at the voluntary request of an adult patient with capacity who meets defined eligibility criteria to enable that patient to self administer the drugs to end their own life, this is sometimes referred to as physician assisted dying or physician assisted suicide
-where doctors would administer lethal drugs at the voluntary request of an adult patient with capacity, who meets defined eligibility critters with the intention of ending patients life this is often referred to as voluntary euthanasia

Question 20

The role of the profession

Answer 20

Historically the medical profession have consistently resisted the legalisation of euthanasia or PAD
There is no prima facie obligation that if our society is to allow assisted suicide or euthanasia that this should involve a the medical profession
It was felt such a move would be contrary to the primary goals of medicine would be unacceptable to many doctors and would change the way doctors were seen in society
This changed in 2021 when the BMA reversed its 2020 statement of opposition to legalisation of physician assisted dying and instead adopted a position of neutrality

Question 21

A communitarian view

Answer 21

Communitarianism is a form of ethics which views the successful flourishing of society as the ultimate ethical goal
It treats the trust as a fundamental ethical currency to allow this happen
It also considers that we live in a delicate ethical ecology where the rights, privileges, and status of certain grousp are in balance with each other
Significant changes can shift the balance within ethical ecologies leading to unforeseen problems
Affects ; protection of the vulnerable, disabled rights, role of the law, religious beliefs, how we see the terminally ill, patient rights, patient autonomy (physician associate dying), rights to life, role of the medical profession

Question 22

A communitarian view 2

Answer 22

Changes will shift the balance. They will change how we see each other, how we view concepts such as life and death and downstream of that may affect how groups can exercise their rights
It may be that having examined these we feel they will mostly be changed for the better
But we must be very careful to consider the groups- particularly vulnerable groups- who may experience a net negative from any changes we make

Question 23

The doctrine of double- effect

Answer 23

Physician assisted dying remains illegal in the UK
In reality in palliative situations doctors often give medications that may shorten a patients life
-eg a dose of morphine- may ease pain, may also decrease respiratory drive and hasten death
Isn’t that active euthanasia
Intent is important in UK law
In this case, the morphine has two effects-a good effect (elimination of pain) and a bad effect (the hastening of death)
It is permissible to give the morphine so long as the intent is to achieve the good effect
The same act if your intent was actually to hasten death would be euthanasia

Question 24

The doctrine of double- effect idea

Answer 24

Derived from Thomas Aquinas
Who said it was permissible to kill in self defence as long as your intention was to save your own life, not to kill your assailant
Double effect is said to be applicable where:
-all reasonable/less risky alternatives have been exhausted
-the act itself is good (or at least neutral)
-there is one action with at least two foreseeable effects one bad one good
-these good and bad effects flow immediately from the act
-the good effect is the end towards which one is aiming
-one foresees the bad effect but intends only the good effect
-the bad effect is not the means by which the good effect is accomplished
-the act is proportionate: the means employed are proportionate to the end (means-end probability), the potential benefits are proportionate to the potential harms (end-end proportionality)

Question 25

Problems with double effect

Answer 25

Critics have pointed out that it is impossible to tell what someone’s intention was
-they could say they only meant to relieve pain but in fact gave a larger dose than they really needed to
Many ethical approaches do not place much value on intention
-eg consequentialism
Is it really possible to foresee a consequence, commit the act that causes it and not have intended it

Question 26

Double effect in UK law

Answer 26

There is legal precedent for the doctrine of double effect in UK law
This was given in the ruling R vs Cox 1992
A doctor had administered potassium chloride to a patient with a painful terminal condition, after which she died. He argued that he had done so to relieve her pain. However, KCl is not an analgesic
The judge directed the jury that the doctrine of double effect applied only when the defendants primary purpose was to relieve pain, therefore it was not a valid defence in this instance
Since it could not be established beyond reasonable doubt that it was the KCl that killed the patient not her terminal condition he was convicted of attempted murder not murder

Question 27

A worldwide perspective

Answer 27

Switzerland: assisted suicide permitted since 1942 as long as motives aren’t selfish. Euthanasia illegal
Belgium and Netherlands: euthanasia by physicians legal as long as certain criteria met (eg explicit request). Dutch legislation also allows physician assisted suicide (physician supplies the drug, patient administers it)
Canada: since 2016 can request medical assistance in dying MAID, voluntary euthanasia or physician assisted suicide, advance directives are allowed, in 2021 the bill was amended to allow the use of euthanasia in those whose death was not reasonably foreseeable. Any adult with serious illness or disability can seek to end their life. There is no regulation that other treatment options must have been exhausted or that doctors are not allowed to suggest it

Question 28

Controversy euthanasia

Answer 28

Rate of euthanasia in Belgium has increased from 235 lives lost per year 2003, to 7 lives lost per day 2021
Belgian citizen Tom Mortier challenged Belgium laws at Europe to court after his mother has euthanised from depression without his Knowledge
Updates to the law have seen Belgium become the first and only country in the world to have no lower age limit enforced for children
In Canada 2022: MAID was suggested to a veteran with PTSD, woman form Toronto who could not find suitable housing was given MAID, paralympain Christine gauthier testified that a veterans affairs Canada employee offered her maid as an option when she was attempting to get a wheelchair lift or ramp installed at her house
A moratorium on mental health diseases being excluded from MAID expires this year
Human rights groups have expressed concerns that the lives of those who are vulnerable are being devalued by MAID and people are coming under pressure to end their lives rather than be a burden on others or the state
Canadas human right commission “euthanasia cannot be a default for Canadas failure to fulfill its human rights obligation”

Question 29

Controversy on euthanasia

Answer 29

‘Slippery slope’ arguments are based on the idea that once a moral authority has permitted a step in one direction, users of the system will inevitably push this permissiveness and ‘slip’ further down that road, in the end leading to situations being permissible that were never in the original framework
Communitarian arguments are subtly different than this
It argues that the initial change alters how we all inter-relate and see each other, our rights, and our responsibilities. These conceptual changes then make it logical to behave in different ways
Legal experts have pointed out that allowing MAID for disability alone is a direct implication that disabled lives are less worth living and less valuable

Question 30

The value of life

Answer 30

So where does this leave us
Humanism:
-grounds for moral status
Withdrawal of care:
-when treatment is futile or against autonomy
Euthanasia/physician assisted dying:
-when life is unbearable
All human lives are of equal value
The value of a human life is the value attached to it by that person

Question 31

What is normal behaviour

Answer 31

Conforming to usual, typical or expected standard of behaviour

Question 32

Six approaches to describing normality Grob 1995

Answer 32

Socio-cultural
Functional
Historical —— context dependent
Situational

Medical —— maladaptive focus
Statistical

Question 33

Socio-cultural normality

Answer 33

Characteristic patterns of normal behaviour and belief
Cohort normality: what is normal for people who share similar life experiences

Question 34

Functional normality

Answer 34

Can an individual function in the roles that have developed around her
Functional normality depends on context: success as a doctor or teacher may not indicate success as a parent, leading to abnormal behaviour

Question 35

Historical normality

Answer 35

Smoking
Other peoples urine: toothpaste
Hysteria or “go forth little womb”: the wandering uterus and the rest cure

Question 36

Situational normality

Answer 36

Normal behaviours are constructed according to environment
A behaviour in one situation can be normal and be completely abnormal in another situation. Dressing to go to a fancy dress party and then wearing the same fancy dress to work

Question 37

Medical normality

Answer 37

Normality is an expected state
Normal and abnormal
Abnormality: crucial in establishing the sick role
Normal ranges
Medical normality is not only assigned to conditions, systems and processes but also to beliefs and attributions
Deviation from expected behaviours or attitudes results in diagnoses of mental illnesses

Question 38

Statistical normality

Answer 38

Normality as typicality or an expression of central tendency (median, mode, mean)
Normal (bell- curve) distribution

Question 39

Examples of use of normal distribution in medical practice

Answer 39

Birth weight
Sperm count
Serum cholesterol
Blood pressure
Growing and adult heights

Question 40

Maintenance of Norms

Answer 40

Ritual/routine things we do as a society/individuals/families
Mores: customs of a society or community- proper dress and appropriate behaviour
Law: legal framework regulates what is acceptable and not

Question 41

Violating norms: on the road to involuntary admission

Answer 41

Ritual/routine: failure to fulfill role obligations
Mores: responding to auditory hallucinations in public areas
Laws: violence or threat against another person

Question 42

Can norms be changed

Answer 42

Smoking has been practiced for centuries
Since 1948 there has been growing evidence that smoking can cause serious health damage
Restrictions on where to smoke
Smoking became stigmatised in the 21st century

Question 43

Can deviation from the norm be positive

Answer 43

Flexibility and progress
New patterns of thinking
Evolutionary engine
Adaptive- maladaptive

Question 44

Social norms and conformity

Answer 44

Crutchfield (1954) defined conformity as ‘ yielding to group pressure’
The pressure can be real or imagined
Myers (1999) defined conformity as ‘a change in behaviour as a result of real or imagined group pressure’
Zimbardo et al 1995 ‘ a tendency for people to adopt the behaviour, attitudes and values of a reference group’

Question 45

Informational influence

Answer 45

We can seek info and advice from others
If many people agree then we can assume they are right
Private conformity: in these situations social influence can lead to private conformity where we change our thoughts, feelings and behaviour

Question 46

Normative influence

Answer 46

We need to work cooperatively with each other to get on in the world
We are motivated by a desire to avoid the severe consequences of being a deviant
Public conformity- dont change your actual opinion but change your opinion superficially to fit into that situation

Question 47

Perceived and actual norms

Answer 47

Perceptions of what is normal behaviour influence self concept to a profound degree, particularly in early adolescence
Drinking behaviour
Sexual behaviour
Misperceived social norms challenge individuals to conform to their perception rather than actuality

Question 48

Maladaptive behaviour

Answer 48

Maladaptive behaviour is behaviour that negatively impacts on your daily life and activities
Avoidance is a common maladaptive behaviour
Social anxiety disorder is a common maladaptive behaviour
Hinders a person from growing and changing and making their way in the world

Question 49

Abnormality

Answer 49

No clear agreement on what normal functioning is on the psychological level
Abnormal behaviour is a combination of personal distress, psychological dysfunction, deviance from social norms, dangerousness to self and others, and costliness to society
Aspects considered when judging abnormality are distress, dysfunction, deviance (unusualness) dangerousness

Question 50

Normality is complex and Multifactorial

Answer 50

Patients and clinicians views of normality may be radically different (eg parent anxiety over child growth patterns)
Sociocultural normality influences beliefs and behaviours (eg alcohol, smoking)
Norms change over time

Question 51

Explicit memory

Answer 51

Past experiences
Factual knowledge
Episodic and semantic memory

Question 52

Implicit memory

Answer 52

Effect on experience, thought or action of past event without conscious recollection of that event
Perform daily activities without having to consciously think about it

Question 53

Working memory model- Baddeley and hitch 1974

Answer 53

Input-> sensory memory (can go decay)—attention—>
Central executive (allocates data to subsystems: the phonological loop or visuo-spatial scratchpad
-visuospatial scratchpad stores and processes info in a visual or spatial form used for navigation. Visual semantics
-phonological loop: deals with spoken or written material.language
—phonological store: processes speech perception and stores spoken words we hear
—articulatory control: processes speech production and rehearses and stores verbal info from phonological store
Central executive monitors and coordinates this and relates them to long term memory
Add episodic buffer in 2000:
-backup store which communities with long term and working memory. Short term episodic memory

Question 54

Atkinson and shiffren 1968

Answer 54

Old model of STM
Environment input-> sensory memory-> short term memory (recall, rehearsal loop)—rehearsal—> long term memory <—retrieval

Question 55

Korsakovs syndrome

Answer 55

Chronic neuropsychiatric syndrome caused by deficiency of thiamine or vitamin B1- can damage multiple areas of the brain causing amnesia and confusion
Most commonly seen in chronic alcohol abuse

Question 56

Bipolar severe mental illness in which episodes of mania and experienced with or without episodes of depression

Answer 56

1. Depressive episode: 5 symptoms occurring most day nearly everyday 2 weeks: depressed mood, diminished interest or pleasure in activities especially those they used to find enjoyable, reduced ability to concentrate or marked indecisiveness, beliefs of low self worth or excessive guilt, hopelessness about future, recurrent thoughts of death, disrupted sleep, change in appetite, psychomotor agitation or retardation, reduced energy, fatigue.
   2.Manic episode: persisting for most day nearly every day for at least 1 week: extreme mood state characterised by euphoria, irritability or expansiveness, increased activity increased energy, increased talkativeness, flight of ideas, rapid racing thoughts, increased self esteem, decreased need for sleep, distractilibilty, impulsive recklessness, increase sexual drive, sociability or goal directed activity.
   Bipolar disorder: feeling sad, hopeless, irritable most of the time, lacking energy, difficulty concentrating and rembering things, loss of interest in normal activities, feelings of emptiness and worthlessness, feelings guilt and despair, pessimistic, hallucinations and disturbed or illogical thinking, lack of appetite, difficulty sleeping, waking up early, suicidal thoughts. Manic phase: feeling very happy, talking very fast, feeling full of energy, feeling self important, easily distracted, easily irritated or agitated, hallucinations, not feeling like sleeping, doing things that have disastrous consequences, making decisions or saying things that are out of character and that others see as harmful.

These phases can last longer than normal life and can have more harmful effects, extreme ups and downs that interfere with daily life

Question 57

The beck depression inventory BDI

Answer 57

Commonly used self report measure of the severity of depression
Questionnaire
Number 1-3
Covers range of symptoms, people dont have to speak about how they feel, more honest, gives a scale
But symptoms might fluctuate often may have periods of ‘normal mood’ maybe between two answers on scale, might not answer honestly, not self aware

Question 58

Functional impairments and stigma associated with severe mental illness

Answer 58

Affect ability to complete work on time and maintain structured routine
Risk of making rash decisions in career
Alone in diagnosis
Stigma and discrimination, self stigma. No acceptance or adaptations. Reduced self esteem loss of hope, worsen condition
Seen as dangerous to others, fear of people
Lack of understanding of the condition, negative attitudes and beliefs