Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

thing, Um, where? Wherever you're based. So I think there's a few more arriving now if you could just pop in the sidebar. So I think they're looking for your med school year of studying where you currently are. That would be really helpful. And also give me a perspective on on where you're where you're based and what what your understanding of sort of the UK system might or might not be. Um, so I'm going to give a run. A session on medical ethics in the UK is quite UK focused. So if I'm making assumptions in what I'm talking about, police sort of shoutout Put your hand up. Put something in the chat bar if there's if there's there's acronyms or the things that there are things that I'm referring to that are not familiar to you. Um, yeah, please do. Please do just shout out. And this is a very informal session. So any questions as we go along, just just please do ask. Um, that would be great. So I am going to look to share my screen now, and hopefully technology is gonna like my favor. Okay, So can you see my screen? We'll just make that a bit bigger. Yeah, that's great. Fantastic. I'm just going to get the cat bar up as well. So if there are any questions, I can see them as we we go along. Fantastic. Oh, so you have some Adelaide urine Southend on sea. So you're in the UK, so some of this might be might be quite familiar. Um, but no pressure if it's not at it as well. Um, that's okay. So this happens and see. Fantastic. So, um, my name is rec muscle. I'm a specialist policy adviser in ethics and human rights at the British Medical Association. So if I could just if you know where your emojis that sort of emoticons our hands up. If you've heard of another person in London Fantastic. If you've heard of the British Medical Association, if you put your hands up or or put your thumbs down if you haven't. Okay, Adelaide, You've heard of British Medical Association? Go great. Anyone else heard of the British Medical Association? Okay, so I'll get all, um so I don't know what the expression is that? No, Ahmed. Okay, Fantastic. So what I'll do is I'll just talk a little bit about where I come from when the organization, because it can differ depending on, uh globally what different medical organizations do in professional associations. The British Medical Association is a trade union and professional association for doctors in the UK as over 100 and 50,000 members across all grades and specialties and over two thirds of all practicing doctors are members. So the B m A negotiate has the negotiating rights with the government in terms of things like terms of conditions of service. So things like pay, Um, in terms of maternity and paternity provisions, it also has a professional side, which is the side of the BMA that I come from. So that has a that would also involve the international side of the B. M. A s work. Um, so they support international medical graduates. They also have the connections with organizations like the World Medical Association, which is one of the main global organizations that set ethical standards for doctors. Um and then there's also my team sort ethics and human rights team. The BMA is distinct from the General Medical Council. The General Medical Council in the UK is the regulator for doctors. The doctors who practice in the UK need to be registered with the with the General Medical Council, um, in order to practice and also they monitor, they monitor things like educational, um, the education that's provided for sort of doctors, what's required and also a fitness to practice. Um, where the doctors of fitness practice they will consider those things. So they're quite distinct organizations I know. In some countries, one body performs both functions. It's professional organization, but also it regulates doctors in the UK They're two quite distinct, um, organizations with different, very different functions. So I've mentioned I come from the BMA Medical ethics and Human Rights Department were quite small team, but we covered quite a lot of issues, and we also do quite a lot of different pieces of work or conducted and pieces of work within ethics and human rights. Um, so we provide a wide range of advice and guidance, and it's the one side of the BMA where it's not. You don't have to be a member to access that advice and guidance. It's publicly available on our website, and if you're interested in many of the issues that we cover, Um, do go and have a look at w w dot BMA dot org dot u k Forward slash ethics. And there's a huge amount of guidance, which will also illustrate how medical ethics is practiced in the UK so as part of the work, we as well as guidance and advice, we influence policy and promote best practice. And that can be through a variety of mechanisms. We influence policy in terms of we have relationships with civil servants in the government or key policy, um, makers. We also monitor legal developments within the UK medical law and medical ethics. Very much it is if it's a very intertwined relationship, there's a huge amount of medical law out there that covered things like consent, confidentiality, beginning of life and end of life ethical challenges. So we monitor legal developments, and that might be a case law. So, for example, if things there's cases but also judicial review, so in the UK, public bodies can be, um, can be taken to court for the decisions they're made and how they go about making decisions so we'll monitor judicial review. Case studies will also monitor bills as they go through parliament. We have UK wide, uh, legislation, but we also because we have the devolved nations. There's also legislation that goes through, for example, the northern ninth Assembly, Scottish government and also the Welsh government. So we'll monitor. And if there's particular issues that are, members want us to take forward in campaigning on those bills, we will provide briefings to parliamentarians. So we we we monitor law in terms of cases in terms of things like judicial reviews, but also in terms of legislation. It's being formed through Parliament. We also support and boom a Medal of Ethics Committee. So this is committee that meets four times a year has are elected members on it, but it always has a leading professors of medical law and so philosophy, theology, and they help steer some of our key ethical approaches to issues. We also promote human rights and healthcare for clinicians and patient's, and this is domestically and internationally so as well as our domestic focus in the work we do. We also take an interest, for example, if doctors are being persecuted in other countries. If, uh, for example, there's not many prisoners can't access medical care. We will. We will also take forward and sort of lobbying campaign on those issues as well. And earlier this year we published a big report on on health and human rights and the global, um, situation. Again, that would be, um, uh, on our ethics Web pages, if if anyone's interested. So when we talk about medical ethics, often we can talk about it in terms of philosophical approach is to medical ethics. Um, and they can be quite useful tools in terms of, if you're facing an ethical dilemma in clinical practice, quite useful tools in terms of how you might think go about thinking about a particular issue. So the main philosophical approach is, I would say, that we referred to in the UK are consequential is, um, the utilitarianism so approaching, uh, an ethical issue, thinking about the outcome, whether it's right or wrong, and not necessarily how you go go about getting there. But it's about the consequences of an act, whether it's right or wrong. So things like utilitarianism so taking decisions that about maximizing good for the for the greatest number. That's one approach that sometimes might be taken or or a viewpoint. Um, to approach an issue. The apologies that's looking at, for example, where there's sort of considered to be absolute and universal obligations, or that or they have absolutely and universal qualities obligation. So things like rights and duties. So you will see. See this, say, reflected in human rights legislation, um, is the long Indian theological. And one of the, uh, inte logical approach is that often sort of cited, particularly in the UK Medical ethics, but also in other in other considerations and approaches globally is a full principles approach to medical ethics dilemmas. So it's breaking down a dilemma, as you see it in terms of looking at in terms of beneficence. So benefit non Millicent, so doing no harm, equality and justice and then the fourth autonomy. And it's going to It's probably going to become quite evident as we go through this session that autonomy is very important in terms of UK medical ethics. So when I talk about autonomy, I'm talking about an individual's ability to self determine and make choices about what happens to them. Another approach that is often referred to virtue ethics. So it's not talking about the the out or the consequences or outcome of a decision. It's not talking about there being some absolutes of duties and rights. Um, it's not about four principles. It's about the character, the character of a doctor. So we look at whether you know things like, um is a doctor, honest? Do that act with integrity, do the out with compassion. Now I talk about these philosophical approach is certainly within the UK context in terms of how medical ethics is addressed in clinical practice on a day to day basis, although these can be useful tools to look at, um issues and sort of try and analyze them. It's a mix of things. Um, they're often in play when we talk about medical ethics in the UK so on that, on that particular are there any questions at this point? Okay, in terms of that development, and this is probably why you know, if there are isn't someone philosophical approach because medical ethics had developed it in in in in the way that it has in a very kind of organic way because of lots of different elements that affect medical ethics and medical law within the UK So, for example, so when we talk about development. Medical ethics in the UK up 19 sixties, it was very doctor led. So it was. Doctor knows best. Sometimes patient's weren't told things Decisions are made about them rather than with them. So it really has changed in the last few decades. So rather than being sort of the doctor is good that you know everything. The doctor says it. It goes, Um, there's a hierarchy within that structure as well. Now it's far more about a partnership between it's a patient doctor relationship and the shared decision making. So that's one of the major shifts in terms of medical ethics. There's also the impact of technology, and we particularly see this in the beginning of life and end of life so developed in response to things like IVF in terms of end of life care in terms of being able to save, for example, extend someone's lie through through ventilators. Um, and we're seeing the impact, maybe of technology currently more so in terms of things like artificial intelligence. And that raises maybe not new ethical issues, but the context in which you think about ethical issues. It range. It raises new sort of challenges and people are starting to get their head around them in terms of making sure, for example, that, um, large databases and a I don't a I don't perpetuate inequalities that already, um, evident, um, so technology really impacts about how we think about things and then sort of new challenges. We need to think about the impact of the law. And I've mentioned earlier that there's a really interrelationship between medical ethics and medical law and the UK In the last two or three decades, there's been a proliferation of of legislation and case law that guides how how ethics is practiced or or how. A doctor in the UK approach is an ethical dilemma, and we also have with devolution. Um, although generally the sort of spirit and an approach to medical ethics medical law issue is the same in terms of, say, focusing on autonomy. Um, there can be differences within the nation's as well on certain pieces of legislation. So, for example, something like mental capacity, how decisions are made when, uh, an adult lacks capacity. There's also the impact of high profile inquiries, and we we've example we currently have a covid inquiry that just started in the UK It's probably gonna take a few years. No doubt that will engage some ethics issue ethics issues about how decisions were made. For example, who, how, what ethical framework was used to make sure that certain people, or how decisions were made about who who had access to limited resources. But we've had, you know every few years probably have a high profile inquiry that then impacts on how medical we think about medical ethics. So, for example, in the late nineties there was a huge inquiry that looked about looked at the retention of tissue and organs from Children. Um, and as a result of that, there's legislation that's more developed in terms of making sure that there's a fairly tight structure in terms of obtaining consent to retain tissues and organs. So they that high profile inquires have a huge impact on medical ethics in the UK There's also the reorganization of medicine and multidisciplinary approach I mentioned previously sort of 19 sixties. It's very doctor led, very doctor focused doctor knows best doctors decision maker. The way that healthcare is delivered in the UK is far more multiple disciplinary nowadays, so it's about our whole team and having those discussions with different perspectives say on the case. Um um, So taking to a council of nurses who who have direct contact, maybe home carers. So it's a far more multidisciplinary approach to how decisions are made and having those discussions with a wide range of people about what, what the best approach is and what to do and then finding it's probably affecting some some of the earlier points, this changing societal values and expectations and autonomy. There's there's patient's go in far more in terms of knowing every sort of rights and what they can expect, and also that they should be part of the decision in terms of what happens to them. So there's a huge shift in societal expectations and values. Are there any questions on? Does that seem familiar? So people who are outside the UK are there similar similar developments as well that have influenced the way that individuals approach ethics issues? Okay, So as a result of all of these challenges and shining the light on how decisions are made, there's a huge amount of legal and professional guidance that has been developed to assist doctors in the UK to manage the dilemmas that they face. Um, so when faced with an ethical dilemma, a solution can often be found not always, but can often be found by referring to guidance from wide range of organizations. So we have the General Medical Council, um, mentioned them before they're the regulator for doctors. And if I just go to the quick, um, subsequent slide, General General Medical Council set some quite high level principles in terms of how doctors should think about ethics in the UK And one of their main thing is the, uh, medical practice. And everybody in the UK should receive a copy of good medical practice. And if any of you are interested or or go to work in the UK um, if you read nothing else, um, in terms of ethics, I would strongly recommend to read good medical practice. It sets very high level principles in terms of how to approach your clinical practice, and it's very much based on making your patient your first concern and to respect their autonomy to act with integrity, honesty. It, um, it covers four domains, so knowledge, skills and performance, so an obligation and ethical obligation professional obligation to make sure that your competence do what you do, um, that you keep up to date with, uh, your your your knowledge and education and understanding of the clinical issues you may face. It's about safety and quality. So it's making sure that you're mindful of your obligations to make sure that patient care is delivered safely. And there's more detailed guidance. For example, so whistleblowing if you think that there are that patient safety is compromised in some way. So it's about communication, partnership and teamwork. And that was reflected in the earlier comments about shared decision making and multidisciplinary team approach to to clinical care and particularly sort of medical ethics dilemmas. Not particularly, but medical ethics dilemmas about maintaining trust, so maintaining trust in what you do but also maintaining trust in the profession. In the UK, doctors are one of the most trusted professions, and I think there's a particularly very mindful not to jeopardize that in way. So sometimes doctors can be called up to, say, fitness to practice because there is a concern that what because of what they've done and their actions, it actually potentially jeopardises trust in the profession itself. So if nothing, if you read nothing else in terms of you came medical ethics. If you're going to work clinically here, read good and medical practice because it really kind of encapsulates the high level principles and approach, Um, in terms of, um, ethical care, the Medical Council. Then we have a B m A. That's where I'm from. Uh, we probably get not so much top level, but get more into sort of the the weeds and sort of details of an ethical issue. There's also guidance from the royal colleges and intercollegiate guidance. So in the UK, we have royal colleges to for specific specialties. So, for example, we have the Royal College of Obstetricians and Gynaecologists, Royal College of General Practitioners, Royal Car Psychiatry or College of Physicians and so on. And they can often produce guidance that might be very specific to the specialty in the clinical, uh, situations that those doctors will face, and we'll touch on some of the ethical issues. I mean, one thing to say is guidance from bodies like the G, M. C and B M A and Gloria. Cultures will always reflect the law. So, although There's a huge amount of medical law, case law and statute. There's no expectation on doctors in the UK to be many lawyers that guide that, that the legislation will be reflected in medical bodies, guidance on ethical issues. So then we have statutory guidance and I said that will be reflected in GM CBM, a college guidance. But we have statutory guidance. For example, we have statutory guidance on female genital mutilation and things like information share ing. Should a doctor become aware that a female is at risk or has undergone FGM, So we have statutory guidance. Whether it sets out the expectations in terms of what would happen should happen. There's also guidance from government health departments. And I said we have a UK what sort of UK wide approach to some things, but also the devolved nations. So there'll be health departments in Scotland, Wales, Northern Ireland that will also have some guidance and say, for example, one area that there will be differences in things like child safeguarding, so there will be guidance from those bodies and that will not just be for doctors, but it will be for other teachers and social workers as well, but there's, um So, um, I would also look to government health departments to provide some of that advice and guidance. It's also defense bodies. So doctors in the UK can be members of the B M, a trade union side of things. If there's contract disputes also have to be with a scientist GM see to practice. But there's also defense bodies. So these are bodies that will, um, sort of defend doctors if there are any sort of say, for example, clinical negligence claims that something has gone wrong clinically so and the G. M C within their guidance, um, is one of their professional standards. Set states that doctors should have adequate, um, liability insurance. They sort of medical defense but signed up to a medical defense body. And they produce guidance. Which, um, there's some similar guidance around confidentiality and consent, for example, but maybe have a more of a sort of legal angle on their guidance. There's also locally we have, um, we have clinical ethics committees and research ethics committees. So the Research Ethics Committee structure is is fairly uniform. It's fairly well embedded. There's, um because there is an expectation in terms of research that they will go certain times of products if they engage, Um, have human participants involved will go to research ethics committees. Um, so that's there's a far, far more sort of nationalized structure and sort of terms of reference in terms of research ethics committees, but that they've very specifically focused on research. We also have Clinical ethics Committee. They're not quite so, um, uniform in their their structure in appearance, but they are in sent hospitals, good resources for doctors to refer cases that raised ethical issues for consideration by Clinical Ethics committee. An example of where these have been used recently is we've had in the last year is quite a lot of high profile cases, um, regarding the drawl of life sustaining treatment from Children. And, um So, for example, great Ormond Street had a case. So did all the hey, these these big sort of centers of excellence in terms of child clinical care. And there was, you know, when you look at the at the judgments in the cases because they went to court's, they did refer cases to they did refer the cases to the clinical Ethics Committee, Um, but they they're they're less of a formalized structure than research ethics committee, although there is currently quite a push to embed them in in the UK Are there any any questions? Because I'm very conscious. It's very UK focus. And if you're not based in the UK, some of these these organizations might be unfamiliar. Is are there any questions about or put it in the chat bar or put your hand up or shout out? Uh huh. Okay, So what is an ethical issue? Um so ethical issues engage concepts such as interest, values, fairness, rights and autonomy. So, for example, interests, you know, individual interest, public interest. It's about values, honesty, integrity, about fairness. It's about writes the right to privacy, um, right to be to be free of degrading treatment on autonomy. Autonomy is featuring yet again, um, and within the UK difficulties and complaints can sometimes arise. So even if you if there's not felt to be a moral imperative to sort of be considerate of medical ethics and the concept that engage, there's an obligation, because if you don't act in the correct way or you're mindful of it or you don't take into account when you. You make certain decisions. Sometimes there can be complaints either to the G m. C is the regulator, but also legal cases. So it's it's Doctors in the UK have to be mindful not just because, you know, I would also strongly argue there's more Olympic. But there's also imperative in terms of being able to continue to practice in the UK because difficulties and complaints can rise. And we sometimes see with the fitness to practice proceedings that there can be a strong element in terms of. So, for example, a doctor hasn't been taken into account communication or hasn't exercised good communication with the patient or the those close patient. And so, for example, confidentiality hasn't been respected or consent hasn't been obtained in the way that 11 would expect. So when ingesting ethical dilemmas considered the law, G m C guidelines good practice guidelines, and I've touched on the bodies that produce those I'm going to go back to in the sidebar uh, we did some analysis is pre pandemic because we appreciate this. I haven't done so and we haven't done quite such the same analysis with Covid because it was a a unique time in which different kind of ethical issues were arising in terms of the ethical issues that you've encountered or you expect to encounter. What kind of issues do you think come up if you put in the sidebar, any thoughts, any thoughts? Okay? Have any of you encountered an ethical dilemma so far? You if if or are there particular ethical dynamos that you're anxious about in the future? Okay, I'll leave it there. So in terms of the B m A in terms of the the ethical issues that are raised with us, um, pre pandemic, we look at the Web hits that we get on our ethics pages. We look at the downloads of the particular materials that we get. We also we we advise we run a ethics advisory service that we analyze the kinds of inquiries that we get in. So in terms of the BMA, the main issues that really kind of cop up the doctors in the UK around confidentiality and health records, it's the main says often sort tensions about, For example, he where information go, what information can go to who and there are a lot of challenges ongoing in terms of, for example, um, employers wanting access to health information insurance companies, different government departments. It's a rich sorts of information that's highly desirable. Too many people. So, um, a huge amount of world work is around, um, responding and supporting doctors and how they deal with privacy issues in the UK So, you know, we're great proponents in terms of that, in terms of trust in the health service, Patient's can have an expectation and right to confidentiality because also they're coming into and, you know, they might be revealing some of the big you know, the secrets that they don't want to be exposed. And we need patient's to feel comfortable to come and talk, because how can, if they don't feel comfortable revealing some of the information that's necessary? It might be. The treatment that's provided is not as optimal as one might hope. So we get a huge amount inquiries about confidentiality, health records after that, the inquiries that we get around confidential and around consent and refusal. So, for example, who can make decisions if a patient lacks capacity in terms of consenting to refuse treatment, how do you go about getting consent from the from a child or those with parental responsibility. So it's also about consent and refusal to treatment. And there are a few other ones around personal beliefs. What doctors? If they have strong personal beliefs about particular issues, um, ensuring that they don't It's not evidence of patient's if it's about to be sort of discriminatory their views. It's about the doctor patient relationship, end of life care, Children, conflicts of interest, child safeguarding, adult safeguarding and obligations of doctors, organ donation and also we because we have an NHS Stimson. But we also have a private think. Increasingly, we're seeing, um, ethical dilemmas raised in terms of whether patient's can can go I/O of state and private healthcare and sort of obligations. And, um, on doctors to to to, uh, ensure that patient's care is optimal, but also that there isn't so conflict of interest of a doctor is working privately as well. Are any of those issues a surprise? Or are there things that you would think with other things that you think would be feature on that word cloud, any thoughts? Okay, So when we support doctors in the UK, we we suggested an approach in terms of thinking about an ethical dilemma. But this is very much a suggestion, and this is the framework that we would encourage. We actually have a toolkit that published early next year that will sort of set out how to approach an ethical dilemma. So the first thing is to recognize that a situation raises an an ethical dilemma, and we do get sometimes it calls from doctors who who don't realize until after the event that there was an ethical issue that was raised. So looking at the word cloud, you know, recognizing that a particular situation that is being faced raises issues around confidentiality, around consent and refusal around mental capacity around mental competence. If you're looking at under under 16 year old's particularly so, it's recognizing that there is an ethical dilemma that needs to be considered, then breaking it down into a component part. So so sometimes situations aren't just straightforward like, Oh, it's just about consent. It's just about confidentiality. Sometimes a situation can be multifaceted and and I have lots of different component parts that need to be broken down, and then it's seeking additional information, including the patient's view. So the patient's view is very important in terms of how a decision is made. Um, so even if their views are not determinative in terms of what happens, they're very their thoughts and wishes are incredibly important. And it also may be getting the views of say, particularly if a patient lacks capacity getting the views of people who care for them, um, other members of the multidisciplinary routine. So it's getting as much information to make as an informed decision as possible. Then it's identifying the relevant legal and professional guidance, and I talked about some of the bodies that provide that guidance, and sometimes they will be very clear and unambiguous, uh, answer in terms of how one might respond to an ethical dilemma. But sometimes it can be a little bit more complicated. There is. The issue is resolved. So, for example, if you face is the situation and you, you go to one of our toolkit, so you go to the G. M. C's guidance, and it says in this situation you do this. It's clear it's issues resolved. It's straightforward. The next thing is to be able to justify the decision with sound arguments, so particularly I've seen in the UK in the last few years. It's not just about the outcome and the decision that was made often what can be quite important is the process been gone through to get to that decision. So, for example, one of things I've read on the past is that a national guidance around decisions around cardiopulmonary resuscitation, for example, how a decision is made about, um say, for example, do not resuscitate order that's placed on the patient's record. And I've you know, certainly there was a judiciary year a few years ago and seeing some doctors who had sort of challenged in the court's in terms of why they came up with do not resuscitate for a particular patient. One of things they were challenged on was how the decision was made. Who have they spoken to in advance of it? Now the decision might have been the same, irrespective of the process behind it. But the process has become particularly important. So that's part of being just just if I say I've made this decision and this is why I've made it, because I've taken into account the patient views and the patient views with this those close to the patient and these, their their views and the clinical picture. So it's taking into account and being able to justify the decision that's being made. And sometimes it's not straightforward. Um, and if it's not resolvable, it's subjecting the dilemma, too. Critical analysis. And sometimes those philosophical approach is I talked about earlier, say, For some, some doctors like to look at it in terms of full principles, sometimes just looking at it from through with a different approach and sort of breaking it down and trying to understanding it, perhaps taking it to, say, clinical ethics committee. Um, sometimes that can help resolve and or set out a framework with the Howard decisions being made that results in in in making decision. But there are, and this is the nature of ethical dilemmas. There are sometimes irresolvable conflicts, or the law is unclear, and it may be necessary to go to court. Um, one thing that we've sort of promoted from the BMA in terms of supporting our members, it's not necessarily a failure if something goes to court. Sometimes there are such irresolvable conflict that they need to go to court. It's an outside external objective body that can make a decision about what can happen and certainly, for example, reference and somewhat high profile, like withdrawal of life sustaining treatment from Children cases. Recently, they've gone to court because, um, it needed that kind of external, um, decision making authority. Um, and in the UK when there's particularly say acute situations, for example, I can think of some of the cases where there may be an emergency there in sections needed or someone needs sectioning. Um, court declarations can be attained fairly quickly over the phone. Um, but if, for example, doctors working NHS trust, there'll be a trust legal team, he will advise with that and so on. Um so sometimes it just is the nature of an ethical dilemma that there's not a clear approach in terms of what to do, and it has to go to court. Are there any questions on that? Any any thoughts? Is this so I can see some of your basic would that be similar in other countries in terms of approach? Okay, we'll leave it back now to come in. The challenges when we think about ethical dilemmas and touch them before is who is right and who is wrong. And there's not always a right or wrong answer. It's, um it's the nature of some ethical issues. Um, so it's about the importance of considering the issue, Um, and how you've gone about and you can justify a particular decision. There's not necessarily a right or wrong decision. Um, and that's the nature nature of, Of of some of the situations that are faced, it's about who decides. So I talked about earlier how previously it was very much the doctor decides that's changed. Now it's a partnership relationship. But then if we, um, start talking about, say, adults who like capacity or young people who haven't got competency, it's who has decision making the authority. Um, is it the doctor and we we've, um yeah, so it's very much sort of who decides has changed over over the years. Um, but it's not simply who's decided in terms of determinative who feeds into that decision. So some of the challenges also individual relationship. What about the rest of us? So we talk about the doctor patient relationship, putting the patient first, but you know, particularly if we think about what's that just happened with covid. It's about public interest as well, so individual choices can sometimes impact on sort of sort of wider society. So okay, individual relationships, important sort of doctor, patient and individual interests. But there's also PA Public interest in terms of decisions that are made and how you might approach an ethical dilemma might, um, change in terms of how, whether you think about it in terms of you, say, looking at things like resources if you're looking at a macro level resource allocation, if it's a resource allocation or a micro level resource allocation, you focus on the individual or you're focused on public and wider society. It can also depend on context. So stay thinking about covid again. Um, the way decisions might be made in a very acute emergency response, where they are very limited resources. And it might shift in terms of how you prioritize care and the emphasis you placed on different things so it can depend on context also open to interpretation. So, for example, when uh, in the UK when we look at decision making for adults who lacked capacity in England, we'll look at it in terms of decisions are made on a best interest basis if someone lacks capacity, and that will take into account not just a couple clinical factors, but also take into things like the wishes that previously expressed wishes of that individual, if they have something called an advanced decision refusing treatment and sometimes because you're weighing up, doctors are weighing up lots of different elements. It to different doctors could interpret that information in a different way and come out with different conclusions. So there is an element that is open to interpretation. That's why it's incredibly important to scrutinize and also be able to justify the decisions that's made the decision that is made. And so it's acceptance that sometimes there are particular kinds of decisions, that there might be an element of gray. And that's why it's really important how the process by which people come to sort of decisions about what they do. Another challenge is what to do when to values conflict. And we can. Who's, for example, if you look at it in terms of the human rights framework whose whose rights trump whose rights if they're in conflict with each other? Um, we've recently, for example, had quite a lot of work we've done around buffer zones around abortion services. So, um, there's recent sort of been legislation or there's going to be legislation, and this is where actually devolution sort kicks in. Um, but the general approach is that there's now going to be buffer zones UK wide around abortion services. So that means within 100 and 50 m radius of an abortion service, anti abortion protesters can't be present. But then there's But there was lots of discussions in the run up to this. You know, the values in terms of the rights of privacy to patient's and also sort of medical staff who involved in those services. But then people who are campaigning saying that we don't need buff stones are talking about rights in terms of the right to freedom of expression. Um, so those values are conflicted, but it's come very much recently, strongly out in the fact that actually patient's and healthcare staff they're right to privacy. To access the service is should should prevail. Are there any other challenges that people can think of in terms of ethics, in terms of things they might face, or that they in the future? No. I'm going to test you that you're you're still listening. So, um, if you put your hand up if does that all make sense so far, Okay. Thank you, Melody. Okay, so, um, any questions? You can put them in the sidebar. Someone was someone just coming off the mic. Does that all make sense so far? Yes, it does. No question. Sorry. Oh, no, thank you. Lola. That's great. Okay, what the common ethical challenge that are difficult to deal with. And I think because we've had a lot of development in terms of, say, medical law and guidance, um, I think some of the more difficult ones are quite resolved when I was going to say, in terms of, say, access. I mean, there's there's access to confidential information, but in terms of say things, that going, I look at it in terms of the ones that are going to court that, um, become more aware that they're going to court's is And I think I've mentioned so withdrawal of life sustaining treatment from Children. So I think, and it's it's what you mean by difficult to deal with this difficult to deal with because the law is unclear. That's difficult, I think, to deal with because of the emotions that are running. And also, we've seen say, in the last few years, the role of social media and engaging and a more global debate, um, and involvement from, say, second opinions from other countries. So what common difficult to deal with? So I think the Children, because it brings up so many emotions that's been particularly difficult. So the recent cases that we've had around with all the life sustained chimneys where, um, doctors have felt that, um, maybe a charge to be, uh, receiving palliative care, that all the sort of viable clinical options have, um, have been exhausted, and nothing can be done so that there should be a shift more of a palliative care approach to the care of a child. But parents have felt very differently about it and maybe have looked overseas, bought for other treatment options as well. And then there's been a tension which between the treating clinical team and parents, about what should happen for the child. So we've seen a lot more of those cases. Yeah, I mean, the goal is going to court. I guess, but But in terms of public profile of them, and that brings with it, um, some, I'd say sort of more recent challenges. Because if you get then Social Media campaigns, then, um, some of the healthcare professionals that involved in those cases are subjected to quite a lot a lot of abuse. So I think they're difficult. They're difficult because they're difficult decisions. They'll never be easy decisions. And if there's a difference of opinion about what should happen to a child between the parents and clinical teams, they're always difficult, Um, sort of emotionally, Um um and so perhaps that's why there's Some of them have gone to court because it's easier to sort of sort of try and sort of resolve them in that way. Um, but I think they've been challenging also because of the public, um, engagement in the issue and some of it being quite hostile and abusive. And and we've also saying some of those cases seem, for example, like Donald Trump got involved in one of the cases a few years ago and actually so people who say in other countries have a different sort of cultural approach to some of these challenges. Also commenting on what's happening on on very, very challenging, very complex, very difficult for everyone involved. Um, individual situations, um, are the ones that are difficult to deal with. Um, just trying to think, um, end of life care. So we're having a lot of discussion, for example, around assisted dying at the moment, assisted dying is physician assisted. Dying is illegal. It's unlawful. In the UK, it's crime. Um, but we do have patient's who say go overseas to say, uh Dignitas in Switzerland. And some of those challenges can be different in terms of because doctors can't be seen to be complicit in what's happening. But at the same time, they might, uh, once that they need to be able to still support their patient, and they're sort of clinical needs. Um, And So, for example, even though it's a crime in the UK, there's there's particular guidance from our Crown Prosecution Service is which talks about actually what cases will they prosecute and what they won't, And generally, healthcare professionals shouldn't get involved because they because of the way that the law is draft, but also in terms of the guidance in terms of he will be prosecuted healthcare professionals and still need to sort of, basically keep their powder dry and not be involved. But there is. I think, there's going to be in the next year or two, there's going to be increasing discussion's about what you know if there is going to be a change in our legislation. What doctors roles are the B m A. As an organization is neutral on this, we are neither supportive of a change in the law for assisted die. We're not, we're not. We're not fazed either. But I think looking forward, it's going to be interesting to see if if if if there is a change in the law and it will most likely come from, say, a private member's bill. So that's where individual MPs can all sort of people in the House of laws can put. It won't be a government bill. It will be about Well, okay, we're neither for against. But what does that mean for, say, doctors being able to conscientiously object in terms of, um, how information is exchanged, how it's raised with the patient. So, um, is there any condition that are not clearly right and wrong to decide. And if you decided together with the team, do you get after your decision of these later in your life? Can you give some examples? Uh, I think that do you go after your decision of these later in your life? I think that's a heart. I think that's a very individual thing. And I think that's with the some of the ethical challenges. It's so individual. How you respond to it and how you might think about it is you go through different stages of your own life and what you perceive to be, um, important also as some of the things that we talked about in terms of, um, how how medical ethics has been influenced in the UK, for example, about society, societal changes and values. Um, so there might be decisions that are made now that in 20 years time because of societal expectations values very different. Um, you might you know, an individual might think quite differently about them. So actually, one of the things that we threw up when we did this is pre pre covid, which we actually, and actually this kind of feeds into your question. What are the challenges that are difficult to deal with. We have quite a lot of discussion around, um, trans healthcare for adolescents. So, for example, puberty blockers. And there's quite a lot of I think, um, discussion about what's the best thing to support adolescents who have gender dysphoria in the UK and what services are available. And I think our thinking in the UK was very different. Say, 2030 years ago on these kind of issues. Um, so that's where so when you talk about sort of regret or where there's clearly a right or wrong, um, I think some of these particularly hot topics it will change. Um, and individuals may change in their their thoughts and and also understanding of it, different issues. So, um, a does that I don't know if that really that I don't That was a bit of a cop out. I didn't really answer your question. If you want to come on on the mic and is there any condition that are not clearly right and wrong to decide even you decided together with the team? I mean the thing and one thing I would say is they're not necessarily blanket right or wrong approaches. It's very so when we get so some of the inquiries that we get into to our team, some will be very straightforward. But some will be. Actually, I need a bit more information. So it very much so something. Actually, I'll do. I'm gonna put up some case studies where, um, I'm going to ask you to think about what the ethical issues engaged. I wasn't going to go into too much detail in terms of how we might approach in the UK, but actually, one of them might illustrate this, Um, where it's not clearly right or or wrong, um, it. But because I was going to get you to think more about what the ethical issues are raised. Um, but if I just move on, if we look at a case T. Since 15 year old patient attends the emergency department and request the emergency contraceptive pill, she's reticent to be drawn into a conversation about her sexual activity. But after some discussion reveals that she is sexually active with a 20 year old, she does not want her mother or anyone else informed of this. I'm going to put it to you. You all of you first. What do you think are the ethical issues that are raised, even if you put it in the sidebar? So it's Case T. If you read Case T, what do you think? Are the ethical issues raised? Sorry, Rebecca. I think someone has their hand up. So, melody, is that a legacy hand or is that a a current hand melody? Okay, so I'm not sure how to move it. Sorry. Okay. I think I can put it down for you. Can I? Yeah. Here we go. Okay. So it was a legacy hand. Um, any and so. Any thoughts? What do you think of the ethical issues raised by that scenario? Even if you just type in the sidebar? Okay. Okay. So I'll I will pick it up for you. And so, um, it raises. It raises a number of queries. It's about confidentiality. It's about consent. So, um, within the UK and under 16 year old would have to be Guillot competent to make decisions. Um, for his or herself. So that's Gillick competence. We when we talked about that, it's about Do they have the ability to weigh up, retain, understand, um, and make a decision. Did that have that mature maturity? That competency to make that decision so it raises is, um, sort of consent issues and refusal. Can they actually access? Healthcare also raises confidentiality issues. So when we talk about the ability to make decisions, it's very much specific to the decision. It's not that you will necessarily say that a 15 year old is either competent or not competent for all decisions. It'll be decisions specific. So for more complex, difficult decisions, they might not have the competency because they can't way up, make understand, retain the information. But for something quite simple, and sometimes we talk about it in terms of, say, their privacy and confidentiality, you go. Actually, they can weigh up and understand that information. So therefore they can make that decision about whether information is shared with X y or Zed. So it raises issues around confident charity and consent. Um, because actually, it sort of revealed that there is a sexual relationship with someone who who is, you know, old five years older, an adult, whereas this is individual is under 16. It was a might, really. These issues about safeguarding is this 15 year old being exploited in any way. And then if it raised safeguarding concerns and there's concerns about it, then then the doctor would need to consider about whether they need to breach confidentiality, um, to safeguard because it is. It is an under 16 year old breach confidentiality to the relevant authorities to if they think that this child is being abused in any way and the safeguarding issues, and that will be done where, unless it jeopardizes the case, that will be done. Um, informing the young person This is going to happen. So So she does not want her mother and anyone who's involved informed of this so again. And this is where I guess you took. There's any condition. They're not clearly right onto side. Even when you decide together, it's not clearly right or wrong. Necessarily. It's very much in specific to the individual circumstances of the case. So this is why we put huge amount emphasis on good communication with patient's. So it starts. It's, you know, there will be things that are raised just by this, uh, sort of brevity of information that's here that might raise red flags. It's not to say that There's necessarily a way to respond a lot that things need to be considered. So then the onus is on the doctor to exercise good communication skills to try and a think. Actually, I need to investigate this a bit more and sensitively discuss with the 15 year old What's happening? What situation they're in. Why don't they want their mother to be involved in that part of our guidance is under 16 year old's If they're Gillick competence that they can do this. Retaining, weighing up and understanding can make decisions. But you would still encourage them to involve a parent or a God or supportive adult in the decision making. So it's to encourage, but not not necessarily to enforce. But I thought, as I said, depending on how the committee you know, the discussion goes, and if you actually think that this person might be being exploited there are safeguarding concerns, You then might start having discussion. Well, actually, we need to do something about this. We maybe need to involve other people. Um, if this if, say, this 20 year old year old is a threat to you and to others. So when I talk about right This there's not always a right or wrong, Um, in this situation, just looking on the information. Sometimes you don't know that there's a clear right or wrong until you sort of start teasing out very situational, the specific, um, elements and understanding of the situation. So I think in that sort of that that flow chart. When we talk about ethical decision making, it's about getting additional information. So there's a huge interest in good communication to understand what is going on in this scenario and acknowledging that people, when they come in to see, um, doctors aren't always as honest about information. So for one thing in the UK that comes up quite a lot is when patient's are asked how much they drink weak. You know, I think there's good research, suggest that people aren't always as honest about the number of units that they drink as and they might be. And it might be an an unconscious thing that they're not aware of how much they drink, but that's particularly one element. So it's about, uh, it's not necessarily right or wrong, but it's about trying to tease out the information and and good communication skills to make sure that you fully understand that what's happening and therefore, you know what what you can and should do in terms of. Can this individual consent and refuse treatment, what in terms of their privacy rights Are there some exceptions to that where I have to actually disclose to someone else? Because what I'm concerned about something. And even even if there aren't absolute rights or wrongs, it's still about how doctor approaches the issue. So still encouraging them to say involved their mother. So almost does that any thoughts or or questions on that, um, your questions reflected in that inquiry. Thanks for gossip. Okay, so if I just, um, any questions on that scenario and I'm very conscious is quite UK specific. And in other countries, there might be very different approaches to to a situation like this have in, uh, in in, in in any other country, would you say, Do you think that that would be approached in a very different way? So the other one I'm just going to touch on case a, um now, because this is not an uncommon one. This is This is drawn from some of the kind of inquiries that we get in, um, to our department. And it raises some some of the key ethical issues that come up in UK practice. So an 84 year old man with lung cancer states that he does not want to be resuscitated if he arrests. A few hours later, his daughter arrives on the unit and ask questions about his care, including about resuscitation. You speak to the patient, but he says that he doesn't want you to tell the daughter about his illness or treatment. So what kind of what ethical issues are raised by that scenario? If you just pop in the sidebar, any thoughts? Details okay, so again it raises confidentiality issues. Um, and assuming this, you know there's a presumption of capacity for adults in the UK so, presuming that this individual has capacity, make decisions, you have to respect their privacy. Also the decisions. But say, for example, um, on the resuscitation question. If you think that you know it's again, it's about communication and exploring whether patient why he does not want to be resuscitated. Um, and if it's clear, that has a good understanding and there are no sort of fears or perceptions that, um needs to be addressed until it's explaining what happens to him. And he makes that decision autonomy. Even if you were to think it was unreasonable, unreasonable position for him to take, you've explained, um, you've explored what? Why he takes this particular view. Um, that would be respected in the UK and also his confidentiality. But it is about having that exploration and that sort of communication. That discussion beforehand just checked that there is no misunderstandings which is formed the basis of his decisions. If he lacked capacity, then we're in a very different situation in terms of sort of. Obviously it take into account his wishes and beliefs, but maybe sort of analyzing, um, out scrutinizing the decision a bit more in terms of, uh, and involving maybe the daughter, um, in that decision, if you lack capacity. So that's the ability to understand, retain and way up information. So any any thoughts or questions so unconscious. So I could we have. We have. We have a couple of options now, and we can either. I can either give you back your time now or would you like to sort of touch on case study be and see if you'd like to touch on case study B and C Put your hand up. Would you, like, 25 minutes of your time back? If you If so, put your hand up. Okay? How's why I was just thinking. Hannah, what do you What do you think? Should we? I'm just wondering if we should call it a day. Um, I suppose if you've gone through all your slides and if no one has any questions, any any thoughts, any comments, okay, just Yeah. So I'll just, uh, finalize now to say, if you're interested in how medical ethics practice in the UK if you want to look at some more sort of resources, um, BMA has a huge amount of information that's available. BMA dot org dot u k forward slash ethics. It covers all the sort of key issues that arise for us. We're always on the lookout as well. If there are particular areas that we're getting feedback from doctors where there's a gap and guidance or they need additional support, things or things have evolved. And so we haven't used trans of guidance going up at the beginning of next year. But if it is all open access, so if it's of interest to take a look at our ethics page and also the GM see the General Medical Council have a huge amount of ethics guy guidance available as well to sort of look at, so do take a look. Um, you got any final questions? I'll stay online for a few more minutes, but otherwise it's lovely Lovely to meet you all. And I hope you all have a good day. And thank you. Thank you very much. Um, for the people who are still on, if you could please do the feedback form, as always, is very important for us to continue and have your feedback. Um, so if you could do that, please. And in terms of certificates, um, if you registered on eventbrite, you'll get the certificate by email and, yeah, I'll share the zoom links for the rest of today