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Hi. So good morning. Good afternoon. Good evening. Wherever you may be. Um, it's really lovely to me. Quite a small group here. So, um, keep it really informal. If you've got questions as I go along, please just sort of put your hand up or switch camera on or shout out or put something in the chat bar. And we can sort of like to have a discussion as we go along. So very informal. Any questions? And I appreciate I'm talking about medical ethics in new cases. It's very much I'm probably making some assumptions without realizing it. It might be some terminology I'm using, or certain systems that I'm referring to that are not familiar. So please do just kind of shout out and seek some clarification if this is something that's not clear. So I see two of you are based in currently in India, and is that everyone? Not everyone is posted on. Um so Yeah, welcome. And thank you. Thank you for coming to this talk, and I'm going to share my screen now, so hopefully Okay. Can you see my screen? Yeah. Brilliant. Ok, I'm just gonna make this a bit bigger, so I can see if anyone's picking their hand up. Actually. So, um yeah, so I'm from from the British Medical Association has on your sort of, um emoji bass. Can you put your hand up? Has anyone heard of the British Medical Association before? Yes. I said, do you have anyone else? Okay, I'll just briefly talk about okay, Another thumbs up from Jeb. Okay. Great. So, um, for those of you don't know or, for those of you know, a bit about the head of the BMA but maybe don't know a bit more about what we what we do and where we positioned in terms of sort of medicine in the UK, The British Medical Association is the trade union and Professional Association for doctors in the UK It's a membership organization. Your doctor is not obliged to be members, but obviously we we sort of promote it. And we've got over 100 and 50,000 members across all grades and specialties. Over two thirds of doctors practicing in the UK are members, So the trade union function. So the BMA has negotiating rights with the government to negotiate terms and conditions of service. Um, we also involved heavily involved in sort of advocating for doctors in terms of education in terms of regulation. On the professional side, we also have an international, um, section that supports international medical graduates who are coming to the UK but also does our work with international bodies establishing that relationship, say, with the World Medical Association. And we also have, um, my team that I come from the ethics and human rights team. The BMA is distinct from the General Medical Council. The General Medical Council in the UK is the body that doctors registered with to practice in the UK and the General Medical Council set the high professional standards of which doctors are expected to adhere to, and they have a huge amount of guidance. Um, some of it's assured some of it is a must of what they expect doctors to do. And if doctors breached those, um, that guidance and then they can can be struck off or suspended from the register and the subject of fitness protect practice proceedings. We are distinct from the G. M. C. I know in some countries, the function of the BMA and the G M C are contained within the same body. But within the UK they're quite distinct bodies. Um, we also have royal colleges in the United Kingdom. That will be very much more clinical bodies, but we're setting sort of professional, clinical professional standards. So, for example, we have the Royal College of General Practitioners, the Royal College of Obstetricians and Gynaecologists, Royal College of Anesthetists, and so on the different specialties. So that's your organization that I work for. I work for them for very, very long time, and I work in BMA medical ethics and human writing, which is a relatively small team of five people. But with our focus is is on medical ethics work. So we provide a wide range of guidance, um, for for doctors and all of that guidance is available on www dot BMA dot org. Forwards u K forward slash ethics and you can see the range of things that we provide guidance on. So we influence policy and promote best practice, and that's for doctors. We also take forward. We listen to what doctors are saying about ethical dilemmas that they're facing in their practice particular areas where there may not be some clarity, and we take listen, Um, and through our Democratic structures, also take through sort of policy that they get behind. So, for example, will have debates on things like, um, confidentiality, abortion, physician, assisted, dying and based on what what we're hearing or what the policy established the Democratic structures. We will then take that policy forward and try and influence the government or whichever key stakeholders, the decision maker. We also monitor legal developments. There's a huge amount of law in terms that's interrelated with medical ethics. So, for example, just yesterday I was I was monitoring, um, as the Supreme Court's handed down a judgment about buffer zones around abortion services in Northern Ireland. And that was about stopping people who antiabortion, um, standing within 100 and feet, 50 m distance from from entrances, two abortion services. And so listening to the court's and hand down its judgment about whether that was permissible or whether that infringed on people's right to freedom of expression. As it was, they upheld the decision that buffer zones were legal. And we're, um we're did comply with the human Rights and convention. We'll also be monitor developments as they go through Parliament. So we have the UK Parliament, but we also have devolved nations. Parliament. So we have the Welsh Assembly Northern Ireland Assembly, which is currently not sitting. But that's another. That's another issue. And the Scottish also have a devolved parliament, which can take forward legislation, particularly in a healthier area. There are some decisions that a UK wide but some things that are devolved the nation's so we'll monitor legal developments and how they impact in terms of medical law and medical ethics. We also have a medical ethics committee that meets four times a year, which has elected members doctor members. But also we have professors of law and theology on that. And we just met this week, and we were talking about, for example, climate change and the ethics medical ethics that one might be engaged in that for intergenerational justice. Um, we were talking about position sister dying, um, a wide range of issues. Another thing that we do in our department is we promote human rights and healthcare, and that's in for clinicians and patient's, and it's on a domestic and international level. So we have to be mindful of all of human rights legislation, everything we do in terms of domestic legislation, but we also have an interest in human rights on a global perspective. So we get involved If, for example, doctors are being persecute in other countries and also for there's medical complicity, Um, or prisoners have been being detained and, for example, not getting access to medical healthcare. We will also do work around that and sort of lobbying those governments or lobbying our own government to take some actions. So we covered quite a broad range of of, um, issues, but also we take them forward in in a broad range of ways. Anyone got any questions? Is that clear what the role of the B M A is? And I said Fantastic. Thumbs up any questions? I can't see my chat bar say, Hannah, you might have to help me if there's anything in the chat bar. God, there's nothing right now. But I'll let you know Fantastic. Thank you. So, um, when we talk about medical ethics there, there are philosophical approach is that people adopt when we talk about medical ethics and that's in the UK, and that's also globally. And they can be quite helpful. Tool or approaches in ways of thinking about medical ethics issues. Um, the ones that come up most in terms of when we talk about medical ethics in the UK is a consequential ist theory. So you think about an ethical dilemma in your practice that you think about it in a consequential list way. So you think about the outcome you think about. So, for example, if you took a utilitarian what what Axion would maximize benefit for for the most. So that's one approach that some people might take in terms of a philosophical approach. We then have. The anther logical approach is which is more about rights and duties, and it's it's It centers on a belief that this makes absolute universal truth. That, and this is where you'll get things like human rights legislation. So they are absolute truth and writes that people should have, um, based on the ontology. There's also four principles, which is often talked about when we talk about medical ethics, which is more of a methodology than an approach. But it's it's one that's common in use. So when I talk about four principles, the four principles are beneficence, so you think about an issue in terms of benefit. The second principle non maleficent, so causing no harm. Thinking about situation is causing no harm or minimizing harm. Then there's justice or fairness, and then finally autonomy. And particularly when we think about medical ethics in the UK, autonomy is king. Autonomy is incredibly important. So when I say autonomy, it's the individuals can have self determination and can make choices for themselves, however irrational, unreasonable there may be. So autonomy is very important in UK medical ethics. Final One that's coming up, I think, increasingly in in schools in the UK is virtue ethics soon. It's not necessarily about the act itself. It's about the character of a doctor. So are they honest of the acting with integrity? How are they acting with compassion? So the focus is on looking at the virtue. Now I talk about philosophical approach is the reality is that when we look at clinical ethics and taught medical ethics in practice, it it can be a mismatch of all of these things, and you can find elements of them in terms of people's thinking. In terms of the standards that are set, um, you can you can find elements of all of these approaches, but sometimes particularly facing a particularly knotty or difficult issue, it can be helpful to think about it through a particular prison. So for principals, I'm faced with this dilemma. What am I thinking about this in terms of benefit um, harm reduction justice and the autonomy so they can sometimes be quite useful tools? Um, but in terms of the actual guidance, sometimes it reflects different element in terms of development of medical ethics. In the UK, there isn't someone philosophical approach that's adopted. It's not, You know, you could argue it's not morally coherent in many ways, but it is because it's a revolved in a very organic way, and also you're dealing with human nature. There are different perspectives and different emphasis that people play some things. So in terms of the development of medical ethics in the UK, it's been really influenced by a number of factors. Um, that got us where we are today. So certainly up to the 19 sixties, it was very doctor lead in in the UK, so it was very much what the doctor said goes The doctor was right, Doctor was God, um and that that's very much the approach that was taken. It's very, very much moved on from there now. So it's that a doctor patient relationship and partnership, it's a partnership rather than being doctor leg, and that really leads into that whole thing about autonomy, that patient's have autonomy to make the choices and self determine what happens to them. Another impact, the impact of technology. So we really particularly say, for example, at the beginning and the end of life really pushed some of the sort of boundaries, and that's raised a lot of ethical dilemmas. Say, for example, around IVF, um, in terms of how long you you you can extend extend people's life for so impact of technology has really shone a light on some of these thornier issues, particularly the beginning and end of life. The impact of law as well in in the UK medical law has grown exponentially in the last say, 20 years. So there's a far more case, law and statute that needs to be taken to account. Um, so and regulation is all medicine in the UK is very heavily regulated, and that will cover things like sort of information, share ng, um consent and so on. So there's been a huge impact in terms of cases going to court, but also things being debated in Parliament and therefore, um, statutes, acts of Parliament being made that sets the high level principles in terms of how things, um um can be done in the UK We had the injury. Oh, sorry. Sorry. There's a question in the chat. Someone's asking. Is that lancet part of B m A. The Lancet knows The Lancet is is not. We have the British Medical journal, which is independent of the BMA were more. I guess the best way to describe it is in fact, can I see that here is a sister organization. I can't. I got to chat now. Plastic? No. So the Lancet is not part of the B m A. It's a different journal, but we do have a sister relationship with the British Medical Journal. But the British medical journal BMJ has edited territorial independence from us. So we can't. So, um, does that have to lose that? Does that? Is that clear enough? Is that any other questions following on from that? Okay, I'll move on. Um, So we also have the impact of Hae profiles we've had. We've had quite a few of these over the years. So for example, in the nineties we had a big inquiry around, um, doctors who are who are performing postmortems on Children who died and sadly, and organs and tissues were retained. And there was a huge inquiry of that because there was there was an outpouring of dismay from particularly parents that this was happening. So we haven't We've had a fairly few sort of public, high profile inquiries that then result, for example, from that legislate and that and it tends consent process is around retention of tissues from from deceased individuals. We also have, for example, with the covid enquiry in the UK has commenced. That's likely to go on for some years, and that will engage some ethical issues. So, for example, things like I'm you know, we're considering, say, the ethical framework in terms of how resources were allocated and and and what how decisions were made about who got treatments and so on. So high profile inquires we have quite a lot of them. That then impacts quite significant impact quite significantly on the way medical ethics and or how individual doctors have to think about medical ethics in their clinical practice. The MP you, it's, uh, mg You, um is is again a different organization. So the M D. U. Is a defense body. Um, so there's several of them, so you'll have the MD. You'll have the M d D us. There's different bodies, their defense bodies and their doctors pay their membership as well, so doctors pay. But then they get legal advice, and it will be things for if there's clinical negligence claims. So if something goes on clinically, it will be a medical defense body who will advise and support that doctor with the legal process around that there are sometimes some overlap. So, for example, B m A. In terms of actually sort of supporting doctors through through, um, processes where where there may be being criticizes primarily if there is a challenge in terms of employment, so employment issues in terms and conditions of service where the where the defense body will pick up more of the claims where they're say something's wrong? Um, with with patient care, um, they'll pick up those. Sometimes sometimes situations can engage both the B M A and M D U um, And then they'll be all sort of conversation between the BMA and the MG about or the defense body about how it's taken forward. There is something Can the g m c for doctors in terms of obliging some to make sure that they are covered in terms of their liability. So many doctors I don't know. I haven't got figures, but many doctors will be also members of the defense body as well. Abdel, it is that is that clear so effectively, Doctors in the UK can kit Well, they have to be registered with the G M C. They can be. And we're strongly recommended to be a member of the B M A and also, um uh of defense body and also can be a member of Royal College as well. So there's quite a lot of does be, um, a defendant's members. What's important of joining BMA rather than MG. They're very. They have very different roles of So, uh, the BMA defends members if there's an employment issue. So if, for example, um, So, for example, the BMA checks doctors' contracts when they start employment if they are being exploited in terms of their contract, they will defend members if they are being treated fairly by their employer, they'll defend members an MD you won't do or defense body won't do something like they will get involved if there's a clinical issue, whereas the b m A get involved. If there is an issue with this sort of employment and the contract say hours, working conditions, the way that the contracts being drafted, you know, if they're not being paid appropriately, if they're, I mean the other thing. Actually, that with the BMA does do is give immigration advice as well. So they they have quite distinct roles. Defense bodies do give sort of medical law medical ethics advice. Um, and often they are advice will chime with them. I think we probably occupy space in terms of our ethics guidance that doesn't cover some of the elements that a defense body would does. Hospital and UK defendants employed doctors. Yes, Jen, So there'll be something like crown liability where doctors working um in UK hospitals will also be defended by their employers. Obviously, it would put some of this will be very dependent on the particular situation and the facts of the case. So yes, they they were in some circumstances. So, Abdullah is that I'm wondering if there's something I can find a sort of pastry. There will be a lot of this information. In fact, there were There is information on the B. M, a website for international graduates that probably talks a bit more about the structure of the UK in terms of what the different bodies doing what the different functions are. But does that if I find that and post post it at the end of dilute that will that will that be helpful, for you can digest the information in your own time. If you just give me a thumbs up or thumbs down axilla, I'll pay some Fanta. Okay, I'll pay something at the end. Um, that explains those kind of structures A bit more acid. Have you got your Have you got a question? Have you got just the thumbs up to paste it up? I mean to say understood. Ok, brilliant. I will. I'll post something at the end that, um I think it's on our website and that gives a bit better overview of those elements of it. So, um, getting about development of medical ethics in New UK. So it talks about high profile inquiries, but also the reorganization of medicine and multidisciplinary approach. Um, the structures in terms of how medicines delivered in the UK changed massively again in the last 20 years, whereas it was very sort of, say, consultant led doctor led. Now there's more acceptance of, Well, there is a multidisciplinary team approach. So, for example, one of the areas that I've done a huge amount of work on is around, um, cardio Pommery resuscitation decisions and who makes decisions about resuscitation and if the patient has a do not resuscitate order and whereas before it was very much the consultant, he would make that that decision. Certainly, in the last 15 years, it's been opened up where where senior nurses, he who have the relevant competence and experienced expertise can sometimes in some settings, also make that decision. So it's very much shifted that there's it's more of a multidisciplinary approach when there is where there is a particular situation or ethical dilemma. Even um, different perspectives will be sought from different healthcare professionals who who are involved in a situation where, certainly in the past, it would probably more likely have been that it would be the the head doctor who would make a decision. We have a much different approach to it and and kind of respect. Um, the different perspectives on a situation so far more multidisciplinary in approach now and then finally exchanging sides of values and expectations. And that's why I'm saying, I'll say again, autonomy. So different expectations now in terms of patient choices. I think certainly decades ago people would maybe turn up in hospital and things would be done to them. I think there is an expectation in society now that they, you know, patient's shouldn't be treated that way that they have rights. They have choices, they it's a partnership. They'll have a discussion. They'll be involved in discussions about their care. So there's definitely some sort of change in societal values and expectations. How does that out of interest? How does that time with experience in where you've been training so far? Is it similar? What? What are the similarities and what the difference is? You're comfortable speaking that's great. Otherwise, if any sort of similarities and or things that are not similar in the cyber will be really, really interesting. Okay, I'll leave it there. If things occur to you, just pop them in the cyber afterwards would be interesting. Interesting to know where the differences might be. So over the years, um, there's a great deal of legal and professional guidance that's been developed to assist doctors in the UK in managing many of the ethical dilemmas that they confront. So when faced with an ethical dilemma, solution can often be found by referring to guidance from a whole wide range of organizations. So I've mentioned the General Medical Council already. General Medical Council is the regulator for doctors and the body that doctors have to be registered with the practice in the UK, not just quickly go to the side. They have a lot of guidance, but their main one is something called good medical practice. And if you were to practice in the UK, you should receive a copy of good medical practice. And if you read nothing else, um, in terms of the sort of professional guidance that's out there on ethics, I would strongly recommend reading good medical practice. It's a very high level principles in terms of the approach, Um, that underpins how the doctor patient relationships work. So it looks at, you know, keeping knowledge, skills, informants being competent about what you're doing, making sure that your skills are up to date, um, safety and quality. So it talks about obligations in terms of, say, whistleblowing. If you think that patient safety is being compromised, is it emphasizes communication, partnership and teamwork and about maintaining trust. So it's a very high level, um, document in terms of setting out principles. But it's very much focuses doctors on putting a patient first and respecting the patient, and then that their individuality. Um, so if you read nothing else, I would strongly recommend reading good medical practice and all of this. Um, there's a link there and you'll find there's lots of other giants around confidentiality consent, for example. So I've touched on the General Medical Council. Well, then already have the b m A, um, where I work, and I've talked a little bit about what we do. I mentioned also royal colleges intercollegiate. So we also have the colleges that have a combined, um, intercollegiate approach to some issues. Um So, for example, you'll see the Royal College of Obstetricians and Gynecologists and the faculty of Sexual Reproductive Health Care doing a lot of work joint work together. You also have the Academy of Medical Royal Colleges, which is the body that represents all of the royal colleges, and they will often sort of produce very sort of specialty, specific guidance that touches on ethical issues. We also have a reasonable amount of statutory guidance in the UK So, for example, um, something one of the, uh, another areas that yeah I covered is female genital mutilation. We have got a lot of legislation around female genital mutilation, um, as a as a criminal act. And under that is also some statutory guidance that sets out certain responsibilities particularly, say doctors. In terms of, say, for example, information share ng identifying if someone is at risk of female genital mutilation. So there's a lot of there can be statutory guidance also on things like, um, generally information share ing between different bodies like, um, the health service, social care and so on. So there's also statutory guidance that needs to be taken into account. There's also government health departments. Um, because the UK has the devolution. There are health departments in in England, Wales, Northern Ireland and Scotland. And there can be some differences between them, particularly in terms of mental, um, medical ethics. So, looking at things like so, for example, mental capacity, there can be differences of approach and technology and process generally the spirit and intentioned. How we approach issues are similar, but there can be there can be some sort of technical differences, and one thing to stress is the General Medical Council on the B. M. A. There's no expectation that doctors will know everything. G, M, C and B M A. Guidance will always reflect that the current law or sign post to the Royal College guidance or also sort of statutory guidance. So it's not that doctors have to look in lots of different places. They will be summarized by the G, M, C and B M, and also the defense bodies. Um, but these are where different sources of information and, um can be in terms of how doctors practice. So we also had defense bodies, and we've touched a little bit on defense Body's already to defense bodies, um, doctors, there's something happening has actually in good medical practice itself about doctors being, um, having having adequate cover and sort of being members of sort of defense bodies if it's required for their role and defense. Bodies produce a lot of guidance primarily probably from a more legalistic point of view on hold, but it does go into sort of medical ethics as well. Also, within the UK, we have clinical ethics committee and research ethics committees. The research ethics committees is quite formalized structure and roll and quite standardized across the UK and that be if someone has a research proposal, it's then gets the Research ethics committee for their approval. And if they will look at the sort of ethical issues you know, is patient consent adequate in this? Who what information is being asked for? Where is this information being shared? What are the risks? The patient, what the benefits to the patient? They're quite formal structures. We also have clinical ethics committees in in a number of trusts, not everywhere, which is a little bit more ad hoc at the moment. And I think certainly is. One of the things that we're looking to pursue is maybe formalizing those struck shins structures across the UK so they're more standardized and generally having been on one myself for many years, Um, the one that I I was on and how it operated is that if there were particularly sort of difficult ethical issues that doctors or clinicians faced in practice, they could refer the case, the Clinical Ethics Committee, and they can consider it. So we would be things like withdrawal of life sustaining treatment on a particular patient. It might be the use of some hospital data for a secondary use. So clinical ethics committees, um, certainly are in place in in some some of the hospitals and looking at someone that we've had some fairly high profile cases recently around the withdrawal of life sustaining treatment from Children and certainly the clinical ethics committees. And some of those cases were referred to. So has anyone heard a great Ormond Street? Great. Ormond Street has a clinical ethics committee. Also, Southampton is. I think it's involved in case and order haze there, there. There are some places where they're within trust hospitals themselves. There are clinical ethics committees. Is there any questions on that? So I I appreciate that this is very much UK centric, and some of these institutions might not be so familiar. Are there any questions based on that slide? No Good to get hands if if you're still awake, if you can put your hand up or thumb, that'd be great. Okay, Fantastic. Okay, so that's good medical practice. They're just a sort of summary, um, referred to. So Okay, I'm not going to go on to the next drug. Yeah, I'm gonna I'm gonna part over to you for a little while. What do you think is an ethical issue? Thoughts in the sidebar or or shout out? What do you think it is? And what makes something an ethical issue, an ethical issue? It might be something the basic, uh, autonomy or the right thing to do. Might intertwined with, I think, uh, I have to say I think I have attended this lecture prior. Uh, no, no, no, no. I think. And last time we discussed regarding the d n A versus Do not treat. So if a person comes to a hospital with some disease And for that, he's being he or she might be admitted in the hospital And they are. They have a d n, a sign that doesn't and due to the complication of the disease or any illness, they, in a word of like they're about to die. So the doctors resuscitate him. So the question comes that I had the question last time. What what it will do because D n a means do not resuscitate. That doesn't mean do not treat. So I had that question last time. So, yeah, we can treat It's just different things because if a person who is suddenly just had a heart attack and, uh, paramedic or a passer by who happens to be a doctor might treat him nor necessitate that person, there's no right. Uh, that patient might have to sue him because the paramedic or the person who save him didn't knew that. So the right to treat times the Vienna, if the person doesn't know of the paramedic for the doctor doesn't know. And that's and and individuals have to work with. And I think there's certainly sort of an except an acknowledgement in they have to work with the information they have at that time. And sometimes particularly in acute acute uh, situations where life sustaining treatment has to be provided very swiftly. All that information might not be available, which is? One of the things I think we're trying to very much promote is if the patient's have particularly strong wishes or desires not to have things done to them or you know or would would like something's on to them. I mean, patient's can't um uh, Patient's can't tell doctors what to do. But if they have particular wishes or for certain treatments or don't want to have certain treatments, it's very much trying to promote. Actually, get that message out, make sure it's in the right record, you know? Is it in your G P record? Do people around? Do people who are close to you know that your wishes and thoughts and feelings about it, um um have those conversations and you know, it's easier said than done, but I think there's very much a movement at the moment to try and actually sort of enhance individual's autonomy that they're wishes will be respected should they find themselves in a particular situation where decisions need to be made and about making sure that that's communicated. I totally accept that That's easier said than done sometimes. But, yeah, doctors have to deal with what they know at that time and respond in the in the appropriate way. And I think I said on that time I put in the sidebar. Um, we have very specific guidance about CPR decisions that we produce with the Royal College of Nursing and the Resuscitation Council, the UK that's available on that ethics, um, Web page that I mentioned if anyone else is interested in, uh, so as has come up with it, so autonomy, uh, we talked about CPR. Any other, any effort? What make what is an ethical issue? Any thoughts? Okay, well, I'm good. I'm good. I will launch into it. So an ethical issue is one that gauge it engages concepts such as interests, values, fairness, rights and autonomy. So when I'm talking about interest, for example, it could be individual interest versus public interest values. It could be values such as honesty, integrity, values of being compassionate. It's about fairness, fairness and justice. It's about rights. So human rights, individual's rights, rights to liberty, like rights to privacy about autonomy. Sorry. This report that this word will come up repeatedly so it engages can engage all of those different concepts. Um, and if it's too cause, his complaints can arise in the UK when, when it's people don't realize that an ethical issue is engaged. Um, and certainly some of our say if you look at our fitness practice proceedings with the General Medical Council, some things that come up in terms of those is a doctor didn't get adequate consent. They didn't communicate something. Confidentiality wasn't maintained. So if if there needs to be an awareness in practice in terms of saying patient's privacy rights, patient's autonomy to make decisions for themselves. So even if the moral imperative can be slightly lost, the why why, it's good to sort of be aware of that ethical issues might be engaged. There's a there's an imperative to do it because they can't. Doctors can run into difficulties and complaints in the UK So when addressing a, um, an ethical dilemma in the UK, considered the law considered the G M C guidelines considered good practice guidelines, and I flag some of the bodies where that come from. Um, but as you know, there's no expectation the doctors in the UK are going to be many lawyers and know all of the law, though that legislation will be reflected in the guidance that comes from out from medical bodies like the BMA, like the G M. C. Like royal colleges. They, um this word cloud here reflects some of the issues that mainly come to us as an organization. So this word cloud is based on data that I pull together. This is pre pandemic. Um, from the number we we would get half a million Web page hits on our ethics Web page hits 50,000 downloads of our ethics material from the inquiries that we get through from doctors. Um, and these are the main issues that come up. This is pre pandemic because I think they obviously the pandemic distorted some of these sort of ethical questions that were coming in. And we hope to do sort of another review. As things are calming down about what the main ethical issues for doctors. So the main ones are confidentiality and health records. It is way and above all, the ethical issues that come up. It's about confidentiality. So, for example, health data in the UK is much thought after. So there will be challenges from, say, the police from the home office, from insurance from employers, from a whole range of people to have access to data. Obviously, there's a new things in terms of the sort of, um, data for commercial use, that that's a big debate in the UK at the moment. And so certainly in terms of our role at the B. M A s, we do a huge amount of work. One of my colleagues does is preserving confidentiality of medical information because we want patient's to feel that they can trust their doctor with the information, um, ace, that they can be treated effectively. But also, it's about maintaining trust in the doctor patient relationship to come. That charity is a very big issue for us, but also we get a little quite about consent, and that might be consent. Who can make decisions? Say, for example, for, um, a young child. The parents are divorced and and one of the parents is estranged who can make decisions when someone lacks capacity. So did those of the people here do those issues look familiar? Are there any that you're surprised to see or any that you would think to see in in the work clouds. I'll give you a minute. The Assad Have you got a question? Is, uh, euthanasia taken as a the conservative viewpoint in UK or it's, uh, libertarian viewpoint like Okay, euthanasia is allowed that money. Okay, this is this is this is a very hot topic at the moment it has been for for a while. Um, it's unlawful in the UK, but we because of the nature of the issue for elite, for there to be illegal change it is most likely to come from something called a private member's bill. It won't be a government bill to change it. And there have been repeated attempts and challenges also in the court's to change the legislation in the UK to permit physician assisted dying. It's unlawful. The moment we've had some more sort of interesting discussions with, uh over the last few years where patient's go to other countries, um, and about the role of doctors and as it stands, um, so assisted dying. It is a criminal offense, but in terms of whether individuals would be, say, prosecuted for helping someone to go there, there has been a reframing of the guidance around who gets prosecuted if they are involved in any way for, say, taking someone to say dignity and Dignitas in Switzerland. It's still the case that if doctors should not get involved in any in any way, shape or form because they might be seen to be sort of, um, remote in the practice. It's not to say that, though it's not going to change in the UK, and I wouldn't want I would like to predict whether it is or not. But they're certainly sort of repeated attempts to change the legislation to permit assisted dying what we're seeing and we're mapping out at the moment what's going on globally. And I say, certainly, in the last five years, there's been a definite shift where more countries have made, uh enabled and made it permissible. But it's not the case company in the UK is that, uh is it possible? Uh, the reason. I think, uh, the euthanasia is frowned upon. I think people don't know the difference between a d. N a euthanasia and suicidal or being societal. Uh, I think, uh, uh, in Asia still allowed on the basis of if a person has a terminal disease such as a terminal cancer or, you know, in a vegetative state where the person who could still be able to make the decisions in a manner. So this is interesting. So when you say euthanasia, what what do you mean by the term euthanasia? The person is, I think, physically unfit, sickly, mentally capable to understand that there's no further used to any medical intervention. But I don't know how people perceive it, because I think most of the time it's the government and the government's elected by the people with cultural approach or with different cultures might see it differently. So, such as a countries like Scandinavia, I think in Scandinavia euthanasia is, uh, allowed. I think it is possible. But in countries like UK or even in India, euthanasia is unlawful, as you said and it's pinching, it's that term and sorry, Sorry. Sort of sort of pressed you on the and what you meant by the term euthanasia because it's sometimes used. Um, certainly my background is philosophy and passive euthanasia means something. Um, that wouldn't be certainly wouldn't be referenced as euthanasia or physician assisted dying in terms of medical context. So I guess what? I'm talk when I talk about positions. Sister dying. I'm talking about a doctor actively doing something to bring about someone's death. And it's the doing. And that's quite distinct from, say, withdrawing treatment. We don't classify that as a sister dying. Uh, you said actively, like, physician knows that this is going to happen but is actively assisting because, uh, there was an issue regarding this, and I think I'm I don't know whether this is appropriate to bring this issue is regarding a show, a TV show. And it was about this medical drama as well, in which, uh, one of the methods was, uh, terminal person who had a terminal cancer and was like in pain and was given the morphine. And he knew that the doctor knew that he might want to end his life. So, And while leaving the ward, he told the nurse in a the code of the machine, which would give the excess amount of morphine, which would kill him. But he told the nurse, not, uh, not the patient himself very far, and he said it out loud. So while saying it out loud the codes of the machine, which could increase the more phone. I think he I don't know whether we would call it an active way on a passive. A physician is assisting, even though physician is not talking to the patient itself. But it's talking to the nurse and the patient, hearing it to the colds and dialing up to the machine and dozing of the morphine and end up killing himself. So how do we approach this? It isn't euthanasia, but can we say it's a doctor? Assisted in the past, surveil and, uh, indirect, because we cannot use the word direct indirect, so that would so within the UK, I mean mean, who's know? I don't know if there's been a test case on that kind of scenario, but it doctors can't be perceived to be assisting. So one of the issues has been, um, in fact, I'll post on the side last I'll. There's a few things that might be of interest about physician assisted dying here about because there's been questions like DOT can doctors right? The medical form for dignity, dignity for patient's to go overseas for dying and anything that might be perceived so I would say I always take, for example, in the scenario that you talk about which I'm assuming is not really He intentionally knew what he was doing by doing that so it could be perceived as assisting. I'm just saying it's a medical drama, but I don't know. Most of the medical drama are inspired by real events, so it could be Well, I'm gonna I'll post um, so we've actually got, uh, we've got some guidance for doctors on physician assisted dying, um, and assisted dying. That might be of interest, actually, if those kind and it covers some of those kind of scenarios About what? What, what in terms of UK legislation will look like assistance from a doctor. So a doctor needs to be incredibly careful because they'll run into the, you know, potentially sort of some criminal sanctions. So if I post that on the side, that might get you go or go into a bit more detail and perhaps sort of, um, sort of illustrate the protect the boundaries for doctors, um, within the UK. But there's something I mean, has anyone heard of the doctrine? The doctor double effect so anywhere, hands up. If you've heard of the doctrine of double effect, Okay, I'll talk briefly about it. How? How? MD or excellent program. Um, so is okay. Seriously? Okay. I'll have to watch that. And was it house? He was speaking very loudly. Assad Actually, it was his friend Wilson who was the oncologist. But he drugged him, and he instead went on his behalf to give the speech. Okay, I I love that program. But say, for example, house, If we were talking about virtue ethics, I'm not sure that house would always satisfy all of the Yes. Yes, he doctor house himself is not a perfect example of medical itics, but but a great clinician. You could argue, um, so that that you know that that kind of in a way illustrates the point about what we're talking about medical ethics. It's not just being, you know, being a doctor is not just being about necessarily being clinically excellent and having a scientific mind. There's also about the way that you interact with your patient and communicate with them and respect them as individuals. And I've slightly digressed here and okay, doctrine. A double effect is that it's where So, for example, of end of life care. Um, it's known if you give some drugs that it potentially sort of suppress breathing and potentially hasten death. And that's the doctrine inductive effects. So the intentions behind giving that medicine is not is not to curtail someone's life. It's to give palliation to give sort of sort of comfort and to support the patient it's in, um, keep them pain free. It's not, but it might hasten death. So the doctrine double effect would mean that you that a doctor could give that, but that it's because they're in tension is not to end end life. It's to to relieve that individual of the pain and suffering. So that's one thing that certainly comes up in sort of discussion's around this sometimes, but also in the UK, and we don't call it a system we don't call euthanasia. It's withdrawal, a life sustaining treatment if a patient is competent and so, for example, a patient is on a ventilator, doesn't want to be on the ventilator, but you know they won't be able to breathe if they're taken off it. If a patient is competent, rational, there's nothing to see that their ability to make a capacities decision is impaired, that that decision has to be respected and treatment. Ventilator withdrawn. Are there any other questions from the workout that comes up in terms of things you've encountered or things that you think might be different? Um, do these seem in terms of your your own sort of experiences? Do Are these quite similar to the ethical issues that might crop up in your practice? Do you think I might not have been a practice for him much more, But, uh, there was a case in India. It was a very old case. And it was regarding, uh, uh, a nurse who was raped by one of the compounders, uh, the some other person who was a working for working in the same hospital. And while the tragic incident, he might have, uh, hit the head a very bad in a in a very brutal way, which caused her to be in a vegetative state. And turns out the the person who did that the rapist was convict ID and was sent to jail. But he did his stones like, uh, 50 years of jail and everything but the victim the lady. She was in a vegetative state for like, the rest of her life. Like I think it was till the age of 80. She was She was very young, and I don't know why. I think that was one of the reasons which sparked a debate regarding Indonesia and India, because the thing is, uh, I think we don't know how to approach this because, uh, for the safety of the woman, it was the state who failed, failed very protecting the woman. But, uh, even though the woman cannot speak, uh, in a paralyzed state, shouldn't state could also be involved again to relieve it, to relieve the pain from it. It's a difficult question to ask, To be honest, you know, there's, um there's lots of ethical debates about, say, a minimally conscious, you know, treatment and decisions around people with minimally conscious states, persistent vegetative states. Um, and, you know, got a few of those cases have gone to the court's in in the UK and sort of developed are thinking about it. Um, I will send you a link. So there's also an end of life care project that we've done in the in the past. That sort of looks at some of these issues about treatment decisions, any any other questions. Most of the questions. The problem is I get from House mg, which is not a good source of I mean, they're they're interesting in shining a light on where some of the tension. I mean, they really draw out some of the tensions and some of the conflicts and that there aren't always necessarily easy answers to things. And so, yeah, one of the cases in the same uh it was like a starting seasons was, uh, an epidemic, uh, started to spread in the maternity ward and for some cases, house finders. Just interesting. So what he does like he gets to infants. It's similar symptoms, but nobody knows what it is, and, uh, they are all treated together. The thing is, the treatment is causing causing the problem itself like they were giving to drugs for the, uh, some kind of care, but, uh, and it happens to be both of the drugs cause is a kidney failure. So the thing is, there it is working. The treatment is working, but they don't know which treatment is working. So it comes up with a very devious, which is I don't know how it is even allowed or it if he says, keep one child with one drug, the other child with me, another drug. And so it is called. He said it. It's called a therapeutic tribe, and, uh, the dean was very upset. She told like You need consent and you You only experiment on adults as well. Even they give consent. These are Children. You need the parents consent. I think even the dialogue between the parents of these Children and the doctors who were working with them was a bit, uh, like it was It was in a manner where the it would cause many questionings because the the dialogues it was like the doctors like pushing the button the emotional button that your child is very sick. We're trying to help. I think that would cause him to get arrested as well. But I don't know how they it's I mean, it's a story, But is it possible that, uh, if this case happens, uh, therapeutic trial is validated or it's It's not validated? I mean, one of the questions that comes up sometimes it UM that comes comes to us and sort of raised more generally in sort of UK. Discussion's about this is what makes something innovative treatment and what is research. Because if it flips into research, then there's a There's a whole sort of framework in process that needs to be a deer, to which draws into ethical principles that needs to be taken account, but some things to innovation. And I guess if you're in a clinical scenario and you're testing things out and so different, ethics is always engaged. But whether it's formalized in a process can be dependent on whether you consider something an imitative treatment where you're just modifying sort. Most of particular scenario, you're trying something cow or whether it's actually research. Um, I think one of the challenges also with Children in the UK is particularly we talked about some sort of medicines. A lot of medicines in the UK are are not what I'm looking for. They're not listed for use in pediatrics because the immune is clearly a lot of investment needing to get that kind of registration. So a lot of drugs in the UK for pediatrics are prescribed off label as Well, so some of these some of these things are not always clear cut. Um, so, uh, I don't know all the details of the scenario you sent, but, you know, if you you know, if this were a real life situation and we were to have something similar to come, it would be interesting to know what's consisted of research, what's considered innovative treatment, what are the options? And I guess if you looked at it from a, uh, full principled approach, what's the benefit and risk to these two individual patient's? Where's the justice if one of them is? You know, if you if you learn from teaching the separate that you know ones obviously getting a better outcome, I think the obligation would be then to make sure that the other one gets the same thing. That's giving the positive outcome. Um, and autonomy, I guess, engaged in that. Because their Children, it would be some with parental responsibility who has decision making. Um, although they their views might not be determinative necessarily. So that was a bit of a waffling response, but I think it raised really interesting questions about what is innovative. What's research? Um and particularly Children. What can what can be done when there might be some somewhat understanding of some sort of therapeutic inventions? Okay, is there any other questions? I'll move on to the next slide, so it's just it's just Yeah, I know. I know. It's it's just I'm trying to tell if you could have time. Just watch it and I'll next time. If we meet, I'll uh, might have different answers. I'll try to find my own answers. Okay. Um OK, that's going to be my with my winter sorted, uh, rewatching house, which is changeable. Okay, So, um, when we in in our ethics part, we have a particular way of approaching an ethical dilemma. It's a suggestion. Different people may approach it differently, but when we get so we have something called the first point of contact to deal with things that are fairly straightforward. But if something is a little bit naughty, a bit more complicated, they come to through to us and what we then sort of analyze it for the individual who's a doctor who's approaching us. So this is this is how we approach it. It's not to say that they're not different ways. That might be better in certain scenarios of your own style of thinking about things. But this is how we approach an ethical dilemma. The first it startled about is recognizing that immigration raises ethical dilemmas. We occasionally get calls from doctors, and it's after the sort of horses bolted. And actually, they didn't spot that there was some kind of potential issue. So does a scenario. Uh um, raise. You know, interest about writes about values, about interest. Is there a conflict of interest? Is there a clash of values? So it's recognizing that situation that's been faced actually raises ethical issue. Then it's breaking it down into its component parts. So, for example, is it raising issues about confidentiality, about consent, about public interest? Um meant capacity. What, what are the elements? And sometimes as particular scenario can engage a range of ethical issues. So it's breaking it down what they are, deke. Additional information, including the patent view. So you faced with the situation, it might be evident what you think the answer might be, but actually it's getting because we place so much emphasis on patient autonomy or because you might think in a particular scenario that this is the right approach or this is what the individual want. It's about making sure you get the patient's be so it's about that dialogue. It's about that shared decision making. Um uh, partnership relationships rather than, um, sort of doctor is God, and, um, the patient is having something done to them. So it's making sure that patient's view sort and identify relevant legal professional guidance. And I hope I haven't completely scared with the mammoth amount of available literature it is not. It's not as overwhelming, I assure you, as it might appear when I showed you the table earlier. But it's it's being aware of the relevant or knowing where to go for that relevant information. It was the issue resolved? Fantastic. If it's straightforward, great. Um, it's then about being able to justify the decision with sound arguments sometimes, and it has been a particular emphasis in the last few years. It's not just about the decision you came to, it's about the process behind it. So, for example, I, I, uh, was watching some doctors in the court a few years ago around a do not resuscitate decision. The actual decision probably wouldn't have been any different. Um, I don't think another doctor would come up. Also. This is part of the shared decision making had it been, but the problem was the process by which they got to the decision so they hadn't talked to the patient enough. They hadn't talked to the patient's family enough. And therefore, even though the decision, the outcome of being that that the patient had to do not resuscitate order of place probably would have been any different. What happened is it wasn't the process by which they got the decision was was scrutinized and was criticized. So it's being being it's not just having a decision. It's being able to justify and also justify how you went about. Making that decision is really important in UK medical ethics, sometimes an issue, even if you if you recognize that you break it down into campaigning. Bart's. You talk to people, you've identified relevant legal or professional guidance. But now maybe there's some gaps that don't come of a particular scenario. The face. Sometimes the issue is not resolved, so it's subjecting it to some further critical analysis. Um, say, for example, looking for second opinions may be taking it to a clinic ethics committee, really sort of threatening the the dilemma, Um, thrashing out and sort of giving, analyzing it further, but still sometimes, um, in the UK if if it's not clear what should be done on some cases, go to, um, the court's. And one thing that we've been promoting over the years is going to court is not necessarily a failure in terms of medical ethic decision making in the UK, it's about recognizing that some ethical dilemmas that are faced are irresolvable. And there's just this tension. So we've had a lot of cases go to court, um, recently about withdrawal life sustainment, staining treatment from Children because they've just not been able to resolve it. Uh, sort of kind of, uh, with within the trust itself with with the parents, for example. So it's gone to court, and sometimes that's good in terms of actually taking, taking, um, taking someone another perspective outside of the situation to to sort of rule on a particular case, some of the challenges that we've flexion them already. So some of the challenges with when you talk about ethical issues is who is right, who is wrong? And I said sometimes that the nature of ethics is there's not always a right answer. There's not always a wrong answer. Sometimes there's the least worst option, and it's in those scenarios, particularly it's about well, I have. I have I given it the due consideration that it should have. Have I broken it down? Have I thought about it? Have I gone and spoken to the people I need to speak to about it? Um, so it's not that there's necessarily right or wrong, but it's about how you how you've come to that conclusion and being able to rationalize it, but giving it the sort of head space that you you should to sort of respect. It is a is a difficult dilemma. Some of the challenges who decides. Um, so I've talked a lot about autonomy bees, but some of the challenges can be that, um, uh, say, for example, uh, some some of the more recent cases around Children, it's parents have an incredibly important role in terms of the decision and their views, but they might not be be able to sort of determine the the outcome ultimately, and it might also not be the clinical team, so it's who decides. I know it's certainly in some countries, there can be, um when I talk about ethics, there can be a difference of approach in terms of who's decision makers are so in other countries. I've heard that it would be the head of the family, and a decision can't be made until the head of the family is available. That's certainly not the case in the UK, but there's still tensions about who decides. So, for example, you have a child where you have two parents with parental responsibility who disagree with each other who decides. So these can be some of the challenges also about individual relationship. And what about the rest of this? And this is, um, individual interests and public interest. And you know, Katie Pandemic is a good example about this in terms of individual interests and what should be done for the public interest in terms of therapeutic decisions or sort of rationing healthcare and the finite resources that I had. And some of the changes depends on context. They're actually talking about to say the pandemic again. So what might have been the way that, uh, ethical decision was approached in in the good times when resources were abundant could be different in a different way of thinking about it or a different framework might be necessary. Say, for example, when we were under an Incredibles pressure with resources when in acute phases of the pandemic and and had they got worse, we might have had to have gone through in a very different sort of sort of almost worse or war footing approach to sort of ethical decision making some of the challenges open to interpretation. So, um, if you look at something like mental capacity, um, decisions are made it I'll use the language that's used in England but on a best interest basis. So if someone lacks capacity decisions made on the best interest basis, and that's not just saying well, clinically, this is the best thing that they should happen to this individual. They should have the antibiotics or whatever it's also taking In best interest is far more holistic, so it's the clinical benefits. But it's also looking at sort of their well, beings or social side of things. What they have previously expressed wishes are, and some of these. So when when doctors are making best interest assessments for individuals that the patient in front of them weighing up all these different factors can be quite challenging. And two doctors could come up with a very different assessment, Um, in terms of weighing up the best interest for that individual. So sometimes these things can be open interpretation again. Another reason why it's it's, um, we strongly recommend people document things, but it's being able to justify a decision. Okay, so this doctor came out with a slight different decision. But how were they thinking about it? How can you justify what you did? Things can be open to interpretation and and have different outcomes. No challenge, what to do, when to values conflict and and this talking earlier. Sometimes when t values conflict, they have to go to the court's in the UK to resolve them. And and you know that they can be particularly challenging with the doctors to deal with in the UK in terms of the the emotional element of dealing with conflict and ethical issues that by their nature, can be very, um, highly sensitive, quite charge scenarios, so we always like good communication is critical. So I guess getting back to acid about thinking if you think about house with houses, you know, houses, communication skills. Some people might like that. Different people like different communication skills. But I'm sure he probably gets quite a few people's backs up as well. But any any question? Okay, Okay. I'm just gonna give him the time. I just, uh, talk through these. Uh, yeah, some of the kind of cases that we sometimes run by. Um, here we go. Okay. Say, I'm trying to think which ones to sort of pull up? Maybe. Actually, what if I give you a couple of minutes? Um, if you just want to look at the cases, sort of read them. These are the kind of issues. I mean, obviously, they're not real. They're drawn from real life cases, but they aren't actually sort of real life cases. Um, and if you think about what some of the ethical issues are, um, how you might approach it, Um and yeah, if we if I give you a couple of minutes just to have a look at them and then I'll touch on each of them individually, OK? is. Everyone had a chance to read them. You want to give me a thumbs up if you have. OK, Jeb. Has anyone else managed to Fantastic. Okay, so we've been okay? I said as well. I'll work on the basis that if three of you have read it in that time, um, the others, if they're they're, uh, here. Have it as well. So, case A, um, is an 84 year old man with lung cancer Doesn't want to be resuscitated. Um, his daughter then arrives and ask questions about his care, including resuscitation. Um, you speak to the patient, but he says that he doesn't want you to tell the daughter about his illness or treatment. So either come off mute or if you want to put in the sidebar What? What do you think of the ethical issues in that particular scenario? Doctor? Patient confidentiality. Yeah, uh, the approach of consent as well, because, uh, we can say the patient might scare, so he is not in a mental capacity to take decisions as well. The d N. R is also an issue. The autonomy. Yeah. So we're looking about autonomy. I mean, and there is capacity. But being scared is not. It won't necessarily, um, invalidate someone's ability to make decisions. But you might want to explore, for example, why they're scared and sort of have that communication. You know, Is there fear founded? You might want to reassure them in some way. So, Ahmed, any other thoughts you're off, Newt. Any other thoughts on that first scenario in terms of the ethical issues that are raised? Okay, so we've got yeah, consent. Confidentiality capacity has been sort of raised, so it's sort of query on that one. So in case study be you have medical stream with strong religious and moral objection to consumption of alcohol. Um, should they be allowed to opt out of medical training? Um, which pertains? Treating illness, associated with alcohol abuse any any thoughts or suggest, um, what the ethical issues engaged there. It's the autonomy and free will again because, uh, but as a medical trainee, we are supposed to treat not to judge anyone. Uh, no matter. Who might they be? So he cannot student, cannot opt out this He has to be trained. It should be training. Any other thoughts and suggestions personally should not hinder the treatment. Okay, so certainly in terms of medical ethics in the UK, there's guidance around personal beliefs, and doctors in in the UK can exercise conscientious objection to something. So, for example, direct participation in abortion and actually aside, you talk about physician assisted dying earlier. Certainly, I think if if, if it ever would be lawful in the UK, that would be one element of it, that there would be conscientious objection. So there were very, very set things that doctors can conscientiously object to within the UK but otherwise generally personal beliefs. There's there's guidance specifically from the G m C on this, in terms of what their expectations are. So the ethical issues about personal beliefs, any other comments on that case? Okay, so then we have, uh, I have a question regarding KSB as well. If that person or the doctor or the medical student has so much, uh, robust regarding his beliefs, his or her beliefs, shouldn't we also monitor, uh, the doctor the practitioner as well? Because if he's so disgusted, he might even take the chance or use his knowledge to, instead of helping killing the patient as well intentioned and showing it as a like, out of disgust or out of in the manner, because he doesn't He or she doesn't like alcoholic, but and so he might also judge the people who have the alcohol in this problem. So I think certainly if you're going along, you know, if if it was to manifest itself in such a strong way, I I would I would suggest that that person probably would be referred to the G m. C and some sort of considerations given to their fitness to practice in the UK because there would be an expectation that, um uh uh I mean, again, I can place it on sort of personal belief, that document from the G. M. C. In terms of setting aside some of your or certainly if you have certainly strong personal belief, that patient's shouldn't feel discriminated against, they shouldn't feel judged. It's about expressing them as an individual. Still, so, um, uh, you know, uh, to exercise it as far as your sort of illustrating. Now, I I Yeah, there will be questions about the ability to to to practice in the UK. So then, case see you have a supervisor, ask you to get written consent from a patient for a procedure. You have limited knowledge about wherever small risk of nerve damage. Should you tell the patient if you know that telling them will mean they declined the procedure? What are the ethical issues in that one, uh, information The right to information the patient should having the physician should know what are the possibilities can happen. So the physician or the consent who's getting the consent should explain everything a proper manner. And I should have tell. Everything shouldn't hide anything, so we often talk about in terms of consent. Um, that has sort of three elements. So it's competent. Someone is competent and has capacity to give consent. It's voluntarily given. So they're not. It's not undo pressure or coercion for them to consent. And it's informed. And it's sometimes a discussion about how much information is being informed to make consent. But in this you rightly point out consent and information any other. Any other thoughts about ethical issues raised by this, Okay. Oh, someone's connecting to audio. Don't. If that's someone is planning to speak. Okay, I'll just flag one other one that that does it and this has come in and there is standalone guidance from us because it was coming through from a lot of our junior doctors a few years ago is about having the ability. Um, if you don't have it, is a doctor yourself. You don't have the knowledge. How can you get consent from someone? So it's about working within your competency as well, which is one of the things that's highlighted in good medical practice. So in terms of being able to provide safe patient care and also give get informed consent, it's about working with your and your capacity. And if you don't have that information, go make sure you go and get it. If you're going to go and get consent from a patient, any other, any other comments on that particular scenario. Okay, so I'll move on to the final 1, 15 year old, an emergency department requesting emergency contraceptive pill resident to be drawn into conversation about sexual activity. But after some discussion feels she's sexually active. The 20 year old she does not want her mother only anyone else informed of this. What are the ethical issues? Do you think that are raised by that particular scenario. Confidentiality, doctor. Patient confidentiality. Yeah. Any other thoughts that would also depend if the patient, um uh, that if she has a recent sexual activity, she's pregnant by a recent sexual activity? I don't think so. Contraceptive will be a problem, because then, uh, I don't know. At what terms does the abortion is not, uh, consider illegal in the UK because it is a reason. Like she just found she is pregnant. So I think it would be, uh, would be fair enough. She's not ready. And she is 15 years old to have to be given the contraception. Yeah, because it's consent. And it's about age of age. Um, infection. So Jeb's those. Are we illegally allowed to inform the parents it? In this particular scenario there there'll be some things that you'd want to unpick on this. But a 15 year old, um, who if they're Gillick competent, we have something under 16 year old. If they're Gillick competence. So if they can retain understand way up information, they can make decisions for themselves, it would be strong. They would be strongly encouraged to involve, uh, involve their parents or some sort of responsible guardian. Um, it would be strongly encouraged. But if that 15 year old girl, if she had was Gillick competent confidentiality would normally be respected, and there wouldn't wouldn't be an automatic or legal obligation to inform the parent, though it will be strongly encouraged. What this also raises potentially, though, is safeguarding issues. Is this 15 year old being exploited? In a way, there's a difference in ages, there are power balances, the coercion because then then you also start considering, um whether to share information, say, with with with social care. So it would be very much something that needed to be picked out. So the ethical issues here would be confidentiality, consent, um, competency of a young person. But also does it raise safeguarding concerns where information might be have to be disclosed the relevant authority. So it brings in lots lots of elements that probably would need further investigation in consideration. Any other questions on Okay, fantastic, Jeff. And actually we have. We have a we have a toolkit on our website, that's all. It's all public access on Children, young people that tackle some of those kinds of issues. I said, Oh, thumbs up. Fantastic. Okay, so that was a bit of a whistle stop tour of some issues. But it's really just to start getting you thinking about what are the issues that these cases that raise? Okay. As I said, um, all of our guidance is publicly available. Our ethics guidance. Um, please do have a look at it if you're interested in medical ethics in the UK Also, the G m. C. Have a huge amount of ethical guidance as well covers some of the same issues, particularly around the court. Things like consent and confidentiality. Um, I will, um, okay, if you have no feedback yet, so I think there's a strong request for some feedback forms. I will now paste on the same side bar once we finished. Um, I mention reference to a few things, and during the talk about actually the structures the UK structures, um, in terms of the defense bodies, Um and also I think I mentioned, uh, physician assisted dying. I'll post something on the side then, but meanwhile, it's been absolutely lovely to meet you all again. And good luck with your studies if you're studying. And, um, thank you very much for having me and coming along this this afternoon or morning or evening wherever you maybe take care. Rebecca, that was amazing. I wasn't at the whole thing. Uh, it's a