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uh, muscle. Who's the BMA? Who works for the B m a, uh, ethics department. And she'll introduce herself more fully. Thank you very much. Rebecca, Uh, can I just check? Is my my screen still being shared? Yes. We see the first slide. Medical ethics in the UK Uh, the next 17. uh. Good morning. Good afternoon. Good evening. Um, to everyone, Um, it's really, really a privilege to be here talking to you. Um, I'm going to be giving a brief talk about medical ethics in the UK just so I can gauge where we are in terms of an audience. Um, can you give me a thumbs up or yes, or thumbs down? Or know if you're familiar with the UK health system and medical education? Thumbs up, Thumbs down. Thumbs up. Okay, So we So we have a mix of people. So as as I speak, I'm afraid if I've made any assumptions, do do, call me out and I'll try and keep an eye on the chat box. But if there are, if there are terms that you're not familiar with that I'm using or that you would like anything clarified, do just sort of shout out, put your hand up or put something in the chat and I'll give a bit more of a, uh, an explanation, Um, for what I'm talking about. So I'm very specifically talking about medical ethics in the UK, but there'll be a lot of elements that I will be talking about that will be relatable to other countries in terms of how they practice and what underpins the ethical framework. So it's it's although it's UK focused and that's my expertise, it will. It is translatable to add to other parts of the globe as well, just to give you a bit of detail. But my background. I have a background in philosophy, medical law and a clinical background as well. And I've been working in medical ethics for for just, um, nearly 20 years, with a few breaks along on the along the way, So give you background where I come. I work for the British Medical Association. The British Medical Association is the trade union and Professional association for doctors in the U. K. A huge proportion of doctors in the UK are members of the organization. We are quite distinct from the General Medical Council, the G M C, which is the regulator for doctors in the UK who who you have to be registered with the practice in the UK and also oversee elements of education and fitness to practice. So I'm certainly aware that in other countries, sometimes they're one organization has dual functions, but we are the professional association, um, the doctors in the UK and I company, um, professional side of the organization, um, and specifically the medical ethics and human rights team. So we do a range of things in the team. We influence policy and promote best practice on medical ethics and human rights. We monitor legal developments, medical law that will affect how doctors practice in the UK We also support the Medical Ethics Committee. That's a committee that meets four times a year and deliberates on some of the finer details of our policy. We also promote human rights and healthcare for clinicians and patient's, and that's domestically and internationally. So we have. We do a broad range of things. We also provide individual ethics advice to doctors and medical students practicing in the UK to our ethics advisory service. So, um, we all specialize in different areas. I, primarily specialist at the moment in sexual and reproductive health care, have also led on confidentiality in the past and Children so looking quite broadly about the issue in terms of the UK there are some philosophical approach is that often come up in debates about how we approach ethics, medical ethics in the UK, and these will probably be translated baseball internationally in terms of how people talk about ethics. So 11 area of consequential is, um, some people take quite consequential ist approach to how they think about medical ethics issues. So we're talking about, you know, for example, utilitarianism. And it's about the greatest, um, the greatest good for the greatest number. Um, so it's whether you're looking at it in terms of benchmarks in terms of sort of welfare or unhappiness, So that's a utilitarian approach. There's also an inch a logical approach, which is more about looking at every or stating that there is universal kind of duties and obligations. There are rights and responsibilities that are set out. So, for example, something like human rights would be a dental logical approach and something that, um, that's quite a lot in terms of an approach to thinking about medical ethics. Ethics issues used is the four principles, and it's not necessarily a physical Asaf Ical approach. But it's a methodology with under a D ontological approach. So it's when you're faced with an ethical dilemma. You think about it in terms of full pre principles, which are autonomy. So the ability of patient's to sort of self governance and make decisions for themselves is about non maleficent, so causing reducing harm or mitigating risk and harm. And it's about beneficence, which is about benefit to individual patient's, and it's also about fairness and justice. So that's that that there's a lot of reference to four principles to get about. Has anyone heard of four principles before, like have thumbs up or thumbs down? I understand Thumbs up. OK, so it's a mix. Another approach that is often talked about is virtue ethics as well. So this is not looking at the consequences of of a particular dishes or an outcome. If you look at the ethical dilemma, it's not talking about the ethical dilemma in terms of certain rights, duties or responsibilities. It's talking about virtue ethics, so it's a about the doctor themselves. So do they present with compassion? Are they honest? It's about character of doctors rather than necessarily they're being a set rule of rights and wrongs and the consequences of actions. It's about virtue now. Philosophical approach is can be really helpful in terms of if you're faced with an ethical dilemma, how you might want to break it down and sort of think about it. But the reality is the way that medical ethics develops in in the UK there is not one set philosophical approach that is reflected in in the way that doctors and medical students are governed in the UK It's a mismatch is mismatch of of different approaches that has brought us to where we are and development medical ethics in the UK has really taken place for for a range of reason. The 19 sixties in the UK ethics or professional practice was very much doctor led. It was about what doctors said it was very paternalistic. The doctor was right. Um, Patient's didn't always have a voice. Patient's weren't always told what was happening to them or what the diagnosis was. It was very, very doctor led. Nowadays it's moved significantly from that. And it's a partnership relationship and it's respecting patient's autonomy. So that's one of the key areas in which we've developed the impact of technology. So really pushing the front is particularly around the beginning of life, say IVF and also in terms of end of life, sort of sustaining life. So that's really brought about a lot of sort of challenges and thinking about how medical ethics, um, has evolved in the UK Then there's the impact of the law. Medical law within the UK has has increased dramatically in the last few decades, and the relationship of law and ethics is quite intertwined with it in the UK So that's really kind of like, you know, that's really reflected. Say, for example, in mental capacity legislation. In terms of placing the patient is an autonomous individual respecting their their their what's a confidentiality and also their ability to consent and refuse treatment. When I talk about you, um, law, these UK law, but I don't know if people are familiar, but the UK is made up of four nations England, Wales, Scotland and Northern Ireland, and there is overarching medical law which reflects elements of medical ethics, which is UK wide, but we're increasingly seeing a separation of approaches. Um, England and Wales legislation tends to be quite grouped together, but we are seeing different approaches saying mental capacity areas around abortion. Um, so I would say Scotland and with Northern Ireland. So there's an impact of the law for UK wide, but also in the devolved nations, Um, that is, that has grown significantly in the last few decades. The other impact of medical ethics, the impact of high profile inquiries. We've had a number of inquiries over recent few decades that have really may just shine a light on practices and and given us quite a lot of public discussion about what was the right thing to do or not the right thing to do. So, for example, one high profile inquiry a few decades ago was the order Hey inquiry, and it was about where what it was. It was discovered that when when the police Morton's were being perf formed, that some tissues and some organs being retained afterwards and research has been conducted, and there was an inquiry about practices at the time, and certainly from stemming from that There's a lot more emphasis where there is emphasis within legislation around consent about what happened to those tissues and organs afterwards. So we've had quite a few public, large public inquiry. You have a large public inquiry at the moment on the covid the Covid inquiry, where there's probably gonna be deliberations for quite a few years about what was the right thing and wrong thing to have done at the time. Some reflective things, maybe some more practical elements to it as well. Um, but we've had quite a few public inquiries, which is really sort of developed are thinking of medical ethics in the UK The other element is reorganization of medicine and multidisciplinary approach. So whereas medicine in the UK was very doctor led a few decades ago, it's far more multidisciplinary in its approach. So who was traditionally say that the key decision maker that has evolved and changed over years? So it's far more disciplinary into respecting of different sort of skills and talents and perspectives that people bring to to think about ethical issues and there's also changing societal values and expectations. And that's reflected, I think, particularly on this issue of autonomy patient autonomy patient's have different expectations than they did a few decades ago. And that's really reflected in the way that we think about medical ethics in the UK. Has anyone anyone got any questions on on those particular points? Okay. Oh, okay. Assad? Yes. How did the Brexit affected the affected the issue of the ethics? Uh, change it. It changes policy while from the European standards. Or it had it own, like the, uh, like the England and the fields. Okay, we're going. We're going through quite a really interesting question. Um, I can't give you a definite answer. We're going through a quite period of transition at the moment. So particularly if we look at, for example, our data laws. Where there's there's a big review, we've also just, um over the last few months, it's coming. It's gone. But I think it's going to come back again. A review of the Bill of Rights in the UK. So I think we're in very sock turbulent time at the moment in terms of knowing what What's going to change? Um, I think certainly in terms of, say, medical ethics and practice, there is an expectation that things will probably stay relatively the same in terms of medical ethics. Um, but we are very monitoring very closely how we disentangle ourselves, um, from Europe and whether that impact on our statute and regulation and professional practice I in terms of core medical ethics, I don't see it probably changing significantly. Um, I think probably the sort of values and interests and emphasis and what what's important on dissimilar? I mean, culturally, I think that they're there. There are similar for expectations in terms of, say, privacy, for example, in terms of decision making. So I don't see in terms of core principles, they're being a significant change. But I think some of the detail, um, around it. And I think some of the detail in terms of having debates about, say, for example, things like data and that tension sometimes between individual interests and public interest. I think we might have to sort of revisit some of those Discussion's okay, there's another question here. Medical council usually regulation for doctors whose regulation these medical regulatory bodies so they are generally arm's length bodies. Um and so um, it is there a particular aspects of this question that you're interested in, so just okay, I'll wait for a minute there as a Does that answer your question in terms of Brexit it. Well, it basically we're in a period of transition at the moment. Fantastic. Okay. And so in armored. I don't know if that addresses the medical council regulation for doctors who's regulating these medical medical charity bodies. So if you're talking, you're talking about in terms of, say, transparency and their decision making, Yes. So, um I mean, the General Medical Council, for example, is a is a public body. So sometimes the way that things are overseen, um, might be through judicial review. So in the UK, any public body can has the potential to be judicially reviewed to the decisions that they are making can be taken to court to an analyze, for example, how a decision was made. Um, And that and I think certainly sort of other public bodies within the UK are always quite conscious. The decisions that they have to make make our, um from withstand scrutiny and have the potential to be judicially reviewed. Um, does that answer your question in part? Okay, well, we can always revisit that. If if if need be. So, um, how things have impacted the development of medical ethics in the UK As a result of all of these things over the years, there's there's a huge amount of legal professional guidance to assist doctors in managing many of the ethical dilemmas in front of them. Um, and this this slide illustrates just a number of the organizations, and I don't want you to see something. Is that this is overwhelming. How many different? There's so much guidance that this potential needs to be taken account. They generally felt the core values, Um, but maybe particularly, apply two particular scenarios. So I've mentioned the General Medical Council, which is quite different to the BMA. And I know in some countries the function of the BMA and G M C would be within the same organization. The General Medical Council is the regulator. They set the professional standards and whereas say, for example, B m A guidance well that will reflect GM, see, and also sort of medical law is more advisory on on in the areas where those aspects aren't picked up by law or regulation, G. M. C sets out professional standards that doctors are expected to follow, and within their guidance they have things that doctors should do, and they have things that doctors must do and a serious failure to comply with. G. M C standards, professional standards and ethics potentially puts doctor's registration at risk. So registration to practice within the UK G. M C guidance in terms of ethics tends to be quite how high level, principled. And so, for example, their main publication that goes to all this is called good medical practice. Um, and this slide just illustrates a very top level, even with good medical practice. Outline the expectations and it's around the expectations in terms of, say, knowledge, skills and performance. So it's about being competent to do what you're doing. It's about safety and quality, communication, partnership and teamwork and maintaining trust. If you're interested in working in the UK if nothing else, I would read good medical practice. What it does is it sets very much the spirit in tension in terms of how the doctor patient relationship should be approached. So it's very much about respect for the individual in front of you. It's about not jeopardizing the public trust in doctors to have their interests hard. It's about being honest. It's about working with integrity. It's about working with safety. It's about, for example, if there are concerns about patient safety, it's about obligations to to act on those concerns. So it's about putting the patient first and foremost, uh, the center of what you do and your actions within your clinical practice. So that's simply also we have royal colleges in the UK So we have the Royal College of General Practitioners, the Royal College of Obstetricians and Gynecologists, Royal College of Psychiatrists, lots of specialty specific royal colleges that also will lay out more specific guidelines and outlined perhaps some of the ethical scenarios that those that particular specialty will encounter and how those doctors should should approach these issues. Also, the b m A. As I've outlined before, we provide a lot of ethics advice and guidance and also individual advice to doctors the statutory guidance. So that's we have a a statute and common law in the UK that that sets out medical law in terms of how it should practice, and there is some statutory guidance. So, for example, we have statutory guidance on one of the others I cover, which is female genital mutilation, which sets out guidance in terms of say, for example, mandatory reporting of F G. M. Um, and so on. We also had Government Health Department to set out some sort of ethical guidance or touch on ethical guidance within with within broader, uh, um, guidance on particular issues. And we have UK government guidance. But also, as I've talked about before, devolved nations. So, um, Wales, Northern Ireland, Scotland's devolved nations. There's also defense bodies in the UK so, um, doctors can also can also, um, being all members of defense bodies, which are are legal and or provide legal. Um um support for doctors. Um, they're not about employment issues, but the British Medical Association deals with sort of employment issues, but defense bodies deal with. If it's, for example, there's a clinical negligence case. So doctors, um, defense bodies do provide also some guidance sorts of medical or medical ethics issues. Also, we find that some of our doctors also can seek advice. On a more practical level, there is some some guidance that will reflect probably the big organizations guidance. There's local ethics, support and guidance as well, there's Clinical Ethics Committee, which is a bit more sort of sporadic that they can offer clinical ethics committee guidance within particular settings. There's also research ethics committees, so there's a ride range of bodies that generally the guidance will all time together. They will be withdrawing from reflecting on the same G M C standards and the same medical law. Um, but there's a There's a huge number of places where support and guidance can be found for for doctors in the UK So is there any questions? I'm very conscious that that was quite UK specific. So if there are any questions on those particular points, do you want to put your hand up or put something in the comment box? Uh, so what is an ethical issue? Um, ethical issues engage concepts in crest values, fairness, rights and autonomy. Um, and obviously I I work. I've worked in med medical ethics. I find it very fascinating. But even if if you're not sort of interested in the ethics of itself, there's an interest, particularly in practice in the UK, of being aware of of current sort of thinking on ethics because often, um, within the UK anyway, Difficulties and complaints come around as as a result of some sort of ethical breaches. For example, breaching confidentiality or not respecting autonomy, enough or not respecting a patient to make choices for themselves. So there's there's obviously, I think, moral obligation to be aware of medical ethics in the UK But there's also within sort of clinical practice. There's there's a it's highly advisable to be engaged and have a level of an awareness because of difficulties, complaints. And so when you're addressing ethical dilemmas, I sort of took touched on earlier. Doctors need to be read the log EMC guidelines and good practice guidelines. So this is a word cloud. This is what are the common ethical? Okay, fantastic amad you, you You brought some to the next slide. So what are the common ethical dilemmas? So this word cloud is drawn from this is pre pandemic. I think during the pandemic, we've had different ethical challenges that have come up different sort of emphasis on and chat. You know, uh, dilemmas that are members have faced this workout is based on the kind of inquiries that we've got into advisory service and which runs into thousands and also looking at the guidance that we have in our website. What what guidance has been, um, mainly access and that runs into the tens of thousands. So we make an assessment about what are the key issues. We also run a quarterly survey. We did pre pandemic asking our members or in our quarterly survey, what are the big issues for at the moment? What are you finding at the big ethical dilemmas? What are the things that we haven't got guidance on? That you need guidance on for the future? So the really the common ethical dilemmas are around confidentiality and consent. Without doubt, the biggest issues that come to us in terms of and we in the UK there is there is constantly a challenge to try and access health data. And certainly BMA has taken quite a key role in always advocating to protect health data. Because we, you know, there there's the respecting, the patient's and the confidentiality. There's also in terms of, say, any secondary uses where that be anonymized economize in terms of having good Epiduo minal tool data actually want patient's to trust that their, you know their see secrets are respected and protected within the health service. But there's often challenges. Say, for example, the police force very say, for example, employers, same insurance companies. There's there's, um Say, for example, the Home office in the UK There's often challenges where, you know people would like to have access to this data. So one of the areas that we do a lot of lobbying work on, Um and we do a lot in terms of advising our members or doctors is on confidentiality, maybe, where they've been asked to disclose information. But also there's challenges that more difficult to unpick. Sometimes things like genetic information. Whether you can share certain information, other family members, um, as as Children that they're emerging autonomy comes out. At what point do um, you say, respect to a child privacy or request for privacy if they're, you know, if they're example safeguarding concerns or a parent wants to have access to that information. So confidentiality is definitely one of the most common ethical dilemmas consent as well who can consent to certain treatments who can refuse certain treatments? Um, and as I sort of mentioned a few times before, autonomy is key in in terms of how medical ethics is developed now. So say, if you look at something like consent, um, autonomy is so well respected. If someone has capacity and there's a presumption of capacity to make decisions within UK, with adults under eighteens, there's an emerging presumption. There's a presumption generally over 16 under that if someone has Gillick competence, they can make decisions. But it's about respecting that autonomy. And I think sometimes particularly some of our members and some of the inquiries we get it can be particularly challenging if it's felt that the decision is irrational or unreasonable. But if we respect autonomy and we don't question someone's capacity, people have a right to make what we might consider unreasonable or rational decisions. So those really are the two key issues. We increasingly, in terms of ethical dilemmas, getting, uh, I think sort of more focus and things like we, you know, we have a national health service, but in the there's certainly been a change. I'd say in the last 10 years there's always been a private health service as well, but it's about the ethical, um, the conflicts of interest and whether patient's can go from a national health service to private healthcare. Um, whether within an NHS so a state funded health service if the service isn't available? Can a doctor, for example, talk about what options are available privately, particularly if they might have a financial interest in it? So those are probably, um, not UK specifically unique. But I think maybe I don't know if that's the that's common elsewhere. If there's a show of hands, is that that come up in other countries as well? This relationship between the state and private healthcare maybe less so. But it's certainly an evolving development within the UK is private practice is becoming more prevalent. And that's, uh, that's a particular issue. As we've come out of the pandemic. That certainly may be. Some of those tensions and conflicts of interests are coming to the floor. Um, so also within here. I mean, there's things are personal beliefs as well. Um, what doctors can conscientiously object to the doctor patient relationship? It's about having respect and having professional boundaries. And doctor, you know, patient's being able to trust doctors. And I guess the kind of classic kind of ethical issues that in terms of inquiries we don't actually get a huge number. But that might be because many of these things are more settled in terms of legislation within the UK So, for example, things like abortion, end of life care, withdrawing treatment or physician assisted dying. Um, we don't get so many individual inquiries, but they do come up as as big so wider ethical debates. So, for example, I am leader on on the BMS work on the sexual reproductive health care, and we're currently lobbying on buffer zones outside abortion services. So we do get some anti abortion protesters outside abortion services, and we've been campaigning for quite a few years, along with the Royal College of Obstetricians and Gynecologists and the Faculty of Sexual Reproductive Health Care to have 100 and 50 m owns outside these services, where people accessing them and the staff who provide the services service aren't targeted and and approached by anti abortion activists. Um, so I don't Is there any other, uh, issues within that work out that people would like a little bit more information about that are interested in put your hand up or pop in the chat box, Whatever's whatever works for you okay? I'm just checking the time. Yeah. Okay, So I've talked about philosophical approach is and I've talked about the loss of legal and professional guidance in terms of method ethics in the UK we in the BMA we tend to suggest a certain approach to approaching an ethical dilemma, and ethical dilemmas can come up all the time. And I think one of the things that has changed more recently it's not. It's not necessarily, uh, right answer to things always. But there's definitely been a lot more emphasis saying some of the court cases that we've seen more recently about this might not be a right answer or wrong answer. Um, that's the nature of some ethical dilemmas, but it's about how doctors approach those issues and rationalize and break it down and think about it and justify the decision that they made. And people will may come to different conclusions, but if they can, they can illustrate that they've actually given the sort of thought to to to the dilemma that's required. Um, that's that's, um, often what's primarily needed in a particular scenario, and there's not necessarily a an an answer to every dilemma. So one of the when we talk about ethical dilemmas and how the doctor might want to approach and we break it down. So the first thing is to recognize that situations raise ethical dilemmas. Occasionally, we do get calls in from doctors where they hadn't realized it raised an issue. Um, and that you know. So it's having it's trying to. We're trying to promote an awareness that particular, say, rights, interest values might be engaged. So it's It's recognizing that situation, um, and that people think differently about things and that it might raise particular attention. So it's recognizing that there is an ethical dilemma. Then it's breaking it down into the component part and sometimes ethical dilemmas. It could be multi faceted. What the issues are raised. There might be confidentiality issues that might be consent issues might be tensions between public interest in, um, individual interests. So it's trying to unpick us in a situation and work out what are the different component parts, so that then you can start giving them, uh, different thoughts, um, and rationalize why you're going to come to a certain decision. Sometimes additional information is needed, including the patient's view and the patient's view is really important within the UK practice. What is what the patient's thoughts, feelings and views on a particular situation and what the outcome might be and what the decision, what decision should be made. It's not to say that it would necessarily be determinative, but patient's view is really important in terms of informing how that decision is made, then it's about identifying the relevant legal and professional guidance. So, for example, if you recognize that situation raises an ethical dilemma such as consent and someone lacks mental capacity, um, that's breaking it down into two consent. And does the person have capacity to make that patient's views? Even someone lacks capacity. You would still seek their view if it will inform that decision and then in terms of identifying relevant legal and professional guidance with, there's a huge amount of, um, there's a mental capacity act that applies in England that you would look at to see how you might go about making decisions and what the parameters of making that decision. So is the issue resolved? Sometimes things are relatively straightforward to say, for example, something like mental capacity. There might be a very clear answer in terms of what you should or shouldn't do. Um, and it's that thing. So if the issue resolved, yes, then it's without being able to justify the decision of a sound argument. So even actually within guidelines, I think the laws felt more recently in terms of. It's not just blindly following what say the law was. It's about applying some sort of rationale and thinking to to a situation. And so sometimes even within guidelines, there may be occasions when someone airs away from what the guidelines says, but it's about being able to justify and rationalize that decision. If the issue is not resolved, subject to more critical analysis, maybe get advice from elsewhere. For example, like organizations like GM CBM, a defense bodies locally, clinical ethics committees there's a whole range of places that doctors can get advice in the UK and if if, um, it's an irresolvable irresolvable conflict, the law is unclear. It may be necessary to seek a court declaration and one of things we encourage, particularly on on some of the more sensitive decisions say, for example, something like where there's a tension around with withdrawal of life sustaining treatment from Children where maybe the clinical teams. That is odds with what the parents think in terms of what's in the best interests of the child. We sometimes say, Actually, it's not. It's not a failure to have to go to court. Sometimes there are particular situations where it a court declaration is required, Um, to sort of unravel and ensure that everyone has had, hasn't had the opportunity to have their voices heard, but also that there isn't necessarily always a clear answer. So it's not always seen as a failure that something ends up in court. Sometimes it's necessary. So any questions on that particular slide So in the countries that your base at the moment is that Gen. Would the would that time with how you would approach an ethical dilemma where you're based at the moment? Assad. Yes, you said regarding the issue, of course, whether sometimes we have to take a wait for the orders of the quote to do any specific treatment or something. But if the condition is very severe and some treatments would require, like the coat, the court's orders wouldn't be possible that we go ahead with the treatment rather than just to wait, if they're waiting, would cause more problems. So I mean I mean, as with a lot of things, it is very situational, specific and do and depend on the individual circumstances, particularly in some scenarios where it's it's life sustaining and there is an element of doubt. The presumption would be to do whatever is necessary in that period of time to provide life sustaining treatment. The emphasis is still there. Unless there was something like so if you actually this would be should be relatively clear so you can have advanced decisions refusing treatment within the UK and if it meets the criteria that you're satisfied that that it's a, um you could you can rely on that, that the process and the way it's documented is correct. And it's valid in advance that someone can make an advanced decision refusing treatment, even if it would save their life, and you would have to respect that. But if there was, say, elements of doubt or there there wasn't wasn't an advanced decision refusing treatment or there is a question mark over it, The presumption would be, um, to preserve life, but certainly within the UK course all decisions from court's can be in particular scenarios, readily or not readily, but they can be obtained within emergency situations, so declarations can be sought over the phone. And it's not it's not. I mean, I'm not saying it's common, but it does happen within the UK that say, for example, things like, um, something that there's some recent examples. So emergency cesarean sections where people have refused them or decisions around life sustaining treatment and sort of older Children, say 17 year olds, Um, you court's can be approached. An emergency orders be sought. Um, that is possible. They're all very situational e specific. But if if a doctor were to find him or herself in a situation where there's an emergency, there's a doubt, Um, and those that kind of support and advice can be sought. Then action needs to be taken. That's based on the presumption of saving life. But there are you know, um, apart from that, if there's any time, actually, emergency court declarations can be thought sometimes as a does that answer your question? Perfect. Are there any okay, Right, Right. I'm gonna just It looks like there's another. There is one question in the chat. Okay, What are the common examples that irresolvable conflict or law is unclear So I can talk about Some might say that the law is clear for some of these some, um, but it raises particular attention. So if I think about some of the cases that we've recently seen and I'm talking in the last three years we've had, for example, quite a few very high profile cases around, um, withdrawal of life sustaining treatment from Children. Um, and there's been a lot of the media media. So there's a child Charlie Gard. Um, Alfie Evans. Um and so this is where there's attention. Where, for example, um, doctors believe that it's not the best interest for for these young Children to receive certain treatments, and they're looking withdrawal treatment and that the parents who have um disagreed with that approach. So we've had some. Quite. We've had quite a few high profile cases. There's quite a lot around Children at the moment. Um, other irresolvable conflict with, I mean again with Children. There's been quite a lot of discussion and debate around, um say, for example, produce of puberty blockers for adolescents who have gender dysphoria. There's been a lot of debate around that, Um, we do have cases around assisted dying, for example, where patient's want to go overseas to have a sister dying? Um, there's often sort of tensions around data and confidentiality. Um, we're talking probably sort of bigger sort of judicial review cases, Um, so it result of the conflict. I I I think probably primarily around Children, um, and also, for example, where parents disagree. We've had a few cases, for example, where um immunization and parents have disagreed about whether a charge be immunized. So I think to an extent, those cases there's been enough through the court's now that maybe things are a little bit clearer. Okay, sorry. I was just looking at the chat there again, Um, so it's whether it's the law is unclear. I think some of these cases they are so sensitive that they can't be resolved locally. There's there's there's been, um, certainly pushed in the last few years, and there's been some approaches within Parliament as well, So amendments to bills, but also private members bills themselves to bring in, um, less adversarial way of dealing with some of these more sensitive irresolvable conflicts around Children and parents and clinical teams. So looking at things like mediation or looking at setting up sort of better established more, um, uniform Clinical Ethics Committee to to to try and some take the heat out some of these debates one of things we have seen also more recently, is getting second opinions. But so, getting second opinions from other countries where approaches to say, for example, joy treatment when someone lacks capacity or a child, um um is the end of life. There's been this look to get second opinions and different clinical approaches from other countries. So it so I mean, it's what it's that I mean. That's one of the things that I think makes the ethics is interesting and talk touched on earlier about how it's evolved about societal values and expectations. And I think just as we think things have resolved, we've got a very clear answer about what should or shouldn't happen or how things should be approached. Um, it's constantly evolving. Um, so how do we approach D in our case, in case we have no indication that the patient is signed or do not resuscitate. So we have Um oh, okay. As it is, this about the no. I have something related to a d n A. But this is not my question. I have some other questions. Okay. Do you want me to talk about D N A? Or do you want to ask you a question? Now, what would be best? Uh, you go ahead first. I'll ask my question afterwards. Great. Um, so if a patient hasn't, there's there's, um I can I can put it in this chat. Actually, there's a whole national guidance on how CPR decisions are made. And that's joint guidance between the British Medical Association, Royal College of Nursing and the Resuscitation Council. And that looks at how decisions should be made. And it would depend on a number of factors. It would depend on whether it's it's likely to be clinically successful. Well, um, what the the views of the patient are in terms of d n a c p. R. So if someone hasn't indicated they don't want CPR, it will look. It will be based on individual factors, and it's very much the emphasis and respecting autonomy about transparency of decision making. So I think we certainly had cases. Um, some years ago, where people were surprised because clinicians have decided that it would be clinically unsuccessful would just put D n a C P R notices on people's records and then then where they would see those and be quite horrified that there's been no discussion or they have been told about them. So in terms of if a patient hasn't very actively and gone through and it, you know, it's a it's a it's a very formal process in terms of having an advanced decision, refusing treatment. So if they haven't gone through that it, then is a question about will it be clinically successful? We very much promote trying to have these discussion's before someone hits a critical point, and I guess that goes back to your point as that. There's been a lot more emphasis in the last few years about advanced decision making and trying to establish when people are not in critical, um, or acute phases of their illness. If something might happen, it's trying to have those discussions well ahead before you in a very acute period to think about what the patient might want or might not want. So for something like CPR. It's about emphasizing that CPR is not. It's not like on the TV, where you know the 10 minutes later someone's having a cup of tea. It's about having a very open and honest disk discussion about the clinical, Um uh, picture and the likelihood of success and also what the patient's views and wishes are in terms of. We know if you're exploring it and saying, Well, if we were to attempt this, it is likely you will have a period and I to you afterwards, we might not be given your clinical makeup. It might be that we can't get you for ventilator. How do you feel? A about that? So it's having. It's very much this patient, doctor discursive relationship of shared decision making. So if someone has signed, uh, do not resuscitate order, advanced decision and it's valid and it's in the right correct form, you have to you have to respect that. The only time I would say that you that there are some elements of doubt is if someone, um and actually, if you if you're interested in this particular issue, do you go, it'll be on our website will be on the RCN's website view on the Resuscitation Council Web website as well. There is standard a national guidance on this that goes through all the lots of different scenarios. Um and yeah, if I have time, I'll pop it on the I'll pop it on the chat at the end of this, if someone just happens to check on a bit of food, if someone's got an advanced decision refusing treatment, it's not to say something like that. You can't It's easily resolve a ble. That's not what it's intended to capture. Um, so Jeb, does that answer your question or view? Is there? Do you want me to to sort of focus on any other elements of it? I mean, the emphasis is very, very much on shared decision making transparency. Um, but if if if, for example, a clinical assessment has made that CPR will not be successful, there is not an obligation to perform it. But what there is, it's about having an open discussion and about it, and I've certainly So, um, I certainly saw some junior doctors a few years ago in In court's who had challenged there was a judicial review actually of of the UK government about the fact that they didn't have national guidance on CPR and it was left to sort of b m a R C N resuscitation Council. They're national guidance, and someone did judicially review because they hadn't been their family member. Hadn't been told that they had d n a C p R. And what did come very apparent from watching the case and watching the cross examination of the doctors is, and I would say this at with a lot of ethical issues. Communication is incredibly important throughout this. It's about communicating with patients', but and the fact that those closer than what's what's going on, what's and it's it's making it relatable and understanding that the language. So what came quite evident in in the particular case around CPR? Guidance is, I think, some some of those close to the patient patient not understanding the different systems, they said. Well, it was just that it was just the lungs that there are problems, so why would it affect the heart and and sort of gauging patient? And those close them their understanding of how what they think is happening and explaining to them for example, that you know Well, actually, if you have a problem with your lungs, that might affect your cardiac output and how you know body systems are interrelated. Um, so, as always, I would always say some My key message always are communicating good communication is incredibly important. And also being able to justify your decisions and document why you've made the decision that you have. Um, and I think that certainly when we look at, say, fitness for practice cases where doctors have been taken G m c. And they do have an ethical components saved to do with confidentiality consent. I think some of those issues might have been resolved, that they've been good communication discussion about what was happening, and views were sought. And there was There was there was a discussion. So it was clear that there was a shared understanding about what? What discussion had taken place and what was going to happen next and why. So as I saw you had your hand up. Is that have you? Yes. Uh, yes, yes, yes, ma'am, The question was regarding the same d n A. And the thing is, uh d n r and a person who is society are two different things where a person who signs or makes a d n a is just saying, Do not resuscitate. But if a person who has signed a d. N A and, uh comes to a hospital for a certain thing like for a disease or a chronic illness and he's being treated while being treated and he's he or she suddenly goes in some kind of shock or some complication which has arises suddenly due to the illness. And in this case, I think doctors will, uh, save or treat the patient because D. N A is do not resist ate it doesn't mean do not treat. Uh, the difference between the d. N A. And the suicidal is I think this suicidal person is actively trying to end the life. And uh, d N A is trying to do it in a passive man, I guess. I mean, that's one of one of the things that we really emphasize, and I will I will paste the link onto it at the end. Um, because, uh, if a person is signing Deanna, how we're not supposed to like think that why this person is signing Adiana wouldn't be person himself, Him or herself would be treated as the same as the societal one because we treat societal thoughts or societal activities as a psychological issue. But why not even treat the Deana as well? Whether the best person, what they would ask the basic question why they don't want to be resuscitated while dying. And so when I talk about advanced decisions refusing treatment, there's there's a whole formal process to go through under mental capacity legislation, which is about making sure that someone is of sound mind and has capacity to make that choice. And I think I guess what you're touching on the point is, and I think it it can be a really challenge. I think maybe, uh, there's an acceptance of the approach more now because it's probably it's discussed. But people can if they are. If they have, there's a presumption capacity and it might be someone suicidal. You might. It might raise questions about your concerns about whether they have capacity decisions, but if they have capacity, they have the capacity to make decisions that you might not make yourself or you might think it's unreasonable and irrational and something, for example, like I do not resuscitate. They might have had quite lengthy discussion's with their GP, for example, or they're leading clinician who's treating their particular disorder. It might be the after those discussion's, um, because of their their the clinical presentation that they think. Do you know what I don't I don't want that invasive treatment. This is a choice I've made. It's rational. It's documented through this formal process where it's it's it's part of that process. It's that they have had the capacity to make that decision, that that decision, if it's documented in that valid way, should be respected. It's interesting when you talk about different things happening in procedures. One of the things we also talked about the National Guard, uh, the national guidelines is someone might have a D n a C p r. Because they you know, um, whatever reasons they've had that discussion and and they think on on on balance, they don't want to be potentially ventilated dependent. But then they might go in for a procedure where their chances of arresting is is, um, greatly increased. And certainly we'll have, say, cases from some sort of say, cardiothoracic surgeons who say, If you've got a d n a c p r in place, I'm not going to take you in to do this particular procedure because it's too high risk for me to do that. So it might be that someone temporarily suspends a d n a c p r. And it's one of the scenarios that we do cover in that that national guidance Um, that's had it. I mean, we've had national guidance for I think it's a couple of decades now and it's on. I think it's like Foot third or fourth edition, which particularly addresses those kind of issues, because medics were coming to us and saying, Well, we're facing this scenario. What do we do? I have a patient I wanted, you know, and they do a stent and they've got D N A C P R case. I'm not happy to do that. And so it's I think that's I guess, where I say our guidance, for example, difference from, say, G M C, which is not far more sort of top level and set, I think, sets the high level principles in terms of how you should approach patient's. But then you can find some quite specific guidance, say, on the CPR from US. Royal colleges will have quite, um, a specific guidance set to stop scenarios there particular specialty will face and maybe work through some of those issues. Uh, yes, it does. Uh, the one thing another just came to my mind was what if a person who knows all the discussion's or the arguments when, when Before signing the Vienna that they know what what they need to say or what they what the points they have to make. What if the person signs that d n A. Completes the d n our agreement and after that, use the d n A as an excuse. The person is societal, but she uses the d n r as an excuse to end his or her life. Like signed the d n A. The next day, he tries to kill him like Does this This, uh, this invalidates the d n A. Or do what What could be done in this situation if someone has gone through the correct process and at that particular point made the d n R CPR that then at that time it were competent and how it I appreciate. It's not always comfortable, but that but that when the if assuming they had capacity, when they made that decision and it's valid and it's in the correct format, it would have to be respected. Um, I mean, I have had scenarios where not not necessarily CPR, but other situations where a patient has refused something and the medics have basically waited till they've lacked capacity to make that decision. And and I think this is This is where it's like not saying it's necessarily comfortable. Um, and if there was any uncertainty, I would certainly get second opinion or get some advice about what to do, particularly. I mean, if there's any question about capacity, that rate, you know, you would, you would act in the best interest if you're concerned about capacity. But it's about people being able to make decisions that you wouldn't necessarily make yourself. Um, and they they are some of the high capacity. They can refuse treatment, um, and make those life choices. And this is where I think, you know, respecting autonomy. Um, can I think, you know, present some challenges for people working clinically who just want to do everything, possibly they can to sort of clinically help someone. Uh, yes, it's not a neat answer for you. It's a bit confusing but like to say respecting the autonomy but actively trying to kill. But after a d. N a is a bit harsh to say. The other thing where that came to my mind is like if it's just a a person like suddenly has a cardiac arrest or in a certain state where a doctor who might be in a proximity saved a person, but the CPR took its to like was prolonged and happens to be like the person happened to be in a vegetative state for the rest of your life. If does the, uh, factor of awareness comes in, like if if nobody knew that the person who is being resuscitated but right now is in a vegetative state signed or didn't, uh, signed and nobody knew that the person has signed a D n will that lead to the problem to the person who has who happens to be a doctor to save the life even though the person is a complete vegetative state and we'll never speak again will be on ventilator for the rest of the life. So I just think it looks like some, um, in the chat. I think it's I don't It's Hannah or, um Shannon of posted up some things about men's capacity. What the men's capacity act binds that individual to do you can only if you so you talk about. If you didn't know that there was a d n a C P R. There was no expectation for whoever whether it be a paramedic, a nurse or a doctor, they have to act within an acute situation. So if they don't know there was a DNA CPR, or they just have to deal with what they're faced with at that time and make an assessment based on what they think is in the best interest. That's what the mental capacity act obliges is them to do so the right to treat triumphs the d N A. Unless it has been known that the person doesn't want to be treated. Or is it it it It's yeah, if it's not known, it's not known or if there's any doubt about it, So it's not there to sort of beat clinicians up with afterwards. if they go well, actually, did you not know that this was in place? And you should have acted differently. This person didn't want this, so it's, you know, and I think this is why we've There's been a lot of emphasis more recently about trying to have advanced decisions about what people want and do not want and to make sure that it's documented. And people who might be, you know, come across this individual and have to face them, sort of make a decision about whether to act or not act. Have that information. There's a little been a lot more emphasis more recently about ensuring that the patient does have that voice. They do have the autonomy respected, but it's not there to sort of be clinicians up. Should they find themselves in the situation again. What do I do? They might have this if there's any doubt, um and then assessment is made on sort of the best interests of that individual. As you see them in front of you and Heinz, you know, there's always the benefit of hindsight, but you have to act on what you see in front of you. Um uh as long as and this is what I'm talking about, sort of being able to justify and rationalize the decision. It's what your face with in front of you making, um, looking at the benefits and harms of taking a particular course of action and being able to justify the actions that you took at that point in time. And there is generally if there's any doubt, um, or the clinical picture is such that you you you're not sure there will be a presumption and sanctity of life. I mean, paramedics in the UK have, um, some more thoughtless, specific guidelines that they won't start CPR. But we're talking to someone's in rigor mortis order decapitated. So it's not. It's not intended to to, um, to criticize or punish someone for acting in what they believe based on what they're faced with. It at that moment in time is the is the best course of Axion. But as always, it's about trying to be able to sort of rationalize and justify the action was taken. I'm just going to say I think, write a note that you'll get a note on capacity. The M C. Is this mental capacity act sets out a two stage test of capacity. Does the person have an impairment of their mind or brain? Whether is there is a result of an illness or external factors such as alcohol or drug use, to does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions but have capacity to make others. Mental capacity can also fluctuate with time. Someone may lack capacity at one point in time, but may be able to make the same decision a later point in time where appropriate people should be allowed the time to make a decision themselves. The M say says a person is unable to make a decision if they cannot understand the information relevant to the decision. Retain that information. Use a way up way up that information as part of the process of making the decision. Actually, and and this I think there's quite a lot pasted there, so we have quite detailed legislation and mental capacity here. Um, I just add Rebecca, I put quite a few things in the chat. It's Sharon here, Doctor Doctor Sharon Raymond, just in case uh, I don't know if I I haven't turned my camera on, but just to say just so people are clear that capacity is decision and time specific. And of course, it can be fluctuating. So it's, uh, you know, it can be challenging at times, but it's just worth bearing those principles in mind. And I think as, uh uh, the previous question, uh, and previous questions have highlighted what's really key is to have, you know, good handover and share ing of information so that you know, those people that are caring for a person. Healthcare professionals who are caring for a patient, um, in these situations is aware of, you know, their wishes and decisions that have been made based on their wishes and best interest if they don't have capacity. And there's very much. And I mean, Sharon talks about, uh, an emphasis correctly, the sort of the emphasis in terms of fluctuating capacity and enhancing decision making capacity. There's a huge amount emphasis on patient autonomy. So even when someone might present as lacking capacity at a particular point in time, there's very much an emphasis of trying to ensure that uh um, it's enhanced their ability to make decisions for themselves. Their ability to have their respect, autonomy respected is made possible. So, for example, if a patient was tied at the end of the day, But you know, in the morning they're much brighter and they'll be able to sort of way up and understand what's been proposed. You might have those discussions in the morning when they have a an ability to make it. And it is, as Sharon said, a specific decision. So there might be quite, um, decisions that a lot more straightforward that patient's will have the capacity to make. But there may be some more detailed, complicated decisions that they might not. So it's very decisions specific. But the UK very much has approach of. There's a presumption of capacity to make decisions, and if there's any fluctuating or doubt at times, is about really promoting those opportunities so people can make as many decisions about themselves as possible. Is that would you say that was the first summary? Sharon? Yes, it's I mean, it can be very challenging. And I suppose, uh, you know, for that reason where you feel that someone hasn't got capacity, there are formal capacity assessments, their best interest assessments. So, you know, as a as a healthcare professional as a doctor, you, uh, you know, you don't need to be making these decisions alone. And in fact, there are teams and and experts in this field. I said, Does that answer your question? And I will post the seat, as CPR seems to be in particular. So I will post yes, the national guidance on the side. Uh, thank you. I see. Elena. There's a question from you if our own soldier and enemy soldier admitted same times hospital. The same type of severe injury and or emergency is done. They're both need ventilator, which will save their lives. Hospital has only one ventilator available for one patient. There is no transport available to other hospital. Which one do you give ventilator to save? How is your approach? Um, I will say one who came first. The one who came first gets the first treatment. Maybe I think that I mean, it's about being able to justify your decision. I think I mean, that's that's a a very changing scenario. All things being equal, there are different approaches. It's something that's come up, particularly through the covid pandemic. Um, fortunately, the UK we didn't face, um, it didn't come. We we didn't have to flip, sort basically a war zone approach in terms of who gets treatment, who doesn't, but certainly was a lot of thought given to who gets ventilators and all things being equal. And I'm gonna I'm gonna slightly Elena slightly duck out of this, um, query, probably. And I'm gonna put on the side by along with the CPR guidance. We do have specific ethics guidance for for doctors who worked in armed forces. Because this can be a particular challenge about, um, who who gets treatment. But, you know, um, that's slightly ducking out for Elena, but it's not straightforward, and it will be such, you know, it will be very much dependent on the individual circumstances. Um, but I doctors in those situation should, um despite probably being potentially under such a huge amount of pressure, it might be that it will be who Who? There might be some distinctive differences between both that mean that one. Get it over the other. But I will post in the sidebar the ethics guidance that we have for for medics and the armed forces. They just thing. Um So, Fiona, an observation from this discussion Best advice to newly qualified doctor is that you will rarely be expected to make these difficult decisions alone and whenever possible, talk to others at the time and then document how decisions made. Absolutely also worth mentioning public health ethics, which are often relevant to decisions made by doctors and other conditions. Examples. Prior authorization. Rationing of her inequity of access to care, forcible treatment, including, uh, mental health, some infectious defeated, mandatory mandatory vaccination and not small. Also, please think about publication ethics important. If you're thinking of writing an article for publication, that's fantastic, right? So I'm conscious of time. So I'm just gonna and and I will post these two so we'll go into a bit more detail. And I mean, Fiona sort of flagged that there's, I mean, there's a whole range of different elements in terms of rationing as well. GM see has quite a guidance in terms of, say, looking at some management sort of publication ethics as well. There is a huge amount out there In terms of UK. There aren't many issue I would say there aren't many, if any, issues that aren't covered in some way in terms of ethical guidance that's available. And as Fiona said, there's people to talk to if you're newly qualified, Um, talking to sort of registered talking about consultant, you can go to external people to talk to about things. So if there is, there is a dilemma where it's not clear necessarily what the right response is or what to do. There are certainly within the UK there are different places that individuals can go for support. And we're about to just start actually big project about what ethical support there is available for for practicing medics. Um, certainly. When we did a survey, pre pandemic people generally they talked to colleagues. They talked to defense bodies. They would talk to GM, see talk to, to be M A, and people sometimes go to the multiple places and see how the and generally I mean the guidance should chime with each other. But there are There is a lot of support, certainly in the UK in terms of ethical decisions, and, you know, just someone taking you through and having a step step approach to breaking it down thinking about what guidance, what legislation you need to look at. So some of the challenges I think we've touched on that from this really, really interesting discussion and so some of the challenges with ethical dilemmas, who's right and who's wrong. I think I've said before there's sometimes not a right answer. There's sometimes not wrong answer. Um, it's sometimes about the process and about how you thought about an ethical dilemma, and you've clearly given it some thought. You've broken it down. Maybe you've got a second opinion. You talked it through with someone else. So it's not necessarily who is right or who is wrong, although I think sometimes it can feel that way. Um, it's who decides who has the decision making authority. And that's some of the tensions people took that irresolvable conflict. Some of the tension can come come about sometimes within the UK, because it's unclear who is the decision maker, or people think that they are the decision maker on. So, for example, although I've put a lot of emphasis on autonomy, doesn't necessarily mean that patient's are always their thoughts and views are determinative in terms of what happens So sometimes it's about some of the challenges is about who decides and what the perception is in terms of who's deciding. It's also challenged individual relationships. And what about the rest of us? And it's about that tension between individual interests and public interest. And I think Fiona's put in the chat bar talking about things like the same. Mandatory vaccination is also tension in terms of sharing data. So there can be tensions that got in sort of challenges arising from that particular context depends on context. So we've talked about some scenarios. It can be very situational specific. Um, and quite a few times when we talk about cases, um, within in in the ethics team at the B. M. A. It's very much, um, circumstance, circumstance specific. And you will also get a quite a lot of core judgements. Um, uh, that will say, I'm saying this about, say, I know a decision around a child and the treatment they do or don't get, but it's very situational. Be specific. So you cannot extrapolate from this case that that means that in another case with a child that looks fairly similar, that exactly the same will happen. It'll be very dependent on context and what's happening. Um, open to interpretation. And this is why I think it's very important, particularly UK context, to document and rationalize your decisions because it can be open to interpretation. And certainly the cases I've seen, for example, around CPR decisions that I've seen in court's. It's been quite evident when people, when you've seen evidence given from, say, family members or from the clinical team, that there's been a very different interpretation on the scenario. So so again, good communication checking, understanding with each other, checking the understand, you know, if you use a term, Um, I think one of the one of the cross examinations Isil was an anesthetist who used a quite clinical term, and what the family understood that was quite different. So things are open to interpretation and be really mindful and aware of that, um, and test people's understanding, Um, and try and, you know, create that sort of doctor patient partnership in terms of resolving ethical dilemmas, Um, and what the tensions might be, and one the challenge. What to do when to values conflict. And again, we've talked about some of those challenges in terms of irresolvable conflicts. Check. You know, I had some case studies. Um, but I'm very conscious that we've got 10 minutes of time. And actually, I think the first case study, um, slightly touches on what we were talking about before around CPR. So what I'll do, I think first before Jennifer will have time to attempt the case studies, we can have a bit more discussion, Maybe. Um, are there any other questions? Okay, so I'll throw it out. You case study A 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 he doesn't want you to tell the daughter about his illness or treatment. So either on the chat bar or if you want to shout out What? What do you think of the ethical issues? Assad? Uh, the issues regarding the deana and confidentiality. If the patient doesn't want to her daughter his daughter to know that, uh, this he has signed Deana, then he cannot tell the daughter that the about Deanna Rest the treatment should have to be has to be continued because it's Deanna. Now the DNT do not treat so we can treat for the lung cancer if the complication arises while such as the arrest and I think in that condition, let it let the goals happen. Any other thoughts and comments or questions? And then how do you the name, uh, capacity is valid yet. So if you're if you've got any clear about capacity, um certainly sort of explore those. Maybe explore. Has he got an actual formal, um, advanced decision refusing resuscitation, maybe explore why he doesn't want to be resuscitated? It might be that there's some misgivings or misunderstandings about what that means and at BMA Toolkit or M c A. Um and actually as that you you raise a really important issue. That's one of the key points that comes out in the CPR. Guidance do not resuscitate. It's just about resuscitation. It's not about everything else, and I think there's certainly in some areas there's a different tool that's used rather than in the UK We have these these in some cases of red forms that have, you know, do not resuscitate on. And there's a different approach in some some areas in the UK saying, Actually, it's not just about this. This is about lots of other treatment decisions as well. And we shouldn't have so much emphasis on that because, you know, I think there's a There's a feeling among some clinicians that having that on people's records sometimes means that the other elements of their care are are not given as much as sort of priorities. They should be so as if that's a really that's a really good point. And it's something that we try and really emphasize is Do not Do not Resuscitate is just one element. It doesn't mean you don't give any other care. So it talks about. I think people have touched on confidentiality. Yeah, if if people um making a presumption he has capacity. He has the right to have his confidentiality respected, and and it's not to say it's not, it won't be a difficult scenario to deal with, but it's it's just explaining to the door. So, like, I have a duty confidentiality, and I can tell you whatever whatever your father's happy for me to talk about, but I have, You know, I do have a duty confidentiality. If there are elements that I can or cannot talk talk to you about. I'm just looking at a time. So maybe if we Casey So your supervisor has asked you to get written consent from a patient For a surgical procedure of about which you have only limited knowledge, you're aware of the very small risk of nerve damage which could lead to partial paralysis. Should you tell the patient if you know that telling them will mean they declined the procedure? What do you think the ethical issues might be in that as a, uh, I think the issue is about regarding information. If I myself don't know what are the complications or the or the bad effects, good ill effects could have happened. I think we shouldn't know this. I I think the patient has the full right to know everything. Even the side effects or everything has confident. That's all I have to say any other thoughts. So again, this is something that we we have we have come up had had come up in the past and there was standalone guidance. Uh, if it, I think it's still available. Where we did have Gina Doxy is who are being asked to consent to treatments that they didn't know it and think about and how you can you consent someone if you don't understand the procedure, to explain it and for consent to be valid in the UK has to be informed. It has to be voluntary. So how can you be informed if the person who's taking your consent can't doesn't know all of the risks? And this thing about very small risk of nerve damage is about Is it relevant for the procedure to give for that person to give consent to it? Um, and it's about having again communication, having that discussion about why that risk and how that risk being mitigated and ensuring that the patient is able to make and as an informed decision as possible, are there any So I'm conscious of time, and I'm also conscious that I wanted to put in the sidebar before we end the guidance that I've mentioned. Are there any more general questions anyone would like to ask before we end? I'm just going to quickly put a plea in for as many people as possible to do feedback because I've only got a handful. So far, I have posted the link on the chat. So, um, uh, for those who have been mesmerized by the session and not looked at the chat, please do. And that's completely understandable. Please look at the chat. Now you'll see a link to the feedback form. It doesn't take more than two minutes to fill in. Uh, and we really need your feedback to keep this online medical school going. Thank you so much. Okay. And just on my last side. And they're the generic email addresses and not email addresses. Website address is where you'll find all of our ethics guidance and also the GM see all their ethics guidance. Um, it was it was a pleasure to meet you all. Um, and good luck with the future and everything that it holds and I will post now the the different guidance that I've referred to during the speech. Thank you, Rebecca. I should say, a huge, huge thank you from all of us from Crisis Rescue Foundation, Ukraine Medical School. For all your efforts, the time you've invested it's been absolutely invaluable. And we are on the edge of our seats waiting for the next session. So, um huge. Huge. Thank you. Hopefully there'll be some comments as well in the chat to thank you. Some narrative comments there in the chat. But, uh, if we have the feedback forms, I'm sure that they will reflect how excellent this has been. So thank you so much. Brilliant. Well, thank you. And have have a good, good night. Good day. Wherever you are around the globe and I will pop those, um, links in now. Thank you very much. Take care. Thank you, everyone for those who are still on, uh, we'll stop the recording in a moment and please.