Intended for healthcare professionals

Rapid response to:

Observations Ethics Man

Once a month, or the secret to raising the status of medical ethics

BMJ 2015; 350 doi: (Published 02 June 2015) Cite this as: BMJ 2015;350:h2883

Rapid Response:

Re: Once a month, or the secret to raising the status of medical ethics

Simon Kenwright (this series of rapid responses 6 June) has commented 'From a clinician’s viewpoint, one might equally think that most decisions about CPR are pretty straightforward but that does not mean by-passing discussion and looking at the problem from the different perspectives of those involved'.

Decisions about CPR are not at all 'straightforward': there is a remarkable amount of confusion centred on the difference between 'CPR could never be successful on clinical grounds' and 'potentially successful CPR is being withheld', and in particular centred on the decision-making and authority for the latter of those two situations. It is even possible to construct a scenario, when it is clearly ethically correct to attempt CPR only if it were absolutely certain to be unsuccessful (ref 1). And many clinicians seem to have a problem with the decision-making authority of attorneys appointed by patients: those attorneys are appointed to make the decisions, not to merely be involved in discussions about the decisions.

But whichever way you go, law or ethics, there is a 'sticky wicket' lurking somewhere. Ethics does not lead to clarity: consider the assisted dying debate, and for example the fact that the pro camp tend to call it assisted suicide whereas the anti camp tend to call it euthanasia. If we instead use law, and return to CPR, the law states that mentally-capable patients can refuse CPR, but it isn't at all clear how mental incapacity can be established if a patient seems lucid. There was a report in The Independent (newspaper), June 24th 2013 (carried on pages 1, 6 and 7), when Sir Mark Hedley, a recently-retired judge, explained that ‘I decided at 10pm that a suicidal man with mental health problems could be allowed to die of an overdose rather than order doctors to pump his stomach ... I decided he had capacity [to refuse treatment], so he died that night. That‘s exactly what he wanted to do... That one never found its way into any report of any sort’. Sir Mark was the out-of-hours Court of Protection judge.

So the law, seems to be clear about patient self-determination, and allows patients to be, to use my phrase, 'self destructive': not an easy thing for clinicians to 'live with'. Medical ethics, seems to be much more concerned with 'good outcomes' but that results in significantly greater ambiguity than is present in a well-drafted law.

Ref 1 Scroll down to my entry at 18/05/14 - 12:14 in the series at:

Competing interests: No competing interests

07 June 2015
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN