Ethics , Medicine and Law Controversies and Current Issues

1.   “Ethics , Medicine and Law” Controversies and Current Issues Dr. Shiv Pande MBE DL JP FRCGP GMC-Current Associate-F T P Panel Member GMC Treasurer-1999-2003 & Elected Member-1994-2003 Hon. Sr. Lecturer-John Moore University , Liverpool Part time GP since 2003 and past GP in deprived Inner City Area of Liverpool for 29 years , Current Chairman – Mersey Faculty Board –RCGP and Executive Committee Member of National Umbrella body of Hindus- Hindu Council of UK. Part time GP since 2003 and past GP in deprived Inner City Area of Liverpool for 29 years , Current Chairman – Mersey Faculty Board –RCGP and Executive Committee Member of National Umbrella body of Hindus- Hindu Council of UK.

2. Lord Sir David Steel.... Lord Sir David Steel said “World of Medical Ethics had become even more complicated since Era of Abortion Law Legislation”

3. Stake holder groups-just to name a few Patients and their families Researchers Clinicians Professional groups-BMA Educational institutions-Royal Colleges Health Authorities and their Finance departments Regulatory bodies- GMC , Human Fertilisation & Embryology Authority-HFEA Policy Makers

4. Stake holder groups-Contd. Health Care Individuals Ethics bodies Defence bodies- MPS, MDU Public Consumer Groups Public watchdogs Legal profession Media- Press , Radio , TV, electronic groups Politicians of all parties- Government and Opposition Non Medical interest groups Pressure groups

5. Past Medical Controversies..... Bristol Royal Infirmary-1995, poor Cardiac Surgery results. GMC investigated in 1998, Surgeon and CEO erased and another Surgeon Suspended. Ground breaking Inquiry led by Sir Ian Kennedy produced 500 pages and 198 recommendations re. Cardiac Surgery and recommended “public should be able to have access to information about the performance of individual trusts and surgeons” Royal Liverpool Alder Hey Children's Hospital -1999 -Vital organs had been retained with out consent of parents. Professor Dick van Velzen , former Trust pathologist at the centre of the scandal was erased in 2005 by GMC. Inquiry chaired by Michael Redfern QC, was critical about “failure of the Trust adequately to deal with the concerns of parents as they tried to find out the truth”

6. Past Medical Controversies..contd. Richard Neale-Consultant Gynaecologist , from North Yorkshire , who performed botched operations on 34 different patients and operated without consent. Was found Guilty of Serious Professional Misconduct(SPM). A government inquiry revealed failure within the NHS complaints and employment systems. Rodney Ledwood- another Gynaecologist from South Kent Hospital –removed Ovaries without consent.198 claims followed. An independent inquiry criticised management in the NHS for failing to pick up on the concerns of patients and its own staff.

7. Past Medical Controversies...contd. Harold Shipman- Single handed GP in Hyde, Greater Manchester, in 2000 was convicted of 15 Murder Charges , later investigations reported up to 200 cases being involved. Inquiry was set up in 2001- In 2005 , in the Inquiry’s Fifth Report, the Chairman , a High Court Judge, Dame Janet Smith DBE, considered the handling of complaints against general practitioners (GPs), the raising of concerns about GPs, General Medical Council procedures and its proposal for revalidation of doctors. She has made recommendations for change based upon her findings.

8. Past Medical Controversies..Contd. Sally Clarke case (deaths of Christopher and Harry Clarke-1997 and 1998).Sally Clarke, a 34 year old British solicitor, was convicted in 1999 of infanticide and sentenced to life in prison. The case turned on statistics and pathology evidence. Both these points were shown to be spurious. Professor Roy Meadow was regarded as an authority on cot deaths. This work led to ‘Meadows Law’-the loss of one baby to cot death is Tragic , two is Suspicious, and three is Murder. Dr. Alan Williams, local government pathologist had performed post mortems. Later on the testimony of a key prosecution witness was thrown into doubt.Lord Justice Kay,of the Appeals Court described this new evidence as “devastating” and said the Courts had reached decisions”wholly unaware of the important aspect of the evidence adding that Dr.Williams had failed to share information, a competent pathologist ought to have appreciated, needed to be assessed before any conclusion was reached”. Sally Clarke was freed on 30th January 2003

9. Past Medical Controversies..Contd This case raised number of issues regarding the use of Medical evidence in Courts. Council for Registration of Forensic Practioners ,which should be responsible for research , evaluation and peer review on a rolling basis. Special training on role of expert witness , which should be renewed every five years. Sir Alec Jeffreys , Professor of Genetics , discoverer of DNA finger printing , expressed his amazement that the flaws in Professor Roy Meadow’s statistical evidence were ‘not tracked right at the beginning and described as failure not only of experts but also of Courts’.

10. GMC hearing going on Dr. Andrew Wakefield, Professor John Walker Smith Professor Simon Murch of Royal Free Hospital- MMR controversy case hearing going on since beginning of this year Paying children at party for blood sample collection Seriously damaging Public Confidence in MMR MMR linked to Autism and bowel disease Lack of Ethical approvals for studies

11. All leading to........ These series of adverse episodes in which NHS patients have been harmed over the last few years has led ministers - and many clinicians and managers within the service itself - to try to create a more “patient-centred health service”. They want an NHS where patient safety is paramount, doctors' clinical practice is audited to check all are delivering care of a similar standard, and patients have the right to information about their individual doctors and hospitals, allowing them - in theory - to exercise some measure of choice about where and by whom they are treated.

12. Moving to Law and Courts....Flawed Forensic scientific evidence Omagh bombings- August 1998 Jill Dando Murder case-April 1999 Damilola Taylor Murder-November 2000 The above list is by no means exhaustive but for purpose of this presentation has been kept concise.

13. Back ground... The Duty of the Court is to see that Justice is done. Guilty ones should not be allowed to escape on technical points. Justice ‘according to law’ demands proper evidence, By that we mean not merely evidence which might be there and to a considerable extent probably is true , but as the learned trial judge put it “evidence which is so convincing in truth and manifestly reliable that it reaches the standard of proof beyond reasonable doubt” This is the cardinal principle of the criminal law which Lord Lowry LCJ emphasised in his concluding observations in delivering judgement of the Court of Appeal in R v Steenson and others-1986-NIJ B17

14. Forensic Science This is the application of knowledge-scientific , technical or other specialist knowledge to assist Courts. The forensic scientific investigation can prove the existence of a crime or connect to other link crimes and the forensic scientist provides information and expert knowledge to investigators , solicitors , judges and juries helping determine the guilt or the innocence of the accused. Examinations should be complete , accurate test performed ,scientific data interpreted thoroughly and written report presented so as to be easily interpreted by the layman and the evidence given to be complete ,unbiased and truthful.

15. Locard’s Principle “There is no such thing as clean contact between two objects . When two bodies or objects come into contact, they mutually contaminate each other with minute fragments of material”. “The microscopic debris that covers all our clothing and bodies is the mute witness and faithful of all our movements and all encounters”. The principle is named after Dr. Edmund Locard was director of Technical Police Laboratory in Lyon, France in early 1900s

16. Types of Forensic Scientific evidence Four categories according to strength of evidential value 1.Conclusive –e.g. finger prints, mechanical fit 2.Could be conclusive-e.g. tool marks, shoe marks, handwriting, multiple flakes/ fibres. 3.Good e.g. Blood and other fluids , minimum of two paint flakes , three or more fibres from different sources 4.Inconclusive e.g. Plain glass , one single fibre one single paint flake

17. By exclusion “The evidence clears far more people of crime than assist in conviction” so if you can say..... ‘No, this blood stain did not come from that person’, then they are not a suspect any more, says Tony Moffat, Professor of Pharmaceutical analysis at University of London. He continues “ Expert witnesses are making science speak louder than ever”

18. Science vs. Law Sir Alec Jeffreys , Professor of Genetics , University of Leicester and the discoverer of DNA fingerprinting himself admits, there is clash of cultures between science and the law. “ The very concept of what we consider evidence is quite different to what the very same word means in a court of law. Context is everything, an expert witness has the knowledge to help work it out”

19. A word of warning.... Analytical scientist Tiernon Coyle says “Every time you give evidence , you expect your character to be attacked. Your reputation is at stake , it is not a matter for the faint hearted” A flair for public speaking is essential. Self confidence plays a large part too , as lawyers will seek to find a loophole in the opposition’s case poking the forensic scientific or medical evidence and the expert presenting it

20. While Lord Justice Wall says “Nothing to Fear” Meadow v GMC is a very important decision for all expert witnesses but one need not to be concerned. The principle messages are (1) that experts in their reports and evidence should never stray outside the particular areas of their expertise and (2) if you are invited to do so , you should either decline the invitation , or make it very clear to the judge that the area on which you are being invited to comment is not one to which your expertise extends. Refer GMC guidance “Acting as an expert witness”

21. Forty years on........ Still Forty years after the introduction of the Abortion Act , Abortion and Contraception remain the most visible and divisive of ethical issues , but they are by no means the only ones. Fertility treatment , end of life issues , withdrawing life prolonging treatments & signing cremation forms are all hotly debated.

22. Some of current Issues..... Stem Cells Therapy- New era in Medicine-repair human organs and tissues at their most fundamental level , that of the Cell. Power of stem cell to regenerate cells of specific type e.g. Heart ,liver ,muscle is unique and extraordinary. Researchers isolated and cultured embryonic stem cells obtained through destruction of Human embryos. An ethical debate raged over ethics of the research.

23. Current Issues contd. High profile cases involving life and death decisions Dilemma involving treating Siamese Twins Ethics and Genetics Savoir siblings-’made to order sibling’-genetic testing of embryos Home testing device to determine sex of unborn child-esp. Problems , in China and India. Possible Abuse / abortions of female foetuses . Ethical objections of doctors- GMC guidelines

24. Current Issues contd. Gastric binding- Controversial weight loss surgical procedure Ethics of body weight-size zero women- boycott by British Modelling Agency Ethics of clinical trials: India has over taken as No.1 destination for clinical drug trials with $ 2 Billion worth market. Shortage of personals to serve on Ethics committees , lead to compromising safety of patients/ participants . Ethics and vulnerable patients

25. Current Issues contd. Ethics and resource allocation Who should get intensive care bed Ethics and Mental capacity Act-2005 Confidentiality Consent issues Pandemic influenza Ethics and co-payment for treatment Competent patient refusing treatment Governance of New technologies-transformations of Medicine-I.T. And Intellectual Properties (I.P.)

26. List of Current issues contd. Abortion Animal rights Artificial insemination Artificial life Artificial womb Assisted suicide Bio piracy Blood/blood plasma (trade) Body modification Brain-computer interface Chimeras Circumcision Cloning Confidentiality (medical records) Consent Contraception (birth control) Cryonics Eugenics Euthanasia (human, non-human animal) Feeding tube

27. List of Current Issues contd. Gene therapy Genetically modified food Genetically modified organism Genomics Great Ape Project Human cloning Human enhancement Human genetic engineering Pathogenesis Infertility (treatments) Life extension Life support Lobotomy Medical malpractice Medical research Medical torture Moral obligation Nanomedicine Organ donation (fair allocation, class and race biases) Pain management

28. List of Current Issues contd. Parthenogenesis Patients' Bill of Rights Placebo Population control Prescription drugs Procreative beneficence Professional ethics Psychosurgery Recreational drug use Reproductive rights Reprogenetics Sperm and eggs (donation) Spiritual drug use Stem cell research Suicide Surrogacy Tran sexuality Tran humanism Transplant trade

29. Let us not forget the basics.....The four Ethical principles The four bioethical principles have been described as: Autonomy - respect for the individual and their ability to make decisions with regard to their own health and future. Actions that enhance autonomy are thought of as desirable and actions that 'dwarf' an individual and their autonomy are undesirable. Beneficence - actions intended to benefit the patient or others Non-maleficence - actions intended not to harm or bring harm to the patient and others Justice being fair or just to the wider community in terms of the consequences of an action

30. IMCA and Doctors The Mental Capacity Act 2005 established a legal requirement to involve an Independent Mental Capacity Advocate(IMCA) in decisions for people when they lack capacity to make their own decisions about serious medical treatment and have no family or friends to consult with. IMCAs contribute to the best interest decision making process by representing the patient and establishing the patient’s current and previous wishes and preferences.

31. Health and Social Care Act-2008 The Health an social care bill received Royal Assent in July and became the Health and social care Act-2008. The part of the act dedicated to the regulation of health professions falls into two main areas; the establishment of a separate adjudicator for GMC’s fitness to practice hearings (OHPA- Office of the Health Professions Adjudicator) and the introduction of ’Responsible Officers ‘ working for healthcare providers. FTP Cases will be considered by OHPA independently of GMC from 2011.

32. Trust , Assurance and Safety-The Regulation of Health Professionals in the 21st Century An order implementing the first proposals in last years above white paper were debated in Parliament. This order contained provisions including Changes to the Council of GMC-smaller , wholly appointed council of 24 members;12 professionally qualified and 12 lay members. The names of these 24 appointed members have been published just this week

33. Helping hands....... just a few Public Interest Disclosure Act-(PIDA)-1998 . How law helps whistleblowers Public Concern at work-(PCaW) Independent Authority on Public Interest *Institute of Medicine , Law and Bioethics *UK Clinical Ethics Network (ETHOX centre)

34. Helping hands.. contd Controversies in Human Gene Therapy,Genosome Mapping Hospital Medicine.org *Global Ethics .org *Ethics *Medmatrix.org

35. And finally my two personal speeches One Short.............”Thanks” And another Long one..............”Thank you very much” Ends