Atoms
Reining in—October 2023 The hazel door swung ajar onto the penumbrally-lit corridor, the guttural scream of the hinges piercing the silence. The line of mute, quietly agitated applicants for the post uncomfortably positioned on the hard, lime green plastic chairs, reminiscent of museum pieces of 1960s furnishing, their survival having been secured wholly through their durability, providing the institution with a perfect excuse to ‘save resources for priority areas’. "Please come in, doctor." Grateful for the cursory introduction to the panel (mouth so dry as to glue tongue to palate) the interrogation began. The routine questions about qualities of a good doctor, lessons learnt, communication hurdles with the aplomb (a half smile maybe) hoped for given the advance rote learning. The benign-looking eminence-grise was the last to speak: the theme, research. In truth, the candidate would have acknowledged privately that the few citable case series perhaps weren’t world...
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Defining surgical success
Although Benjamin Franklin opined that death and taxation are the only certainties in this life, for most of us, the need to undergo a surgical procedure at some point is also inevitable. Society consequently has a vested interest in the outcomes of surgery being successful. Through recorded history, just surviving an operative intervention was regarded as near miraculous. Aseptic technique, anaesthesia and understanding of resuscitation made surgery safe, at least for first world populations, but the objective analysis of what surgeons do and the outcome of their activity is a relative novelty in historical terms. While the universal acceptance of Archie Cochrane’s insistence on randomised trials as proof of efficacy has ended many worthless interventions, we are still left with difficult questions when we think about surgery and what defines success and how we measure it. For some conditions, the definition of success would seem self-evident. Five-year disease-free survival...
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Informed non-dissent for brain death testing in children: ethical and legal perspectives
A 14-year-old girl, Hana, is admitted to the paediatric intensive care unit following a sudden collapse at home. She is found to have sustained a severe haemorrhagic stroke. Despite emergency neurosurgical intervention, she deteriorates over several days. Her family have been struggling to accept the possibility that she would not recover. Hana remains unresponsive, has fixed dilated pupils and has developed diabetes insipidus. The clinical team suspect that she is brain dead. Should the family’s consent be sought for brain death testing? (This case is fictitious.) In mid-2022, the high profile case of Archie Battersbee raised a number of ethical and legal questions about the medical care of children suspected to be brain dead, particularly in the setting of family disagreement.1 2 Ultimately in Archie’s case, formal brain death testing was not possible (because he did not meet the preconditions). However, there was a long...
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Don't 'take consent. Provide disclosure
The purpose of consent English courts have confirmed the importance of consent prior to clinical interventions. Accepting that this is an essential prerequisite for lawful treatment, does consent serve any further purpose other than providing information? Children’s doctors have a duty to take reasonable steps to put the patient (or their parent) into a position where they can make an informed decision about whether to subject themselves to the proposed treatment. Court judgements echo the tone of ‘taking consent’ (a phrase so often used by doctors), construed as an acquisition. Lord Donaldson, in Re W [1992] 4 All ER 627, viewed consent as a ‘flak jacket’, thus casting the patient as an adversary; providing the doctor with protection from the accusation of unlawful practice. Neither construction adequately articulates the active provision of information. The notion of acquiring (‘taking’) something from the patient or parent which will protect the...
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