The covert recording of medico-legal consultations.

We describe our misgivings concerning the use of transcripts of covert recordings of medico-legal assessments made by claimants as evidence in actions for compensation for personal injury. These recordings raise issues of lack of trust between the claimant and the medical expert, leading to bias in the consultation that is hidden from the medical expert. In addition, there is a risk of widespread dissemination of the recording through social media to the detriment of the reputation of the medical expert, and likely interference with the probity of the court hearing. We argue that the claimant and the medical expert have equal rights to privacy within a medical or medico-legal consultation, and recordings should not be made without mutual agreement. Furthermore, the courts should rely only on the report of the medical expert since a recording of the consultation represents only part of the process of medical assessment. We argue that the current advice given by the General Medical Council on covert recording of medical or medico-legal consultations should be reconsidered by a panel of experienced medical and legal experts.

Human rights abuses: toward balancing two perspectives.

There are two perspectives on the problem of human rights abuses: the perpetrator perspective and the system perspective. The perpetrator perspective focuses on the shortcomings of persons, blaming them for neglect, cruelty, or moral weakness, and it attempts correction through education, activism, and judicial intervention. The system perspective acknowledges that the social circumstances within which individuals live can surreptitiously co-opt otherwise good people into participating in human rights abuses. Here, the corrective approach needs to focus on the complex task of altering structures and functions of systems in order to overcome structurally propelled abuses of human rights, while at the same time recognizing the moral and legal importance of allocating individual blame for the violation of such rights.

Is human existence worth its consequent harm?

Benatar argues that it is better never to have been born because of the harms always associated with human existence. Non-existence entails no harm, along with no experience of the absence of any benefits that existence might offer. Therefore, he maintains that procreation is morally irresponsible, along with the use of reproductive technology to have children. Women should seek termination if they become pregnant and it would be better for potential future generations if humans become extinct as soon as humanely possible. These views are challenged by the argument that while decisions not to procreate may be rational on the grounds of the harm that might occur, it may equally rational to gamble under certain circumstances that future children would be better-off experiencing the harms and benefits of life rather than never having the opportunity of experiencing anything. To the degree that Benatar's arguments preclude the potential rationality of any such gamble, their moral relevance to concrete issues concerning human reproduction is weakened. However, he is right to emphasise the importance of foreseen harm when decisions are made to attempt to have children.

Face transplantation: a review of the technical, immunological, psychological and clinical issues with recommendations for good practice.

Three years ago, the Working Party on Facial Transplantation concluded that until there was more information available about risks any potential patient would be exposed to, it would be unwise to proceed with transplantation of the human face. Over the last three years, there has been a deepening understanding of the potential psychological problems of facial transplantation as well as a very considerable debate on the ethical aspects of the procedure. Further data on experimental work in animal models of facial transplantation as well as medium-term follow-up data from 24 hand and forearm transplants in 18 patients has now become available. Furthermore, a partial facial transplantation has been performed in France and a second one in China. In this second edition of the report, the technical, immunological, psychological, and ethical issues are discussed again in the light of this developing knowledge. In particular, there has been a major expansion of the sections on the psychological and societal issues, as well as the ethical and legal problems of facial transplantation. The working party still has considerable reservations about facial transplantation. Although it accepts that on balance the risks cannot be precisely quantified, they remain substantial. Therefore, if patients are allowed to make an informed choice to proceed, they must be very carefully selected and protected in the process, along with the families of both the donors and the recipients. To achieve this, the working party insists that 15 minimum requirements, described at the end of this report, must be fulfilled before it would be appropriate for a research ethics committee/institutional review board to approve of a proposal to undertake facial transplantation.

Informed consent in clinical practice: pre-registration house officers' knowledge, difficulties and the need for postgraduate training.

In clinical practice consent is often obtained by junior doctors. This study investigates the involvement of pre-registration house officers (PRHOs) in the process of obtaining consent, the supervision they receive and their knowledge on the subject. Some 74% of the PRHOs in post completed the questionnaire; 68% had often or sometimes obtained consent during their year as PRHO; 18% stated that on the occasions when they had obtained consent they were always the only person eliciting consent; 62% of the doctors perceived some lack of knowledge with regard to the nature of the procedure as a difficulty. Despite a comprehensive undergraduate programme in ethics, law and communication there is a need for applied education regarding the clinical procedures for which PRHOs are obtaining consent.

Ethical principles and the rationing of health care: a qualitative study in general practice.

BACKGROUND: Researching sensitive topics, such as the rationing of treatments and denial of care, raises a number of ethical and methodological problems. AIM: To describe the methods and findings from a number of focus group discussions that examined how GPs apply ethical principles when allocating scarce resources. DESIGN OF STUDY: A small-scale qualitative study involving purposive sampling, semi-structured interviews and focus groups. SETTING: Twenty-four GPs from two contrasting areas of London: one relatively affluent and one relatively deprived. METHOD: Initial interviews asked GPs to identify key resource allocation issues. The interviews were transcribed and themes were identified. A number of case studies, each illustrative of an ethical issue related to rationing, were written up in the form of vignettes. In focus group discussions, GPs were given a number of these vignettes to debate. RESULTS: With respect to the ethical basis for decision making, the findings from this part of the study emphasised the role of social and psychological factors, the influence of the quality of the relationship between GPs and patients and confusion among GPs about their role in decision making. CONCLUSION: The use of vignettes developed from prior interviews with GPs creates a non-threatening environment to discuss sensitive or controversial issues. The acceptance by GPs of general moral principles does not entail clarity of coherence of the application of these principles in practice.

Breaking bad news: experiences, views and difficulties of pre-registration house officers.

OBJECTIVES: To obtain information regarding the involvement of pre-registration house officers (PRHOs) in the discussions on bad news, and the competency and difficulties they perceive in clinical practice. DESIGN: Structured telephone interviews. PARTICIPANTS: 104 PRHOs. MAIN OUTCOME MEASURES: Information about frequency and quality of involvement of PRHOs in discussions on bad news with patients and relatives, perceived competency and difficulties related to this task as well as ethical views concerning the disclosure of bad news. RESULTS: 82 PRHOs (78.9%) had initiated the breaking of bad news to a patient at least once, whilst patients themselves had initiated discussions of bad news by asking the doctors questions (92.3%). Almost all (96.2%), indicated that they had broken bad news to relatives of a patient. The majority of the junior doctors participating in our study felt fairly or very confident (90.4%) to break bad news. 'Often' quoted difficulties for over a fifth of the sample included 'Thinking I was not the appropriate person to discuss the bad news', 'Having all the relevant information available', 'Dealing with emotions of patient/relative', 'Lack of privacy' and 'Patients/relatives do not speak English'. Although 99 PRHOs (95.2%) believed that patients should be informed about a serious life threatening illness, 30.8% of the participants stated that doctors need to judge whether or not to tell a patient bad news. Factors most frequently selected by the PRHOs from a given list of possible factors contributing to a gap between theory and practice included problems with the organization of clinics (73.1%), insufficient postgraduate training (63.5%) and lack of staff (54.8%). CONCLUSIONS: The results indicate that PRHOs are frequently involved in the breaking of bad news. Whilst no claims can be made for their,actual performance in practice, their perceptions of competency would indicate that the extensive and compulsory undergraduate teaching they had received on this subject has served to prepare them for this difficult task. Organizational and structural aspects need to be taken into account as factors assisting or undermining doctors in their efforts to put into practice ethically sound and skilled communication when disclosing bad news.

Choosing children: intergenerational justice?

In this discussion, we argue that the concept of intergenerational justice, usually used in environmental matters, is applicable to reproductive decisions also. Additionally, we propose that this permits certain reproductive choices to be made prior to conception or during the pregnancy, and that these choices should not be confined to clinical concerns. In particular, we argue that consideration of the interests of future children should be viewed from the perspective of objective well-being. That being the case, decisions about the sex of future offspring can, in terms of intergenerational justice, be legitimate. We do not argue that every reproductive choice is legitimate; for example it would not be legitimate deliberately to choose characteristics that prevent future children from potentially successful participation in social life.