Analysis and comment on practicalethicsnews.com

Regular commentaries on ethical issues in the news - appearing on the practicalethicsnews blog

Past topics include:

Activism and mercy killing 030708
Adoption and the golden rule 190308
Cloning and animal exploitation 060608
Deceiving children for their own good 170608.doc
Difficult choices in screening for disorders during pregnancy 150908
Don't Panic 220908
Doublethink and double effect 010308
When the heart stops: harvesting organs from the newly (nearly) dead  140808
Improving prenatal tests 260908
Keeping dying patient in ICU alive 250608
Letting (human) animals die 040408
Longer life or more lives 040308
New hope or false hope for vegetative patients 250408
Preventing birth to teenage parents is discriminatory 080208
Radical organ retrieval procedures 280808
Should genetic discrimination in sport be banned 250408
Smoking and conception decisions 230608
the consequences of art 170708
The slippery slope to humanzees 020508
Viability of extremely preterm infants and abortion limits 190508
Viability premature infants abortion 090508
What’s wrong with the hermaphrodite world 170708

The Window Of Opportunity: Decision Theory And The Timing Of Prognostic Tests For Newborn Infants

In many forms of severe acute brain injury there is an early phase when prognosis is uncertain followed later by physiological recovery and the possibility of more certain predictions of future impairment. There may be a Window of Opportunity for withdrawal of life support, but if decisions are delayed there is the risk that the patient will survive with severe impairment.
In this paper I focus on the example of neonatal encephalopathy and the question of the timing of prognostic tests and decisions to continue or withdraw life-sustaining treatment. How should parents decide what to do given the conflicting values at stake? I apply decision theory to the problem, using sensitivity analysis to assess how different features of the tests or different values would affect a decision to perform early or late prognostic testing. I will draw some general conclusions from this model for decisions about the timing of testing in neonatal encephalopathy. Finally I consider possible solutions to the problem posed by the Window of Opportunity.
Decision theory highlights the costs of uncertainty. This may prompt further research into improving prognostic tests. But it may also prompt us to reconsider our current attitudes towards the palliative care of newborn infants predicted to be severely impaired.

This is the pre-peer-review version of the following article: Wilkinson, D. The window of opportunity: decision theory and the timing of prognostic tests for newborn infants. Bioethics (2009) vol. 23 (9) pp. 503-14 which has been published in final form at http://dx.doi.org/ 10.1111/j.1467-8519.2009.01762.x

Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients

D J Wilkinson, G Kahane, M Horne, and J Savulescu. J Med Ethics. 2009 August; 35(8): 508–511. Published online 2009 July 23. doi: 10.1136/jme.2008.029165.

Recent studies using functional magnetic resonance imaging of patients in a vegetative state have raised the possibility that such patients retain some degree of consciousness. In this paper, the ethical implications of such findings are outlined, in particular in relation to decisions about withdrawing life-sustaining treatment. It is sometimes assumed that if there is evidence of consciousness, treatment should not be withdrawn. But, paradoxically, the discovery of consciousness in very severely brain-damaged patients may provide more reason to let them die. Although functional neuroimaging is likely to play an increasing role in the assessment of patients in a vegetative state, caution is needed in the interpretation of neuroimaging findings.

Ethical issues in the use of hypothermia in newborn infants with hypoxic-ischaemic encephalopathy

Wilkinson D. Ethical issues in the use of hypothermia in newborn infants with hypoxic-ischaemic encephalopathy. Acta Paediatrica Published Online first Dec 2008. DOI:10.1111/j.1651-2227.2008.01127.x

Hypothermia is the first treatment for newborns with hypoxic-ischaemic encephalopathy (HIE) with consistent evidence of a reduction in the risk of death or severe disability. This paper addresses a number of ethical and practical issues faced by clinicians as cooling moves from an experimental treatment into practice. These issues are not unique to therapeutic hypothermia. They include the extrapolation of evidence from trials to clinical care, as well as the impact of hypothermia on prognosis and withdrawal of life-sustaining treatment.

Conclusion: Hypothermia is a promising new therapy, but further research will be necessary to help resolve some of the ethical concerns associated with its use in newborns with HIE .

The version below is the author's pre-print version. The final version of the paper can be accessed at DOI:10.1111/j.1651-2227.2008.01127.x

Challenging the status quo

Challenging the Status Quo.  Dominic Wilkinson.  Bioethical Inquiry (2009) 6 (2): 235-7 http://dx.doi.org/10.1007/s11673-009-9148-3

Harold Jaffe argues that we should adopt opt-out testing for HIV. There are paternalistic and utilitarian arguments for such an approach. In this commentary I draw attention to some similarities between his arguments and debates about opt-out systems of organ donation. I argue that the status quo bias provides both part of the reason that opt-out approaches work, and an explanation for why such approaches are sometimes resisted.

The final published version of this article can be found at http://dx.doi.org/10.1007/s11673-009-9148-3

A randomized crossover trial of two algorithms for managing desaturation episodes in ventilated preterm infants.

[ii] Wilkinson D , Andersen. A randomized crossover trial of two algorithms for managing desaturation episodes in ventilated preterm infants. Neonatology 2008 vol. 95 (4) pp. 306-310 Published online Dec 4 2008 (DOI:10.1159/000179611)

Background: Desaturation episodes occur commonly in ventilated preterm infants. It is not clear how best to reduce the frequency and duration of desaturation. Objective: To study the management of desaturation episodes using two bedside algorithms. Methods: Using a randomised crossover design, over two 8-hour periods, episodes were managed with either titration of inspired oxygen (FiO(2)) alone or adjustment to ventilator pressures with smaller changes to FiO(2). Functional oxygen saturation and heart rate were downloaded from the bedside monitor. Ventilator parameters were captured simultaneously. The primary outcome was the proportion of time in the target saturation band. A cumulative measure of desaturation and oversaturation was also developed to compare groups. Results: 33 studies were performed in 23 ventilated infants <32 weeks' gestation. Infants spent 51% of the time with saturations in the target band. There were more changes in ventilator pressure when the second algorithm was in use. There was no difference in the proportion of time within the saturation target, in the frequency and duration of desaturation episodes, or in the desaturation/oversaturation index between the two algorithms. Conclusions: Further study is required to determine the best way to manage desaturation in ventilated preterm infants.

Consequentialism and the death penalty.

Wilkinson D, Douglas T. Consequentialism and the death penalty. Open Peer Commentary. American Journal of Bioethics 2008; 8(10): 56-8. http://dx.doi.org/10.1080/15265160802478461

Arguments in defense of the death penalty typically fall into one of two groups. Consequentialist arguments point out beneficial effects of capital punishment, normally focusing on deterrence, (Sunstein et al. 2005) while non-consequentialist arguments seek to justify execution independently of its effects, for example, by appealing to the concept of retribution.(van den Haag 1986) Arguments defending physician involvement in capital punishment can be divided along similar lines. A consequentialist might claim that physician involvement in capital punishment reduces the amount of suffering endured by prisoners, allowing them a more humane death.(Waisel 2007) A nonconsequentialist defense might, on the other hand, maintain that doctors should participate in capital punishment simply because a legitimate state requires them to do so.

Michael Keane’s target article ‘The ethical “elephant” in the death penalty “room”’ should, we believe, be read as an attempt to present an interesting new consequentialist defense of physician involvement in capital punishment.

This is the author's version of the work. It is posted here by permission of 'Copyright Holder' for personal use, not for redistribution.
The definitive version was published in The American Journal of Bioethics, Volume 8 Issue 10, October 2008. DOI:10.1080/15265160802478461
http://dx.doi.org/10.1080/15265160802478461

Answering the challenge: moral philosophy and the cognitively disabled

Draft paper

Does cognitive disability present distinct problems for philosophy and moral philosophy? Until fairly recently philosophers have given precious little attention to the question of the care, the internal experience and the moral status of those human beings whose cognitive capacities are significantly less than the rest of the species. But in the last 2 decades or so there has been increasing focus on the ethical and meta-ethical questions that relate to the cognitively disabled, particularly those who are most profoundly disabled. These questions were the focus of a conference in New York in late 2008 – “Cognitive Disability: a challenge to moral philosophy”. (http://www.stonybrook.edu/sb/cdconference/)
The conference raised a number of interesting questions, and the presentations will be available online as podcasts, in a special issue of the journal Meta-philosophy, and in a published collection by Blackwell. Here I will briefly outline and draw links between two questions that underpinned a number of the presentations. Firstly, what is the appropriate conception of the good for individuals with severe cognitive disability ? Second, how should we think about and treat individuals with severe cognitive disability (SCD) compared to non-human animals with similar (or greater) cognitive capacities? Is it even appropriate to make such comparisons? Finally I will point to some important distinctions that are relevant to attempts to answer the question of how we should treat humans with SCD.

Is it in the best interests of an intellectually disabled infant to die?

J Med Ethics 2006;32(8):454-9.

One of the most contentious ethical issues in the neonatal intensive care unit is the withdrawal of life-sustaining treatment from infants who may otherwise survive. In practice, one of the most important factors influencing this decision is the prediction that the infant will be severely intellectually disabled. Most professional guidelines suggest that decisions should be made on the basis of the best interests of the infant. It is, however, not clear how intellectual disability affects those interests. Why should intellectual disability be more important than physical disability to the future interests of an infant? Is it discriminatory to base decisions on this? This paper will try to unravel the above questions. It seems that if intellectual disability does affect the best interests of the child it must do so in one of three ways. These possibilities will be discussed as well as the major challenges to the notion that intellectual disability should have a role in such decisions. The best interests of the child can be affected by severe or profound intellectual disability. It is, though, not as clear-cut as some might expect.

"Neglected personhood" and neglected questions: remarks on the moral significance of consciousness.

Wilkinson D, Kahane G, Savulescu J.  Am J Bioeth. 2008 Sep;8(9):31-3.

Open Peer Commentary on
Fins, Illes et al Neuroimaging and Disorders of Consciousness: Envisioning an Ethical Research Agenda
http://www.informaworld.com/smpp/content~content=a904034531~db=all~order=page

Fins et al. (2008) outline a number of ethical issues associated with neuroimaging in conditions where consciousness is absent or impaired, and make a number of useful suggestions. However they are virtually silent on what we take to be crucial questions Here we briefly discuss two key issues. Firstly, talk about consciousness is notoriously contentious and can refer to a range of potentially distinct phenomena, not all of which might be of moral significance. Secondly, if some of these patients are indeed conscious in a morally significant sense, what would be the implications for treatment?



This is the author's version of the work. It is posted here by permission of 'Copyright Holder' for personal use, not for redistribution.
The definitive version was published in The American Journal of Bioethics, Volume 8 Issue 9, September 2008.
doi:10.1080/15265160802412486 (http://dx.doi.org/10.1080/15265160802412486)

Influenza in the Neonatal Intensive Care Unit

Wilkinson DJ, Buttery JP, Andersen CC. J Perinatol. 2006 Dec;26(12):772-776

Influenza has historically been an uncommon illness in the newborn period, although epidemic outbreaks in neonatal intensive care units have been described. There is currently significant concern about the possibility of a new pandemic of influenza in the near future. During a pandemic neonates are likely to be exposed, with significant illness more likely in pre-term newborns due to reduced levels of passively transferred protective maternal antibodies. While newer therapies have been shown to be effective in reducing the severity of illness in adults and children, such therapies are untried in neonates. Supportive care and measures to contain and prevent spread of infection may well be the most important measures in the event of a neonate acquiring influenza, including the avian variety.

Awake upper airway obstruction in children with spastic quadriplegic cerebral palsy.

J Paediatr Child Health. 2006 Jan-Feb;42(1-2):44-8.

OBJECTIVE: Some children with severe cerebral palsy develop symptoms of upper airway obstruction (UAO) while awake. The aetiology, natural history and treatment of this complication have not previously been systematically described. This study documents a case series of children with severe cerebral palsy admitted to hospital because of severe awake UAO and reviews the relevant literature. METHODS: The case records of children admitted to hospital with UAO while awake over an 8-month period were reviewed. Details of antecedent illness, comorbidities, acute management and follow up were collated. One case is presented in detail. RESULTS: Eight children were admitted with UAO. Seven children required intensive care admission. One child died, and two underwent tracheostomy. Nasendoscopy showed pharyngeal collapse without anatomical obstruction in the majority. One child was discovered to have a brainstem malignancy. CONCLUSIONS: Upper airway obstruction is a potentially severe and life-threatening complication of cerebral palsy. In this series, a majority of children had obstruction related to pharyngeal hypotonia and collapse. This can lead to prolonged hospitalization and intensive care admission. It may raise difficult management issues.
(The definitive version is available at  www.blackwell-synergy.com)

Catching the Cradle (Review: When the bough breaks, a mother's story)

Journal of paediatrics and child health (2008) vol. 44 (9) pp. 531-532

Paediatricians who are also parents have one advantage over those who have not had children of their own. They have personal memories of the highs and lows of child rearing that often help provide insight into the thoughts and concerns of the parents that they encounter. However, some parents that we meet in our work have experiences that are dramatically different from those that the majority of paediatricians have personal exposure to. It can be difficult for us to imagine ourselves in the situation of parents who care for infants and children who have serious or life-threatening illness or have severe disabilities. The personal stories of those parents can sometimes help us to see the world through their eyes.
In ‘When the bough breaks’ Julia Hollander describes her
own experience of a traumatic birth and its consequences. Her second child, Imogen, developed hypoxic-ischaemic encephalopathy after a placental abruption, and sustained devastating brain injury. Hollander vividly and movingly evokes the emotional turmoil of the months following Imogen’s birth that eventually led her to put her daughter in foster care.
(continued in full article - available at above link)

Death in the neonatal intensive care unit: changing patterns of end of life care over two decades.

Arch Dis Child Fetal Neonatal Ed. 2006 Jul;91(4):F268-71.

BACKGROUND: Death remains a common event in the neonatal intensive care unit, and often involves limitation or withdrawal of life sustaining treatment. OBJECTIVE: To document changes in the causes of death and its management over the last two decades. METHODS: An audit of infants dying in the neonatal intensive care unit was performed during two epochs (1985-1987 and 1999-2001). The principal diagnoses of infants who died were recorded, as well as their apparent prognoses, and any decisions to limit or withdraw medical treatment. RESULTS: In epoch 1, 132 infants died out of 1362 admissions (9.7%), and in epoch 2 there were 111 deaths out of 1776 admissions (6.2%; p<0.001). Approximately three quarters of infants died after withdrawal of life sustaining treatment in both epochs. There was a significant reduction in the proportion of deaths from chromosomal abnormalities, and from neural tube defects in epoch 2. CONCLUSIONS: There have been substantial changes in the illnesses leading to death in the neonatal intensive care unit. These may reflect the combined effects of prenatal diagnosis and changing community and medical attitudes.

Should high flow nasal cannula be used for respiratory support in preterm infants?

Wilkinson DJ, Andersen C, Holberton J Neonatology Today 2008; 3: 1-5

High flow nasal cannula (HFNC) is a novel means of respiratory support in infants that has been adopted by a large number of neonatal units in the US, UK and Australia in the last 5 years. HFNC refers to the delivery of heated, humidified and blended oxygen/air via small caliber nasal cannulae at flow rates of >1 l/min. HFNC has been used post-extubation in extremely low birth weight infants (when the use of conventional continuous positive airway pressure (CPAP) may be technically difficult, and lead to significant nasal trauma), as well as for the longer-term support of CPAP-dependent infants with evolving or manifest chronic lung disease. However the popularity of this modality has caused some concern and controversy. To date, the evidence base for its use in preterm infants is thin, and it has been suggested that HFNC may subject infants to dangerously high (and unmeasured) pressures. This paper will review the recent evidence for HFNC, and explore some of the specific reasons why HFNC may have become so popular so quickly. It will provide some practical guidelines for the use of HFNC while awaiting further trial evidence.
Neonatology Today is available at http://www.neonatologytoday.net/

Neuroimaging and the withdrawal of life-sustaining treatment from patients in vegetative state

L Skene, D Wilkinson, G Kahane, J Savulescu Medical law review 2009; 17 (2): 245-261

In a recent English case before the Family Division of the English High Court, the Official Solicitor objected to the withdrawal of treatment from a patient diagnosed as being in vegetative state (VS), despite agreement between the NHS Trust and the patient’s family that treatment should be withdrawn. One objection arose from the possibility, based on a recent medical article,2 that a functional magnetic resonance imaging test ( fMRI, commonly called a brain scan) might indicate that the patient retained a degree of consciousness...

Pharyngeal pressure with high-flow nasal cannulae in premature infants.

J Perinatol. 2008 Jan;28(1):42-7. Epub 2007 Nov 8.

OBJECTIVE: The aim of this study was to measure pharyngeal pressures in preterm infants receiving high-flow nasal cannulae. STUDY DESIGN: A total of 18 infants were studied (median gestational age 34 weeks, weight 1.619 kg). A catheter-tip pressure transducer was introduced into the nasopharynx. Flow was sequentially increased to a maximum of 8 l min(-1) and decreased to a minimum of 2 l min(-1). RESULT: There was a strong association between pharyngeal pressure and both flow rate and infant weight (P<0.001, r (2)=0.61), but not mouth closure. This relationship could be expressed as pharyngeal pressure (cm H(2)O)=0.7+1.1 F (F=flow per kg in l min(-1) kg(-1)). CONCLUSION: High-flow nasal cannulae at flow rates of 2 to 8 l min(-1) can lead to clinically significant elevations in pharyngeal pressure in preterm infants. Flow rate and weight but not mouth closure are important determinants of the pressure transmitted.

Hypothermia: a neuroprotective therapy for hypoxic-ischemic encephalopathy (letter)

Pediatrics. 2007 Feb;119(2):422-3.

Death in the Netherlands: Evidence and Argument

Arch Pediatr Adolesc Med. 2009;163(10):958-959

In this issue of Archives, Verhagen et al1 provide thorough and thought-provoking insight into end-of-life decision making for newborns in the Netherlands. The authors retrospectively reviewed the case histories of 98% of all infants who died in the 10 tertiary Dutch neonatal units during a 1-year period. They interviewed pediatricians involved in all cases in which end-of-life decisions appeared to be influenced by considerations other than straightforward futility. The results of the study have some relevance for debates about Dutch end-of-life practices, particularly the controversial protocol for active euthanasia in newborns, the Groningen Protocol.2-3

The full text of this article is available at http://archpedi.ama-assn.org/cgi/content/short/163/10/958

Sympathetic activity in patients with panic disorder at rest, under laboratory mental stress, and during panic attacks.

Arch Gen Psychiatry. 1998 Jun;55(6):511-20.

BACKGROUND: The sympathetic nervous system has long been believed to be involved in the pathogenesis of panic disorder, but studies to date, most using peripheral venous catecholamine measurements, have yielded conflicting and equivocal results. We tested sympathetic nervous function in patients with panic disorder by using more sensitive methods. METHODS: Sympathetic nervous and adrenal medullary function was measured by using direct nerve recording (clinical microneurography) and whole-body and cardiac catecholamine kinetics in 13 patients with panic disorder as defined by the DSM-IV, and 14 healthy control subjects. Measurements were made at rest, during laboratory stress (forced mental arithmetic), and, for 4 patients, during panic attacks occurring spontaneously in the laboratory setting. RESULTS: Muscle sympathetic activity, arterial plasma concentration of norepinephrine, and the total and cardiac norepinephrine spillover rates to plasma were similar in patients and control subjects at rest, as was whole-body epinephrine secretion. Epinephrine spillover from the heart was elevated in patients with panic disorder (P=.01). Responses to laboratory mental stress were almost identical in patient and control groups. During panic attacks, there were marked increases in epinephrine secretion and large increases in the sympathetic activity in muscle in 2 patients but smaller changes in the total norepinephrine spillover to plasma. CONCLUSIONS: Whole-body and regional sympathetic nervous activity are not elevated at rest in patients with panic disorder. Epinephrine is released from the heart at rest in patients with panic disorder, possibly due to loading of cardiac neuronal stores by uptake from plasma during surges of epinephrine secretion in panic attacks. Contrary to popular belief, the sympathetic nervous system is not globally activated during panic attacks.

Panic disorder: coronary spasm as a basis for cardiac risk?

Med J Aust. 1998 Apr 20;168(8):390-2.

Patients with panic disorder often complain of angina-like chest pain during panic attacks, but this is not usually considered life-threatening. We describe three patients with panic disorder and documented cardiac ischaemia during episodes of chest pain. In two, it progressed to myocardial infarction. As none had atherosclerosis evident at coronary angiography, the mechanism was presumed to be coronary artery spasm. These cases illustrate that pain typical of angina during panic attacks may have an organic cause.

High flow nasal cannula for respiratory support in preterm infants

Wilkinson DJ, Andersen CC, O'Donnell C. High flow nasal cannula for respiratory support in preterm infants. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD006405. DOI: 10.1002/14651858.CD006405.

This is the protocol for a review and there is no abstract. The objectives are as follows:

The objectives are as follows:

In preterm infants, to compare the efficacy and safety of high flow nasal cannula with other non-invasive methods of respiratory support including:

head box oxygen
low flow nasal cannula (LFNC)
nasal CPAP
NIPPV

Subgroup analysis will be performed to determine the efficacy of high flow nasal cannula in infants with different underlying illness and of different gestational age:

parenchymal lung disease (requiring supplemental oxygen)
apnoea of prematurity
corrected gestational age > / = 30 weeks
corrected gestational age < 30 weeks

Selling organs and souls: should the state prohibit 'demeaning' practices?

Wilkinson DJ. J Bioeth Inq. 2004;1(1):27-31.

It is sometimes argued that practices such as organ-selling should be prohibited because they are demeaning to the individuals involved. In this article the plausibility of such an argument is questioned. I will examine what it means to demean or be demeaned, and suggest that the mere fact that an individual is demeaning themself does not provide sufficient justification for legal prohibition. On the contrary, such laws might be argued to be demeaning.
The definitive version of this paper is available on the journal website at the above link