Protecting self-determination in healthcare: a comparative study of the consent model and a novel property model

It is generally accepted in legal and bioethical discourse that the patient has a right to self-determination. The competent patient should be in a position to make informed decisions about his/her care. In practice, this is often not the case. Paternalism, the approach to medical practice that left decision-making in the hands of the doctor, is waning and it is increasingly recognised in both the legal and medical arenas that there are values other than medical factors which determine the choices that patients make. Unfortunately, these developments have not resulted in huge advances for patient self-determination. This is largely because the mechanism by which the law purports to protect self-determination – the consent model – has fundamental flaws that constrain its effectiveness. In the last three decades, various attempts have been made to reconceptualise consent on order to make it fit for purpose, but these have achieved only limited success. This thesis starts with the premise that it is often more productive to consider what an alternative model has to offer, than to persist with amelioration of a model that is fundamentally flawed. The limitations of the consent model are discussed and a novel model, the property model, is advocated. The theoretical underpinnings of this model and its structure are presented. Essentially, the patient’s bodily integrity is protected from unauthorised invasion, and his/her legitimate expectation to be provided with the relevant information and opportunity to enable him/her make an informed decision regarding treatment is taken to be a proprietary right. It is argued that the property model potentially overcomes the limitations of the consent model, including the obstacle caused by the requirement to prove causation in consent cases. The property model provides a means by which the patient’s right to self-determination can be recognised as a distinct legal right. The model does not create new rights, only seeking to afford stronger protection of an existing right. No constitutional, professional, or other conflict is generated by applying property analysis to patient self-determination. The model fits with the rights-based approach that the courts have evolved in UK consent cases, and is consistent with modern medical professionalism

Engaging fathers in childbirth: A meta synthesis

This presentation explores the evidence from a meta synthesis undertaken as part of a programme of work entitled, Engaging Fathers in Childbirth (EPIC). There is growing evidence that active involvement of fathers in maternity care is associated with many health and social benefits for the mother and baby. However, maternity care expectations and experiences of expectant and new fathers have received little attention from policy makers and maternity service providers. Twenty three papers were included in the meta-synthesis and studies where undertaken in 9 countries (7 UK, 5 Australia, 4 Sweden, 2 USA, 1 Japan, 1 Taiwan, 1 South Africa, 1 Finland, 1 New Zealand). Ten of these focused on the prenatal period (prenatal diagnosis, A/N education & care), 5 focused on the intrapartum period (place of birth, premature birth & experiences),8 focussed on the postnatal period (transition to fatherhood & post-traumatic stress disorder). Six themes emerged from the included studies: risk and uncertainty,exclusion, fear and frustration, the ideal and the reality, issues of support, experiencing transition. 'As Partner and Parent’ fathers experience as not-patient and not-visitor situates them in an interstitial and undefined space with the consequence that many feel excluded and fearful. They cannot support their partner effectively unless they are themselves supported, included, and prepared for the reality of risk and uncertainty in pregnancy, labour and parenthood and for their role in this context.Engaging Partners in Childbirt

Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study

Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis.

OBJECTIVE: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally. METHODS: Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980. RESULTS: The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65). CONCLUSIONS: There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

The timing of elective caesarean delivery between 2000 and 2009 in England

BACKGROUND: In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries. METHODS: We identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA). RESULTS: There were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter. CONCLUSIONS: NHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the "timing of elective caesarean" as a quality indicator to support clinical practice