The BIRD Study:How should best interests decisions concerning end-stage kidney disease care for adults be made?

This thesis investigates “best interests” decisions concerning the care of adults with or approaching end-stage kidney failure. I focus on the ethico-legal dimensions of questions of dialysis provision versus conservative kidney management. Through an empirical bioethics approach, I complement my normative inquiry with qualitative exploration of the views and experiences of three stakeholder groups: nephrologists, renal nurses, and “consultees” (family members).Limited existing literature lacks consensus on how these decisions should be made, but overwhelmingly recognises difficulties in involving various stakeholders and manoeuvring towards an appropriate decision without conflict. There is acknowledgement of the complexity of balancing medical and non-medical factors, with particular reference to what the patient might value. Participants in my own empirical research similarly highlighted areas of conflict in their own experiences. Whilst wanting to respect the patient’s own care preferences, healthcare professionals and consultees alike spoke of a difficulty in accurately identifying such preferences. For professionals, resulting disagreements had the potential to lead them down the “path of least resistance” in trying to maintain relationships with those close to the patient.Employing a process of reflective equilibrium, I combine my own intuitions with the perspectives identified in the literature and my empirical data to reach a set of coherent positions on how these best interests decisions should be made. I argue that active discussions should begin in advance of any significant care decision arising. These should focus on exploring not only what care options the patient might want, but also how the patient might want any future best interests decision to be approached. Further, these discussions should include the clarification of stakeholder roles in best interests decisions and sensitively set expectations – following which, strong communication should remain consistent. In addition, I highlight where research is needed to supplement my recommendations

The Telemedical Imperative

Technology presents a means of improving health outcomes for vast numbers of individuals. It has historically been deployed to streamline healthcare delivery and reach those who would previously have faced obstacles to accessing services. It has also enabled improved health education and management. Telemedicine can be employed in everything from primary care consultations to the monitoring of chronic diseases. Despite recommendation by the World Health Organization, countries have been slow to embrace such technology in the health sector. Nonetheless, it is expected to become more prevalent with increased digitization. Further, amidst the COVID-19 pandemic, there was a rush to implement forms of telemedicine where possible to prevent patients breaking social distancing rules. In this paper, I present and defend what I term the 'telemedical imperative'. The telemedical imperative represents a duty for healthcare systems to implement remote access to services where possible, thereby furthering the mission of equity in access to healthcare. It is intended as an addition to in-person services rather than a replacement. After highlighting the benefits of telemedicine, I provide four criteria that must be met for the telemedical imperative to arise. The first three-safety, effectiveness, and acceptability-are consistent and essential. The fourth adapts to the service in question and requires that there be no other obstacles specific to that service that cannot reasonably be overcome. Finally, I address several potential objections to the telemedical imperative based on more general concerns around the implementation of telemedicine

Deemed consent for organ donation:A comparison of the English and Scottish approaches

Deemed consent for organ donation has long been discussed as a potential solution to the shortage of organs for transplantation, with several countries having implemented it. In Great Britain, Wales was the first nation to introduce such a system, having done so in 2015. Now, the other two nations are following suit. In this paper, I compare the approaches of England and Scotland in moving to systems of deemed consent for organ donation. After outlining both sets of legislation, I focus on three points on which the two nations differ. First, the role of those close to the deceased in the consent process and the extent to which clinicians are required to consult them ahead of consent being deemed. Second, the role of government ministers in ensuring widespread public awareness. Third, the ways in which the two nations responded to the challenge of the COVID-19 pandemic in relation to the implementation of deemed consent. I conclude that on all three points, the Scottish approach is preferable

Best Interests v Resource Allocation:Could COVID-19 cloud decision-making for the cognitively impaired?

The COVID-19 pandemic is putting the NHS under unprecedented pressure, requiring clinicians to make uncomfortable decisions they would not ordinarily face. These decisions revolve primarily around intensive care and whether a patient should undergo invasive ventilation. Certain vulnerable populations have featured in the media as falling victim to an increasingly utilitarian response to the pandemic-primarily those of advanced years or with serious existing health conditions. Another vulnerable population potentially at risk is those who lack the capacity to make their own care decisions. Owing to the pandemic, there are increased practical and normative challenges to following the requirements of the Mental Capacity Act 2005. Both capacity assessments and best interests decisions may prove more difficult in the current situation. This may create a more paternalistic situation in decisions about the care of the cognitively impaired which is at risk of taking on a utilitarian focus. We look to these issues and consider whether there is a risk of patients who lack capacity to make their own care decisions being short-changed

In defence of the bioethics scoping review:largely systematic literature reviewing with broad utility

There is growing interest in the possible role of systematic methods of reviewing literature in bioethics. This has arisen alongside the growth of empirical bioethics and a general push towards introducing some level of rigour and reproducibility into scholarship in the field. However, there remain a range of approaches to reviewing literature utilized in bioethics, which vary significantly in their 'systematicness' and suitability for different purposes. In this article, we first detail a taxonomy of various existing reviews used in bioethics and how scholars have defended and critiqued them, presenting them relationally along axes of 'systematic' and 'critical'. Considering the suitability of these reviews, we then explore the inherent differences between normative and empirical literature in relation to how they can be reviewed. In particular, we highlight the challenges in reviewing both normative and empirical literature in a single review. As something of an answer to these challenges, we introduce and defend the scoping review as, in many ways, a method of reviewing literature with wide-ranging utility in bioethics. Demonstrating the many benefits of the scoping review, we then position it within the existing taxonomy of reviews, ultimately arguing that its combination of systematic and critical, inclusive of a reasonable degree of flexibility, makes it deserving of increased attention and use in bioethics

“All hands on deck”: Safeguarding and the transition to telemedical abortion care in England and Wales

The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work