Moving on From Bland: The Evolution of the Law and Minimally Conscious Patients

The decision in Bland centred on the withdrawal of artificial nutrition and hydration from a patient in a persistent vegetative state (PVS). Since then, a new medical condition has emerged, known as a minimally conscious state (MCS). In W v M, the Court of Protection was asked to authorise the withdrawal of artificial nutrition and hydration from a patient in a MCS. Baker J refused to grant the declaration. More recently, however, the courts were also asked to rule on the lawfulness of withholding treatment in a similar, albeit factually different, case. In the Court of Appeal decision in Aintree University Hospitals NHS Foundation Trust v David James and Others, Sir Alan Ward, with the agreement of Arden LJ and Laws LJ, granted a declaration that it would be lawful to withhold treatment. The Supreme Court then upheld this ruling, Lady Hale stating that the Court of Appeal reached the right result but for the wrong reasons. This article seeks to critically appraise the evolution of the law in regard to withdrawing treatment from MCS patients. The piece begins by explaining the differences between the two conditions of PVS and MCS and defines the law from the starting point of Bland. From here, the discussion progresses to focus on the challenges that the law has had to face in trying to keep pace with the advancing nature of medical understanding of conditions of the brain and explains how it has responded to these. The narrative then critiques the legal mechanism of best interests as it has been employed in the case law concerning MCS patients to date by analysing the various judicial perspectives on the concept. After addressing both the narrow and wide viewpoints, a conclusion is ventured as to how the balancing of best interests should be approached in respect of future MCS cases

The closest black holes

Starting from the assumption that there is a large population (> 10^8) of isolated, stellar-mass black holes (IBH) distributed throughout our galaxy, we consider the detectable signatures of accretion from the interstellar medium (ISM) that may be associated with such a population. We simulate the nearby (radius 250 pc) part of this population, corresponding to the closest ~35 000 black holes, using current best estimates of the mass distribution of stellar mass black holes combined with two models for the velocity distribution of stellar-mass IBH which bracket likely possibilities. We distribute this population of objects appropriately within the different phases of the ISM and calculate the Bondi-Hoyle accretion rate, modified by a further dimensionless efficiency parameter \lambda. Assuming a simple prescription for radiatively inefficient accretion at low Eddington ratios, we calculate the X-ray luminosity of these objects, and similarly estimate the radio luminosity from relations found empirically for black holes accreting at low rates. The latter assumption depends crucially on whether or not the IBH accrete from the ISM in a manner which is axisymmetric enough to produce jets. Comparing the predicted X-ray fluxes with limits from hard X-ray surveys, we conclude that either the Bondi-Hoyle efficiency parameter \lambda, is rather small (< 0.01), the velocities of the IBH are rather high, or some combination of both. The predicted radio flux densities correspond to a population of objects which, while below current survey limits, should be detectable with the Square Kilometre Array (SKA). Converting the simulated space velocities into proper motions, we further demonstrate that such IBH could be identified as faint high proper motion radio sources in SKA surveys.Comment: Accepted for publication in MNRA

Live or Let Die?: Fine Margins Between Life and Death in a Brain-Dead Pregnancy

In PP v Health Service Executive, the Irish High Court was recently asked to decide on the lawfulness of maintaining somatic treatment that was being provided to a brain-dead woman who was 15-weeks pregnant. In delivering judgment, Kearns P held that the treatment should not be maintained and that the artificial support being provided to the woman could lawfully be withdrawn. The legal basis for this ruling, however, is not free from criticism. The focus of this discussion is to consider how an English court would deal with a case similar to this should the need ever arise. There are crucial differences between English and Irish law which could impact upon the reasoning and, quite possibly, the outcome. Given that it is not beyond the realms of possibility that a similar case could occur in England at some point in the future, it is important that a number of legal questions are explored and their implications illuminated

"If the Problem Persists, Come Back to See Me": An Empirical Study of Clinical Negligence Cases against General Practitioners

The law of negligence, as it applies to General Practitioners (GPs), is underexplored in the literature. There has been no substantial research undertaken that has penetrated deeper into claims that have actually reached court in order to analyse judicial reasoning pertaining to both breach of duty and causation. Given the increased pressures that GPs now face, these are important questions to consider. It is against this backdrop that this article seeks to present the findings of an empirical investigation into a number of reported clinical negligence claims brought against GPs. This analysis provides an original contribution to the developing academic discussion surrounding the changing nature of the doctor patient relationship, and how it has come to be viewed in the eyes of the law. It also assesses the extent to which judges have become more receptive to protecting patient rights through the law of negligence, engaging in the expanding discourse concerning judicial deference to medical decision-making. It is argued that judges should sometimes show a greater propensity to question expert medical testimony in support of GPs, because some of the issues GPs typically face are less complex than in other clinical negligence cases involving technical areas of medicine, and that causation does not appear to be such a key factor in defeating patient claims. The work also provides useful guidance for GPs and their advisers in respect of where liability is most likely to be founded and how behaviour can be modified accordingly to reduce the chances of being sued

Systemic negligence and NHS hospitals: An underutilised argument

The ongoing Covid-19 pandemic has caused National Health Service (NHS) frontline operations to be stretched to near breaking point. Despite coming under immense pressure, the service held firm at the height of the crisis thanks to heroic efforts on the part of all the healthcare professionals concerned. All those involved should be commended for their excellent response. Nevertheless, concerns have recently been expressed that in the wake of the emergency, an influx of clinical negligence claims may arise. Even though the Coronavirus Act 2020 stipulates that arrangements can be made to indemnify individual healthcare professionals against Covid-19 related adverse incidents, negligence’s tendency towards apportioning blame to individuals does not always sit comfortably when applied to medical errors, particularly in these unprecedented circumstances. It is for that reason that the Medical Defence Union (MDU) has called for a debate on whether healthcare professionals should be granted immunity from any claim arising out of the response to the pandemic, although whether this would be desirable, and indeed is necessary, has been contested

Glider observations of thermohaline staircases in the tropical North Atlantic using an automated classifier

Thermohaline staircases are stepped structures of alternating thick mixed layers and thin high-gradient interfaces. These structures can be up to several tens of metres thick and are associated with double-diffusive mixing. Thermohaline staircases occur across broad swathes of the Arctic and tropical and subtropical oceans and can increase rates of diapycnal mixing by up to 5 times the background rate, driving substantial nutrient fluxes to the upper ocean. In this study, we present an improved classification algorithm to detect thermohaline staircases in ocean glider profiles. We use a dataset of 1162 glider profiles from the tropical North Atlantic collected in early 2020 at the edge of a known thermohaline staircase region. The algorithm identifies thermohaline staircases in 97.7 % of profiles that extend deeper than 300 m. We validate our algorithm against previous results obtained from algorithmic classification of Argo float profiles. Using fine-resolution temperature data from a fast-response thermistor on one of the gliders, we explore the effect of varying vertical bin sizes on detected thermohaline staircases. Our algorithm builds on previous work by adding improved flexibility and the ability to classify staircases from profiles with noisy salinity data. Using our results, we propose that the incidence of thermohaline staircases is limited by strong background vertical gradients in conservative temperature and absolute salinity.</p

Radio Detections During Two State Transitions of the Intermediate Mass Black Hole HLX-1

Relativistic jets are streams of plasma moving at appreciable fractions of the speed of light. They have been observed from stellar mass black holes ($\sim$3$-$20 solar masses, M$_\odot$) as well as supermassive black holes ($\sim$10$^6$$-$10$^9$ M$_\odot$) found in the centres of most galaxies. Jets should also be produced by intermediate mass black holes ($\sim$10$^2$$-$10$^5$ M$_\odot$), although evidence for this third class of black hole has until recently been weak. We report the detection of transient radio emission at the location of the intermediate mass black hole candidate ESO 243-49 HLX-1, which is consistent with a discrete jet ejection event. These observations also allow us to refine the mass estimate of the black hole to be between $\sim$9 $\times$10$^{3}$ M$_\odot$ and $\sim$9 $\times$10$^{4}$ M$_\odot$.Comment: 13 pages, includes supplementary online information. Published in Science in August 201