Home » Posts tagged 'medicine'
Tag Archives: medicine
How do we interpret the significance of living well with dementia?
Strange through it may seem, I have been most influenced in my philosophy of living better with dementia by the late Prof Ronald Dworkin who died in 2013 at the age of 81 (obituary here).
One recent campaign has the tagline ‘Right to know’ from the UK Alzheimer’s Society – about the right for you to know if you have dementia as a diagnosis, a right to treatment, and right to plan for the future.
I feel that people newly diagnosed with dementia have other rights too. I would say that, wouldn’t I. Above all, I feel that people who have received a diagnosis of dementia have a right to live well. This is truly a legal right, as this is not negotiable under the Universal Declaration of Human Rights. Recent case law, in the judgment from Lady Hale in R v Cheshire West and Chester Council (et al), re-emphasises that human rights are inalienable. And given that dementia is a disability under law, the right of that person with dementia is a right to dignity, reinforced by our universal human rights.
Focusing on a right to treatment further consolidates the biomedical model which I think is utterly unjustified. We have just seen the peak of one of the most successful campaigns ever mounted by Pharma and large charities for dementia to raise funds for pharmaceutical approaches to dementia. But at the expense of offering jam tomorrow there was very little on offer for people currently living well with dementia. The answer given to Helga Rohra by the World Dementia Envoy gave little in the way of concrete help for people currently trying to live well with dementia. And the ignorance of this is not benign – for the millions of dollars or pounds sterling spent on molecular biology and orphan drugs for dementia to meet the deadline of 2020, this amount of money is being taken out of the pot for developing the evidence base for and for strategies for living better with dementia in a non-pharmacological way.
Just a minute. Look at the evidence. The medications known as cholinesterase inhibitors are generally thought not to slow down the progression of Alzheimer’s disease in humans, even if they have a short valuable time window of use for symptomatic treatment In the UK, and across the world, there has been a drive for reducing the number of inappropriate prescriptions of antipsychotics for people living with dementia; there is now a growing consensus that where symptoms exist they often are due to a fundamental failure in communication with that person living with dementia, and often other therapeutic routes are much more suitable (such as psychological therapies).
The great FR Leavis, intensely under promoted at Cambridge, reminded us that criticism had to be free and flexible: and hence the famous description of the ideal critical debate as an ongoing process with no final answer: “This is so, isn’t it?” “Yes, but …”
Criticism of the English dementia policy may seem like criticism of senior clinicians, senior personnel in charities or senior politicians, but Leavis gives us a powerful reminder to stand up for what it is right. Surely, people living well with dementia have a right to comprehensive high quality dementia care and support? The evidence in support of multidisciplinary teams, including social work practitioners, speech therapists, doctors, cognitive neuropsychologists, occupational therapists, speech and language therapists, working to produce pro-active plans is now overwhelming. There is now increasing evidence that specialist nursing could prevent many acute admissions to secondary care.
As the late Ronald Dworkin asked us to consider, we might think about what makes an “interpretation” true. As Dworkin notes, psychoanalysts interpret dreams, and lawyers interpret contracts. I would go as far as to say clinicians, of various backgrounds, interpret whether a person presenting with a particular cluster of mainly psychological symptoms is presenting with a dementia. I don’t think the diagnosis of dementia is necessarily easy to make. Given that you’re giving a diagnosis of dementia not just to a person with possible dementia but also to his friends and family it is essential to get right; not to misdiagnose depression as dementia for example. My gut instinct is that doctors of all variety do their utmost to get this diagnosis correct. I think there is also a degree of interpretation in how much a person will successfully adapt to their diagnosis in taking an attitude of ‘living well’, or how they will put their faith in pharmacological treatments. The drugs do work for some people for part of the time after diagnosis, so their importance must not be diminished either. I think there is also a degree of interpretation of how disruptive a diagnosis of dementia might be for that person and his or her community.
Dworkin also notes you would be prone to sack a Judge who said, “I am not sure if this person is guilty or not guilty. I think he’s guilty, but you could probably find great many judges who finds the person not guilty.” It is possible that in the more complicated cases a Doctor might find a person living with dementia, another one not living with dementia. Dementia is presented as a definite diagnosis, a binary decision; but this would be to ignore that even the diagnostic criteria, such as the critical importance of memory (or not), has changed with time. Likewise, there has been a growing conflation of whether you fail a series of tests is the same thing as having a diagnostic label; see for example how some people recorded as having ‘delirium’ in the medical notes have in fact, strictly speaking, failed a specific set of screening tools.
But we can say that there are non-medical routes which are not an idle exercise but are of a person flowing from the diagnosis of probable dementia. This is there is much which can do to enhance the living environment of a person, whether a hospital ward, home or town. Or somebody can be directed towards advocates who can help persons with dementia communicate decisions. Or a person can be directed to inexpensive assistive technologies or lifestyle adjustments that can allow a person to live with dementia just like any other disability. This is framing long term care as living with a condition, rather than the single hit treatment.
Dignity, independence and a vast array of other values will, I feel, are a very necessary outcome of this more helpful approach to dementia. The person who has received a diagnosis of dementia is as much of a need of an acknowledgement of uncertainty as a water-tight explanation. The person who has received a diagnosis of dementia needs to be partnership with the people who wish to share that diagnosis with him or her.
I feel it is now time to unmask the medical professional who may simply be not be able to cope with this cultural shift. The medical profession does not know all the answers, nor indeed do all the people who’ve signed up to the Pharma script.
People who want to live better with dementia can be secure in the knowledge that that is their human right. They have a right to this solution, wherever it comes from.
Reference
Is there truth in interpretation? Prof Ronald Dworkin
Public engagement with science must be two-way: that’s why persons with early dementia are so important
I spent some of this afternoon at the Wellcome Trust on Euston Road. Euston Road is of course home of the oldest profession, as well as the General Medical Council too.
I was invited to go there to discuss my plans to bring about a behavioural change in dementia-friendly communities. You see, for people with early dementia, say perhaps people with newly diagnosed dementia and full legal capacity, I feel we should be talking about communities led by people with early dementia.
The last few years for me as a person with two long term conditions, including physical disability, have really given me an urge to speak out on behalf of people who can become too easily trapped by being ‘medicalised’.
I have had endless reports of persons with dementia who have received no details about their dementia from the medical profession on initial diagnosis, and at worst simply given an information pack.
This is not good enough.
How we all make decisions is a fundamental part of life. When a person loses the ability to make decisions, it can be a defining moment – loss of capacity triggers certain legal pathways. Whilst the state of the law on capacity is quite good (through the Mental Capacity Act 2005), it is likely that further welcome refinements in the law on capacity will be seen through the current consultation on the said act.
I have been thinking about applying for a big grant to fund activities in allowing a discussion of decision-making in people with early diagnosis, the science of decisions, and what one might do to influence your decision-making (such as not following the herd).
I’ve also felt that quite substantial amounts of money get pumped into Ivory Tower laboratories on decision-making, but scientists would benefit from learning from people with early dementia regarding what they should research next, as much as informing people with early dementia what the latest findings in decisions neuroscience are.
Also, the medical profession and others are notoriously bad at asking people with dementia what they think about their own decision making. This ‘self reflection’ literature is woefully small, and this gap I feel should be remedied.
I simply don’t think that what scientific funding bodies do has necessarily to interfere with the NHS. I think a motivation to explain and discuss the science of decisions to stimulate a public debate is separable from what the NHS does to encourage people to live well with dementia. This debate can not influence what scientists do, but can influence what lawyers and parliament wish to do about capacity in dementia.
Persons can be encouraged to live well with dementia, and when they become ill they become patients of the NHS. Living well with dementia is for me a philosophy, not a healthcare target. If I can do something to promote my philosophy and help people, I will have achieved where many people in their traditional rôles as medical doctors have gloriously failed as regards dementia.
The G8: when dementia care got personal (well, molecular actually)
At best, the donation of patients’ DNA for free globally in #G8dementia to enhance Pharma shareholder dividend can be sold as ‘coproduction’. It’s easy to underestimate, though, the significance of the G8 summit. It was overwhelming about the ‘magic bullet’, not the complexities of care. It made great promotional copy though for some.
It was not as such health ministers from the world’s most powerful countries coming together to talk about dementia. It was a targeted strike designed to decrease the democratic deficit which could arise between Big Pharma and the public.
Here it’s important to remember what #G8dementia was not about. It was not about what is a safe level of health and social dementia care is around the world. It had a specific aim of introducing the need for a global collaboration in big data and personalised medicine. Researchers whose funding depends on the wealth of Big Pharma also were needed to sing from the same hymn sheet.
For such a cultural change to take effect into this line of thinking, a high profile publicity stunt was needed. Certain politicians and certain charities were clearly big winners. However, with this, it was deemed necessary from somewhere to introduce an element of ‘crisis’ and ‘panic’, hence the terrifying headlines which served only to introduce a further layer of stigma into the dementia debate.
And yet it is crucial to remember what was actually discussed in #G8dementia.
In a way, the big data and personalised medicine agenda represents the molecular version of ‘person-centred care’, and these are academic and practitioners “circles to be squared”, or whatever.
Big data and personalised medicine have been corporate buzz terms for quite some time, but while it’s widely known there are correlations between the two, many are still struggling with how to effectively leverage mass amounts of data in order to improve efficiencies, reduce costs, and advance patient-centric treatments.
Medicine’s new mantra is “the right drug for the right patient at the right time.” In other words, medical treatments are gradually shifting from a “one size fits all” approach to a more personalized one, so that patients can be matched to the best therapy based on their genetic makeup and other predictive factors. This enables doctors to avoid prescribing a medication that is unlikely to be effective or that might cause serious side effects in certain patients.
Personalised drug therapy in its most sophisticated form uses biological indicators, or “biomarkers” – such as variants of DNA sequences, the levels of certain enzymes, or the presence or absence of drug receptors – as an indicator of how patients should be treated and to estimate the likelihood that the intervention will be effective or elicit dangerous side effects. In the case of Alzheimer’s disease, the hunt for a marker in the ‘brain fluid’ (cerebrospinal fluid) has been quite unimpressive. The hunt for those subtle changes in volumes or abnormal protein levels has not been that great. The information about DNA sequences in Alzheimer’s Disease (more correctly a syndrome) is confusing, to say the least. And there at least 100 different types of dementia apart from Alzheimer’s Disease (making the quest for a single cure for dementia even more banal, but a great soundbite for politicians who won’t be in office long anyway.)
With healthcare costs in the U.S. increasing steadily over the last 20 years to 17% of GDP, and similar scaremongering about ‘sustainability’ from economically illiterate people on this side of the Atlantic too, overall moronic healthcare “experts” are looking for every path possible for “efficiency”, “productivity” and “reform”. Many believe that a long-term source of savings could be the use of big data in healthcare; in fact, the McKinsey Global Institute estimates that applying big data strategies to better inform decision making in U.S. healthcare could generate up to $100 billion in value annually.
Significant advancements in personalised medicine, which includes genomics, is making it easier for practitioners to tailor medical treatments and preventive strategies to the characteristics of each patient — advancements that supporters say will improve care and reduce costs. Private markets have long capitalised on fear, and dementia represents a nirvana for private healthcare. It is potentially a huge ‘market’ for drugs. Yet progress is being slowed by a number of factors, including the limited sharing of patient information. This is why there was so much shouting about the need for relaxed regulation at #G8dementia. And yet ultimately, these stakeholders, important though they are, know they can go nowhere without the license from the public. Patient groups and charities represent ‘farms’ for such projects in medicine, as they do for law firms.
Greater sharing, it is argued, would allow medical institutions that are creating patient databases — some with genomic information — to expand the size of the patient pool, thus making it more likely to identify and treat rare conditions. Such discussions necessarily avoid the contentious issue of who actually owns personal DNA information. What’s more important? That patient’s privacy, or the public interest? Data sharing, it is argued, would also allow patients to personally store and share their data with different practitioners. The day that everyone will have every detail about their personal health on their smartphones isn’t that far off, some hope.
The other component of the data-accessibility issue is how medical researchers should go about building massive databases of patient records. The ultimate application is a big-data program that could analyse a patient’s data against similar patients and generate a course of action for the physician. This is why the #G8dementia want to get seriously ‘global’ about this project.
Data can help practitioners diagnose patients more accurately and quickly, and identify risk factors much earlier.
Edward Abrahams, president of the Personalized Medicine Coalition, has said,
“The tricky part is that the public wants control over information, but as patients they may think differently”.
The creation of this value lies in collecting, combining, and analysing clinical data, claims data, and pharmaceutical R&D data to be able to assess and predict the most efficacious treatment for an individual patient. This might be possible through ‘big data’ and ‘personalised medicine’ in a number of key areas.
Clinical trials are of course necessary for every drug to get to market, and the gold standard is currently a randomised clinical trial backed up by a published paper. Big data approaches are complementary to traditional clinical trials because they provide the ability to analyse population variability and to conduct analytics in real time. I
Secondly, the ability to manage, integrate, and link data across R&D stages in pharma might enable comprehensive data search and mining that identify better leads, related applications, and potential safety issues. The sequence alone is much more useful as it is correlated with phenotypes and other types of data. This has naturally affected the way companies think about data storage and structure, with cloud solutions becoming more popular. The two leaders in next-gen sequencing technologies, Illumina now offers cloud solutions for data storage and analysis to meet this growing need. Hence it was ‘name checked’ in #G8dementia.
Thirdly once R&D data and clinical trial data is indexed for big data analysis, the third piece of the big data puzzle into routine clinical practice. Ultimately personalised medicine is about this correlation of diagnostics and outcomes, but tailored to each and every patient.
While big data has already been used successfully in consumer markets, challenges remain to its implementation in healthcare. The primary challenge in moving to big data approaches is simply the vast amount of data in existing systems that currently don’t “talk” to one another and have data that exists in different file types. Hence there is considerable talk about ‘harmonisation’ of data at the #G8dementia conference. The second challenge for data in the clinical space is how to store and share these large amounts of data while maintaining standards for patient privacy. Achieving better outcomes at lower costs (aka ‘doing more for less’) has become the exhausted strapline for the NHS recently, and big data may seem particular attractive to NHS England in their thirst for ‘efficiency savings’.
However, bridging the “democratic deficit” remains THE fundamental problem. If you though the #G8dementia was like an international corporate trade fair, you may not have been invited to other similar events.
The 16th European Health Forum brought together 550 delegates from 45 countries, to take the pulse of Europe’s healthcare systems five years after the 2008 financial crisis and consider what needs to be done now to build, ‘Resilient and Innovative Health Systems for Europe. The Big Data workshop was organised by EAPM and sponsored by EFPIA, Pfizer, IBM, Vital Transformation, and the Lithuanian Health Forum.
There, key issues to do with ownership, security and trust must be addressed, believed Amelia Andersdotter, MEP: “We have some serious challenges for politicians and industry to preserve citizens’ confidence.”
Vivienne Parry in #G8dementia had wanted to talk about ‘safe’ data not ‘open’ data. And where did this idea come from?
Ernst Hafen, Institute of Molecular Systems Biology, ETH Zurich, has said, “We all have the same amount of health data.” Applying big data to personalised medicine, “Only works if we are comfortable with [our data] being used. We have to provide a safe and secure place to store it, like a bank,” also accoding Hafen. Tim Kelsey used exactly the same language of banks at a recent event on innovations in London Olympia.
If you think you’ve had enough of PFI, you ain’t seen nothing yet. Public-private partnerships open the way for health data to be shared, and so improve research and translation, according Barbara Kerstiens, Head of Public Sector Health, DG Research, European Commission. The aim was, “To get stakeholders working together on data-sharing and access, and ensure there is a participant-centred approach,” she said.
And how will the law react? Case law is an important means by which we know what is patentable at the European Patent Office (EPO). However, sometimes the EPO’s view of what is patentable in an area changes before the case law does. This can sometimes be detected when Examiners start raising objections they would not have previously done. Meetings between the EPO and the epi (the professional institute for EPO attorneys) are very useful forums for obtaining ‘inside information’ about the EPO’s thinking which is not yet apparent from the case law. The June 2012 issue of epi Information provides a report of such a meeting held on 10 November 2011 between the EPO and the biotech committee of the epi.
Discussion item 8 was reported as follows:
‘8. Inventions in the area of pharmacogenomics
This concerns cases which are based on a genetic marker to treat a disease, for example methylation profiles. It can involve a new patient group defined by an SNP. The EPO said that often the claims can lack novelty, as one patient will have inevitably been treated with the SNP, even if the art does not explicitly say so.’
The EPO’s comments seem to indicate that it is about to change the way it assesses novelty when looking at medical use claims that refer to treatment of a specific patient group.
A “SNP” is a form of genetic marker which varies between individuals. The idea behind the relatively new field of pharmacogenomics is that, if you know which SNP variants a patient possesses, you can personalise the drugs given to a patient in accordance with his genetic makeup. It is now recognised that the genetic makeup of an individual can be very influential as to whether he responds to a drug, and so one application of pharmacogenomics is to only give those drugs to patients who will respond to them.
Presently, suitable biomarkers for personalised medicine are proving difficult to find. So it seems that the sector is going to require a lot of investment. There’s where #G8dementia came in handy. But in investors in biotech do like to see that strong patent protection is available in the relevant sector; hence the upbeat rosy approach from the speaker from JP Morgan at #G8dementia who framed the debate in terms of risks and returns.
Personalised medicines, and in fact diagnostics in general, has been thrown into uncertainty in the US after the Supreme Court’s decision in Mayo v Prometheus which found that a claim referring to steps that determined the level of a drug in a patient was directed to a law of nature and was thus not patentable. It would be unfortunate for personalised medicines to be dealt a further blow by the EPO, making the test for novelty stricter in this area.
So there may be trouble ahead.
The #G8dementia was merely the big players, with the help of this Pharma-friendly community in the UK, dipping their toe in the water. It was really nothing to do with frontline health and social care, and any mention of them was really to make the business case look relevant to society at large.
It was for academics interesting in that it was when person-centred care came ‘up front and personal’. Molecular, really.
Related articles
- The #G8Dementia Summit: a lack of cure for dementia, and tough on the causes of the lack of cure (livingwelldementia.org)
- All stick and no carrot? How much diagnosis, but how much actual care, of dementia? (livingwelldementia.org)
- Living well with dementia: diet not drugs? (livingwelldementia.org)
- Doctors Urge Focus on Diet to Tackle Dementia in UK (theepochtimes.com)
Information imbalances are the heart of many recent disasters
Had certain people at the BBC known about, and acted upon, the information which is alleged about Jimmy Savile, might things have turned out differently? George Entwhistle tried to explain yesterday in the DCMS Select Committee his local audit trail of what exactly had happened with the non-report by Newsnight over these allegations.
‘Information asymmetry’ deals with the study of decisions in transactions where one party has more or better information than the other. This creates an imbalance of power in transactions which can sometimes cause the transactions to go awry, a kind of market failure in the worst case. Information asymmetry causes misinforming and is essential in every communication process. In 2001, the Nobel Prize in Economics was awarded to George Akerlof, Michael Spence, and Joseph E. Stiglitz for their “analyses of markets with asymmetric information.” Information asymmetry models assume that at least one party to a transaction has relevant information whereas the other(s) do not. Some asymmetric information models can also be used in situations where at least one party can enforce, or effectively retaliate for breaches of, certain parts of an agreement whereas the other(s) cannot.
In adverse selection models, the ignorant party lacks information while negotiating an agreed understanding of or contract to the transaction, whereas in moral hazard the ignorant party lacks information about performance of the agreed-upon transaction or lacks the ability to retaliate for a breach of the agreement. An example of adverse selection is when people who are high risk are more likely to buy insurance, because the insurance company cannot effectively discriminate against them, usually due to lack of information about the particular individual’s risk but also sometimes by force of law or other constraints. An example of moral hazard is when people are more likely to behave recklessly after becoming insured, either because the insurer cannot observe this behavior or cannot effectively retaliate against it, for example by failing to renew the insurance.
Joseph E. Stiglitz pioneered the theory of screening, and screening is a pivotal theme in both economics and medicine. In this way the underinformed party can induce the other party to reveal their information. They can provide a menu of choices in such a way that the choice depends on the private information of the other party.
Examples of situations where the seller usually has better information than the buyer are numerous but include used-car salespeople, mortgage brokers and loan originators, stockbrokers and real estate agents. Examples of situations where the buyer usually has better information than the seller include estate sales as specified in a last will and testament, life insurance, or sales of old art pieces without prior professional assessment of their value.
This situation was first described by Kenneth J. Arrow in an article on health care in 1963. The asymmetry of information makes the relationship between patients and doctors rather different from the usual relationship between buyers and sellers. We rely upon our doctor to act in our best interests, to act as our agent. This means we are expecting our doctor to divide herself in half – on the one hand to act in our interests as the buyer of health care for us but on the other to act in her own interests as the seller of health care. In a free market situation where the doctor is primarily motivated by the profit motive, the possibility exists for doctors to exploit patients by advising more treatment to be purchased than is necessary – supplier induced demand. Traditionally, doctors’ behaviour has been controlled by a professional code and a system of licensure. In other words people can only work as doctors provided they are licensed and this in turn depends upon their acceptance of a code which makes the obligations of being an agent explicit or as Kenneth Arrow put it “The control that is exercised ordinarily by informed buyers is replaced by internalised values”
In standard civil litigation, disclosure of information takes place between the two parties in standard proceedings, a party must disclose every document of which it has control and which falls within the scope of the court’s order for disclosure. Even if a party discloses a document, the other party is not entitled to inspect the document. Of course, this disclosure procedure might have effects in producing information imbalances, where it is important to see ‘the big picture’. Such a situation is the Leveson Inquiry, ultimately looking at how activities might be better regulated if appropriate (and by whom). The communications with the former News International chief executive and the News of the World editor-turned spin doctor, Andy Coulson, were reportedly kept from the hearings into press standards after the Prime Minister sought legal advice. Labour said that David Cameron, the UK Prime Minister, must make sure that “every single communication” that passed between him and the pair be made available to the inquiry and the public. The cache runs to dozens of emails including messages sent to Mr Coulson while he was still an employee of Rupert Murdoch, according to reports. It was described by sources as containing “embarrassing” exchanges with the potential to cast further light on Mr Cameron’s relationship with two of Mr Murdoch’s most senior executives. However, Downing Street was said to have been advised that it was not “relevant” to the Leveson inquiry as the documents they contained fell outside its remit, according to The Independent.
Information imbalances, for us on a more daily basis, have a direct effect on the consumer-supplier relationship of the econy, We have been told to absurdity on how much of our problems as consumers would be solved if we could simply ‘switch easily’ between energy suppliers. In a sense, either there should be far less competition (i.e. the whole thing merges into one state supplier, reducing absurdities in a few suppliers all providing the same product at a high price, similar to exam boards currently), or there should be far more competition (there is currently an oligopolistic situation in many markets, which would be greatly ameliorated by having many more active participants in the competition market.) In 2009, the four largest banks supplied 67% of the market of mortgages, and, in 2006, the ‘big four’ banks accounted for 47% of the market. According to the “Cruickshank review”, the ‘big four’ banks accounted for 17% of the market. Demutualised building societies held 48%: these are, (a) Lloyds TSB, Halifax and Bank of Scotland; (b) Royal Bank of Scotland, Natwest; (c) HSBC, First Direct; (d) Abbey, Alliance and Leicester, Bradford and Bingley.
The Competition Commission believes that helping customers to easily switch products is paramount to the effective operation of competitive markets: markets do not function without customers who vote with their feet. As Dr Adam Marshall of the British Chambers of Commerce told the Commission: ‘There’s lots of products and services on the market, but the theoretical competition between those products and services is limited by the real world barriers of form filling, hassle, bureaucracy, decisions not being taken, etc…’ The regulator responsible for consumer protection regulation should have both: (a) an explicit mandate to promote effective competition in markets in the financial sector; and (b) the necessary powers to regulate the sector to achieve this, including the ability to apply specific licence conditions to banks and exercise competition and consumer protection legislation. These powers will be concurrent with the competition powers of the OFT, and will enable the regulator to both enforce competition law and make market investigation references to the Competition Commission.
The aim of consumer protection regulation is to promote the conditions under which effective competition can flourish as far as possible, and where not, the regulator will be able to take direct action. In order best to promote the interests of the consumer, the regulator will encourage financial firms to compete: on the merit of the quality and price of their products and services; and to gain a competitive advantage by investment in innovation, technology, operational efficiency, superior products, superior service, due diligence, human capital, and offering better information to customers. Ideally, the regulator would then step in whenever there is a sign of market failure. Market failures include: (a) poor quality information being disclosed to consumers when they are deciding whether to purchase products; (b) information asymmetry between the provider and the consumer; or (c) providers taking advantage of typical consumer behaviour such as the tendency evident in retail customers to select the default option offered, and reluctance to switch products because of inertia. Any sign of market failure indicates that competition is probably not effective, and the regulator should then take action to counteract the failure.
Therefore, it is hard to see how information imbalances are not at the heart of many ‘decisions’ affecting modern life, and can lead to imperfect decisions being made. Ideally, it is up to parties to make a full disclosure about things, whether this includes personal health or corporate misfeasance; if they are not so willing to give up their secrets, they possibly can be ‘nudged’ into doing so. Of course, some parties, particularly those intending to generate a healthy shareholder dividend, may not be very keen at all at spilling the beans, and that is where law and regulation come in. However, even then there can be significant imbalances in the legal process which can be obstructive in the correct solutions being arrived at. Certainly the field has progressed substantially since this Nobel Prize for Economics was first awarded over 30 years ago.
The death of Ian Tomlinson – important issues of 'but for' and 'the thin skull rule'
This week, Simon Harwood was cleared of killing newspaper seller Mr Tomlinson during the G20 protests in London in 2009. The latest developments, at the time of writing, are outlined here, for example. Ian Tomlinson was an English newspaper vendor who collapsed and died in the City of London on his way home from work during the 2009 G-20 protests. An inquest jury found in May 2011 that he had been unlawfully killed. Simon Harwood, a constable with the Territorial Support Group of London’s Metropolitan Support Group was charged that month with manslaughter and was found not guilty on 19 July 2012 at Southwark Crown Court. The first PM, conducted two days after the death, concluded that Tomlinson had died of natural causes after suffering a heart attack. His death became controversial four days later when The Guardian published video footage from an American investment manager who had been visiting London. The video showed Tomlinson being struck on the leg from behind by a police officer wielding a baton, then pushed to the ground by the same officer. He walked away after the incident, but collapsed and died minutes later.
Here is the footage from the Guardian, watchable on YouTube, with a helpful explanatory commentary.
After The Guardian published the video, the Independent Police Complaints Commission (IPCC) began a criminal inquiry. Further postmortems, conducted by three other pathologists on April 9 and 22, indicated that Tomlinson had died from internal bleeding caused by blunt force trauma to the abdomen, in association with cirrhosis of the liver. The Crown Prosecution Service (CPS) announced over a year later in July 2010 that no charges would be brought against Harwood, the officer identified as having struck him, because the disagreement between the first and later pathologists meant the CPS could not show a causal link between the death and the alleged assault. That position changed in May 2011 when an inquest jury returned a verdict of unlawful killing, ruling that the push and baton strike had involved unreasonable force. This led the CPS to review its decision and charge Harwood with manslaughter.
Voluntary manslaughter occurs either when the defendant kills with a mental state which could be described as “malice aforethought” (an intention to kill or cause serious harm), but there are mitigating circumstances which reduce culpability, or when the defendant kills only with an intent to cause serious bodily harm. A killing which occurs after provocation by an event which would cause a reasonable person to lose self-control. There must not be a cooling off period negating provocation. If there is an interval between the provocation and killing sufficient to allow the passion of a reasonable person to cool, the homicide is not manslaughter, but murder. Here, critically, the footage video shows no provocation on Tomlinson’s part—he was not a protester, and at the time he was struck was walking along with his hands in his pockets. If one argues that it is uncertain beyond reasonable doubt that Harwood wished to kill Tomlinson in the first place, voluntary manslaughter for securing a conviction is not an option.
Constructive manslaughter is also referred to as ‘unlawful act’ manslaughter. It is based on the doctrine of constructive malice, whereby the malicious intent inherent in the commission of a crime is considered to apply to the consequences of that crime. It occurs when someone kills, without intent, in the course of committing an unlawful act. The malice involved in the crime is transferred to the killing, resulting in a charge of manslaughter. For example, a person who runs a red light in their vehicle and hits someone crossing the street could be found to intend or be reckless as to assault or criminal damage (see DPP v Newbury). There is no intent to kill, and a resulting death would not be considered murder, but would be considered involuntary manslaughter. The accused’s responsibility for causing death is constructed from the fault in committing what might have been a minor criminal act.
The difficulty here is proving beyond reasonable doubt, and this is where the Court can only be directed by expert opinion evidence from medical professionals, who can give such evidence which is admissible in a criminal court, that causation had taken place. There has been to proven a direct link between the baton strike and the subsequent death. This was discussed in R v White (1910), where the prosecution failed to establish causation in fact; The defendant put cyanide into his mother’s drink, but she died of heart failure before the poison could kill her. The answer to the question ‘But for what the defendant did would she have died?’ was in fact ‘No’ as she would have died anyway. She had not committed murder.
I’ve never read the judgment, but patients with severe cirrhosis, in my knowledge, always have deranged clotting evidenced by their clearly abnormal prothrombin and APTT times. Such patients would therefore be extremely prone to haemorrhage, and a direct blow by the baton to Harwood would be different as Harwood is a susceptible individual. This rule is therefore highly relevant, in my view. Cited formally, the ‘thin skull’ rule says that the defendant must take his victim as he finds him. Therefore, even if injury or death is not reasonably foreseeable the law still considers the defendant liable if the victim suffered from some physical or mental condition that made him or her vulnerable.
Helena Kennedy QC explained on BBC Any Questions last night that the burden of proof in criminal law was necessarily high, beyond reasonable doubt. This was to large degree a public policy consideration, so that the State and the public could feel safe in the convictions that the Crown had secured, and this necessarily was a good thing. Having a jury go through the evidence in detail was felt to be far superior to trial by media, argued by other panellists such as Kelvin Mackenzie.
I personally feel that we should not go down a path where ‘trial by media’ becomes superior to the criminal justice system. I feel that the public, especially law students, should be very careful about what they tweet in public, as the law and medical issues in this case are extremely complicated.
The author of this blogpost does not practice law or medicine, has postgraduate degrees in both, but has a strong academic interest in such matters.
Sue Marsh has just reminded that medicine is a wonderful profession
It is many years since I set foot in a hospital as a Doctor (in the early 2000s). The last decade however has taught me a huge amount about being a patient in the NHS, mainly from the time I completed accelerated neurorehabilitation after a six coma due to bacterial meningitis in 2006, which left me physically disabled.
In a nutshell, there’s no “ifs, ands, or buts”. Doctors, nurses, OTs, speech and language therapists, physios and health care professionals, I firmly believe, should be amongst the highest valued members of society.
However, Sue Marsh has just written a blogpost in the famous blog ‘Diary of a Benefit Scrounger’. This single blogpost has reminded me what an absolutely wonderful profession medicine is.
It is really an honour and privilege for those who work in it. Sue’s blogpost explains the importance of Doctors listening to the patient, and making use of all possible clues in making the correct diagnosis. They say that most of the history can be obtained from the history, even before examining the patient. Sue’s blogpost is a brilliant description of that. Sir Arthur Conan Doyle, more famous for having written the Sherlock Holmes detective novels, was a leading physician in his day-job, and a Fellow of the Royal College of Physicians.
Sue’s blogpost also should also remind Doctors that, instead of grabbing for the notes, it’s always worth listening to the patient directly. And above all the patient is always right, and knows more about his or her own condition that you do (if you’re a Doctor).
The legal and medical professions are protecting the public's faith in them
A Doctor from the NHS tells a man with a BA(Hons) in politics what he thinks about the NHS Bill, based on his experience of more than 30 years of working in the NHS. Many Doctors are concerned about the reputation of the medical profession amongst the general public, if this Bill is enacted, it is widely reported.
Andy Burnham MP, Shadow Secretary of State for Health, will repeal the Act (assuming it gets Royal Assent), if Labour wins the General Election of 2015.
Des Hudson, meanwhile, Chief Executive of the Law Society of England and Wales, was delighted this evening that their Lordships have inflicted a heavy defeat on the Legal Aid and Sentencing Bill. Like Clare Gerada, the Chair of the Royal College of General Practitioners, they do not enter public life to be political, but to uphold the professional standards of the groups the represent, including reputation of law and medicine in the general public.
ht: @DrEoinClarke
Should young children be subject to passive smoking?
The question about whether young people should be subject to passive smoking (or “second hand smoke” (SHS)) soon resolves an issue of the rights of the child or the responsibilities of the parent. A person may wish to exert autonomy over their desire to have a cigarette, but does his or her child have an overriding right not to be subject of that smoke? As is usual with the law, the judgment crucially deciding upon conflicting interests, and balancing their decisions to make an apt decision. Ethicists have long wondered who exactly confers these rights, how are they defined and on what basis (Hall, 2005)
In fact, it is tempting to believe that UK health policy exists in a total vacuum, when it comes to the outside world. This is in fact not true, because the UK is a signatory to the United Nations Convention on the Rights of the Child (UNCRC). Although UN Conventions do not have ‘the force of law’, countries do report at regular intervals to the relevant UN Committee on their progress in implementation. From a legal point, it is noteworthy that the UNCRC does not have the same force as the Human Rights Act, although it is widely quoted in policy documents (Hagger, 2005). The concept of “rights’” cannot change human behaviour, but it “adds an element of accountability and a legal framework that can be used to make governments wake up to their obligations to make things happen’”. (Hall, 2005)
It is therefore nonetheless encouraging that one of that the UK’s leading lung charities seems to be very serious about children and lung health.
One of their election points, in relation to the British Lung Foundation’s “Children’s Charter”, argues the following:
The BLF therefore believes that parents and carers should be given opportunities to learn how to keep young lungs healthy and that children should have the right to enjoy a smoke free environment both inside and outside of the home.
In some ways, this is reminiscent of the NHS Patient Charter, which had its oft-exhausted list of inherent strengths and weaknesses. Christine Farrell has done a very considerabke review of the NHS Charter process (Farrell, 1999). The weaknesses of the Charter were seen by patients and staff as falling within three categories although staff were much more vocal in their criticisms than patients and carers. The problem areas were categorized into three groups:
1. problems with standards and rights;
(From this point of view, it is worth noting therefore the phrasing of “opportunities to learn how…” is not trivial, given the previous problems in how people understand standards and rights. NHS staff and patients have in the past commented on the lack of clarity and the confusion about what was a “standard’ and what was a “right”. This is an issue much discussed in the literature too (Hogg, 1994; Bynoe, 1996).)
2. difficulties with monitoring;
3. patient expectations raised too high.
Smoking, lung disease and policy
A very recent study has looked in fact at the relationship between childhood environmental tobacco smoke (ETS) exposure and the development of subsequent lung disease (Lovasi et al. 2010) Mechanical stress to alveolar walls, the little units which make up our lungs, may cause progressive damage after an early-life insult such as exposure to environmental tobacco smoke. Childhood ETS exposure was assessed retrospectively as a report of living with one or more regular indoor smokers. Childhood ETS exposure was associated with detectable differences on computed tomography scans of adult lungs of nonsmokers.
Indeed, young children who are exposed to tobacco smoke are in general significantly more likely to develop health problems during childhood and in later life. who are exposed to second-hand smoke (Health Care Commission (2006), ATS (1999). Although parental smoking is the commonest source of ETS exposure to children, children are also unfortunately exposed to ETS in schools, restaurants, public places and public transport vehicles.
Apart from containing thousands of chemicals, the particle size in the ETS is much smaller than the main stream smoke, and therefore has a greater penetrability in the airways of children. Exposure to ETS has been shown to be associated with increased prevalence of upper respiratory tract infections, wheeze, asthma and lower respiratory tract infections. Therefore, arguably, an increased awareness of the harmful effects of ETS on children’s health is warranted for formulating health policy overall (Cheraghi and Salvi, 2009). Furthermore, specifically, environmental tobacco smoke exposure carries a number of risks for the developing lung of the fetus, infant and child. (Wallace, 2009)
Despite the recent campaigns to eliminate smoking and hinder the detrimental effects of passive smoking , actual smoking rates still increase worldwide. Several physiological systems, with the respiratory being the primary, are disrupted by PS and progressively deteriorate through chronic exposures. This is of particular importance in children, given that respiratory complications during childhood can be transferred to adulthood, lead to significantly inferior health profiles. (Metsios, Flouris, and Koutedakis 2009).
SHS exposure is a known cause of disease among non-smokers, contributing to lung cancer, heart disease, and sudden infant death syndrome, as well as other diseases. Yet thousands of children remain unprotected from exposure to SHS in private homes and cars. New initiatives targeting SHS in these spaces have raised ethical questions about imposing constraints on private behaviours (Jarvis and Malone, 2008) In the countries where the smoke free legislation was successfully implemented (Ireland, Italy, Scotland) there is evidence of reduced prevalence of the smoking induced diseases, especially acute coronary attacks (Kemp, 2009).
Summary
One would, arguably, want to follow one’s intuitions and to see a society where children’s lungs are not damaged to the actions of their parents or adults generally. However, the whole issue brings up the added problems of whether second-hand smoke or passive smoking does without doubt cause lung problems (is science infallible?) and, as a country, whether we can do anything other than ‘encourage opportunities’ rather than to ‘enforce rights’. It is not an electoral issue, however, and nor is it likely to become one. It might become, on the other hand, a very campaigning issue for charities such as the British Lung Foundation and the British Heart Foundation.
References
Bynoe, I. (1996), Beyond the Citizen’s Charter. New Directions for Social Rights, Institute for Public Policy Research, London.
Cheraghi, M, Salvi, S. Environmental tobacco smoke (ETS) and respiratory health in children. Eur J Pediatr. 2009 Aug;168(8):897-905. Epub 2009 Mar 20.
Farrell, C. The Patient’s Charter: a tool for quality improvement? International Journal of Health Care Quality Assurance 12/4 [1999] 129-134
Guyer, B, Ma, S, Grason, H, Frick, KD, Perry, DF, Sharkey, A, McIntosh, J. Early childhood health promotion and its life course health consequences. Acad Pediatr. 2009 May-Jun;9(3):142-149.e1-71.
Hall, DMB. Children, rights, and responsibilities. Arch Dis Child 2005;90:171–173. doi: 10.1136/adc.2004.053017
Health Care Commission report, Clearing the Air 2006
Hogg, C. (1994), Working with Users: Beyond the Patient’s Charter, Health Rights, London.
Jarvis, JA, Malone, RE. Children’s secondhand smoke exposure in private homes and cars: an ethical analysis. Am J Public Health. 2008 Dec;98(12):2140-5. Epub 2008 Oct 15.
Kemp, FB. Smoke free policies in Europe. An overview. Pneumologia. 2009 Jul-Sep;58(3):155-8.
Lovasi, GS, Diez Doux AV, Hoffman, EA, Kawut, SM, Jacobs, DR Jnr., Barr, RG. Association of environmental tobacco smoke exposure in childhood with early emphysema in adulthood among nonsmokers: the MESA-lung study. Am J Epidemiol. 2010 Jan 1;171(1):54-62. Epub 2009 Nov 25.
Metselos, GS, Flouris, AD, Koutedakis, Y. Passive smoking, asthma and allergy in children. Inflamm Allergy Drug Targets. 2009 Dec;8(5):348-52.
The American Thoracic Society (1999) Pulmonary rehabilitation, American Journal of Respiratory and Critical Care Medicine
Wallace, J, The respiratory effects of tobacco smoke exposure on the fetus and child. S D Med. 2009;Spec No:11-2.
The new @Legal_Recruit verbal reasoning practice assessment for law students
The @Legal_Recruit system (which will be available here) is a very attractive easy-to-use cloud-based service which will allow @Legal_Recruit learners to complete sample tests, under real assessment conditions.
It will be available on Monday 3 October 2011 for the first time.
Current law students, who are doing the GDL, LPC, LLB(Hons) or LLM, especially those who are seeking training contracts or vacation placements for 2013/4/5 being made available in the next academic year may find this new service/product useful. It will be available on the internet via a secure website, and will cost £7.50 for unrestricted lifetime use. All Legal Recruit learners will have their own secure website username and password, and be invited to participate in the development of the huge bank of validated questions. These questions are set in a fair way, with due attention to equality, diversity and culture.
This product has been built because it is felt by many that law students, the staff of their colleagues/universities (including their academics and their career services) and corporate law recruiting managers that the pivotal importance of the verbal reasoning test is grossly underestimated. This is not sensible, given the intense effort needed to complete any qualification in law. However, if your performance in a verbal reasoning test, and you fail to meet the cut-off score, it is possible that you will not be invited for interview, despite having a II.1 or above. This is clearly a tragedy.
Such practice will be ideal for any law students needing to complete a SHL Direct assessment for their real training contract/vacation placement application. Candidates are strongly advised to look, as a top priority, the practice tests in the practice area of the SHL website. There you can take a full-length verbal reasoning test which has been made available from the main SHL Direct website and it’s well worth looking at the example questions. You’ll also most likely enjoy looking at the advice given about verbal reasoning tests on leading corporate law recruitment sites, such as Eversheds and Clifford Chance. Obviously, Legal_Recruit does not actively endorse any of the entities above, or vice versa.
There will be very clear instructions in the @Legal_Recruit practice assessments which are akin to the current SHL verbal reasoning instructions. In the practice test, you are allowed to go backwards, although in the real assessment you will not be given this option. You must complete the practice examples before you do the test, and you are told not to press any function keys or do any background jobs such as printing during the test itself.
The word count per passage will ideally vary from 70 to 150, with a mean length of 107. Passages will avoid as far as possible the use of semi-colons, and be of no shorter than 8-10 words. They will be written in plain English, with no spelling or grammar errors. The passages will therefore avoid American spelling or American English. The mean number of words in a sentence will be about 15-20.
Assessments will consist of 30 questions, containing 15 passages (2 questions per passage). The 15 passages will be selected at random by the Legal_Recruit system from a huge database consisting of an equal number of questions in the following 16 subject areas.
- Biology
- Business
- Economics
- Education
- Engineering
- Environment
- Geography
- Geology
- Health and Safety
- Human resources
- Medicine
- Modern Languages
- Physics
- Technology
- Transport
@Legal_Recruit follows the leading twitter accounts in the world which daily produce news stories, which make excellent narratives for the verbal reasoning assessment that Legal_Recruit will be offering.
Legal_Recruit learners will be able to choose a maximum time permitted from 19 to 39 minutes; this is to that it’s easy to do the assessments with reasonable adjustments for learners who will benefit from them to allow them to perform on a ‘level-playing field’.
It’s interesting that there is no subject bias at all in the exemplars. Interestingly the passages appears to avoid contentious branding, politics, or subjects which are generally controversial.
It is essential for our system to work for our questions to be carefully set in keeping with the real verbal reasoning tests which our Legal_Recruit learners will face in their real assessments set by SHL for their training contract/vacation placements. If you would like to participate for free, and receive immediate feedback, in our sample assessments, please direct message @legalaware or @legal_recruit, and if there are any problems in me following you, please do let me know immediately, and I will remedy. We benefit from obtaining a huge bank of normative data, which indicates to us that all the questions are of the same (correct) standard, and from being able to give you an accurate indication of where you sit on the normal distribution curve.
You may enjoy following up-to-date developments in online psychometric assessment on the @SHLGROUP twitter feed.
Shibley Rahman personal message: Get outta my way!
As this year draws to its close, my father died on 10th November 2010. I cannot practice medicine or law yet despite being highly trained at postgraduate level, and I just have one message. I am very proud to have completed my Master of Law this December, which my father inspired me to do, and I am ecstatic about to begin a paid-for MBA here in London for two years given I am already a company director of my own e-learning company Law and Medicine Limited.
and
GET OUTTA MY WAY!
Cheers to you Kylie Minogue! I begin 2011 with optimism in the name of my father and my mother who is still alive.
