Newsletter - Queen's University Belfast

Newsletter
Northern Ireland Forum for Ethics in Medicine and Healthcare
http:// www.qub.ac.uk/methics
No. 1 DECEMBER 2004
Secretary’s Column
Welcome to the first issue of our revamped Ethics Forum Newsletter. This
issue contains information on forthcoming conferences and activities, including
notice of our AGM in December, and an announcement of the annual student
essay competition. There is also a summary of the responses received to the
questionnaire recently circulated to all members, and information on recent articles
of interest to our membership.
Although only one evening meeting has taken place during 2004, there has been
considerable activity behind the scenes. The Council has met on 5 occasions
during this year and undertaken a lengthy review and evaluation of the Forum’s
mission and future direction, which has been informed by the replies received to
the members’ questionnaire. An exploratory meeting with representatives of the
Office of Research Ethics Committees of Northern Ireland (ORECNI) has also
taken place to discuss ways in which our two organisations might work together to
the mutual benefit of both (a report is contained in this issue). A full programme of
meetings has now been arranged for 2005, and preparation of the new issue of the
Journal is now at an advanced stage. Proposals for establishment of workshops
and provision of formal ethics training are also under active consideration, and
compilation of a database of useful resource materials is being undertaken.
The intention is to publish 3 issues of the Newsletter and one volume of the
Journal annually. Members are encouraged to submit letters and comments,
announcements and reports for inclusion in the Newsletter, and also more
substantial articles for publication in the Journal. These publications will be
distributed by regular post and will also be available on the members’ section of
our website. Members are encouraged to visit the website regularly; we will
endeavour to develop and update the site as frequently as possible. Thank you for
your continued support and participation in the NI Ethics Forum. I look forward to
meeting with you all at our AGM,
David
Dr David Bell, Hon Secretary

Forthcoming Meetings
(Dates for your diary)
2 nd Year Medical Students at QUB will be debating the issue ‘Should
doctors who perform voluntary active euthanasia on their patients be punished?’
The debate will be chaired by Dr James Douglas (Consultant Nephrologist, BCH
Trust) and will be held at the QUB Lower Lecture Theatre, Institute of Clinical
Science, Royal Victoria Hospital on Wednesday 8 th December from 1.30pm-
3.30pm. All Forum Members are cordially invited to attend this debate.
Our next evening meeting will be a debate on the topic ‘Health Fascists and
Smokers’ Rights: banning smoking in public places’. Speakers will include Dr
John Catherwood (Lecturer in Applied Ethics, QUB) and Dr Gerry McElwee
(Ulster Cancer Foundation/Action on Smoking and Health).
The debate will be held on Wednesday 8 th December at 6.30pm in the
Postgraduate Lecture Theatre, Belfast City Hospital Trust and will be followed by
our Annual General Meeting 2004. A buffet tea will be served in the foyer of the
Postgraduate Centre from 6.00pm.
Members who have items they wish to have included on the agenda for the AGM
should forward these to the Honorary Secretary as soon as possible.
Our annual conference will take place on Saturday 5 th March 2005 at the Peter
Froggatt Centre, QUB, and will focus on the subject of ‘Stem Cell Research: what
can we do and what should we do?’ Confirmed speakers to date include: Dr Grant
Jordan (Trauma and Orthopaedic Surgery, QUB Medical School), Professor Tony
McGlennan (School of Law, University of Ulster), Father Gary Toman (Chaplain,
QUB) and Rev Dr William Crawley (Chaplain, UUJ, and presenter on BBC
Radio’s Sunday Sequence). Further information and registration forms will be
circulated to members in advance of the meeting.

A further evening meeting will be organised for late May/early June 2005.
Suggested themes currently under consideration by council include Withholding
Treatment, The Four Principles, and Designer Babies. Members are encouraged to
forward any alternative suggestions to the Council for consideration.
Previous Meetings
At our evening meeting held at 7 Lennoxvale on 24 th March 2004, members
engaged in an excellent debate on the topic ‘Are disabled people made in God’s
image?’ It was particularly good to welcome a number of new members to the
Forum, including some new student members. Our thanks are extended to our
speakers, Rev Dr Harold Cunningham (Institute of Theology, QUB) and Rev Dr
Alan Russell (Ballywalter Presbyterian Church) for a stimulating exploration of
the issues. Their key arguments will be summarised in the forthcoming edition of
the Forum’s Journal.
Undergraduate Student Essay Competition
The NI Ethics Forum Essay Competition is held annually. This year a prize of
£100 will be awarded for the best undergraduate student essay on a topic of the
entrant’s own choice within the broad remit of ‘health and social care ethics’. The
competition is open to all registered undergraduate students within any Faculty in
Queen’s University Belfast or the University of Ulster.
Essays (recommended word limit 1,500 words) should be word-processed
(double-spaced, A4) and two copies submitted to the Honorary Secretary before
the closing date of Friday 13 th May, 2005. Suggested essay topics include:-
Legalisation of VAE; withholding and withdrawing treatment; Human Tissue Bill;
Organ Transplantation; Abortion; Designer Babies; Ethical issues in Health
Promotion; Ethical issues in Reproductive Technologies; Stem Cell Research;
healthcare rationing; social equality, discrimination and rights.
The above list is not exhaustive and entrants may wish to write on an alternative
topic of their own choosing. Further information can be provided on request.
Members, particularly those who hold academic appointments in either University,
are asked to bring this competition to the attention of undergraduate students in
their Schools and Faculties.
The Council are also giving active consideration to provision of a postgraduate
student prize; further information about this will be disseminated shortly.

Formation Of The Office for Research Ethics Committees in Northern Ireland
New ethical review arrangements for research involving human subjects, tissue or
data came into force in Northern Ireland on 1 st May 2004, to comply with a
European Union Directive on Clinical Trials. HPSS Research Ethics Committees
have been established by the DHSSPS, with members appointed through a public
appointment process. These committees are generalist (that is, capable of
considering the ethics of all proposed research projects which involve human
subjects, their tissue or data in relation to biomedical and social care research) and
each has a remit covering the whole of Northern Ireland, meeting monthly, thereby
creating a system where a committee will meet most weeks of the year, capable of
reviewing any research proposal.
The mission of OREC is to support Research Ethics Committee arrangements in
Northern Ireland, and to ensure that HPSS RECs are able to comply with
Governance Arrangements for Research Ethics Committees (GAfREC) and the
Medicines for Human Use (Clinical Trials) Regulations 2004 (UK Regulations
2004). These regulations transpose the European Directive 2001/20/EC relating to
good clinical practice in the conduct of trials on medicinal products for human use.
OREC will work closely with the Department of Health, Social Services & Public
Safety (DHSSPS) to ensure that the new arrangements are fit for purpose, and that
the HPSS REC chairs, members, researchers, HPSS managers and the wider
community all understand the new arrangements for ethical review.
Council members of the Northern Ireland Forum for Ethics in Medicine and
Healthcare recently held exploratory talks with representatives of ORECNI, to
identify areas in which we might be able to work together for the mutual benefit of
both organisations. Areas in which co-operation might be possible include
occasional joint meetings such as our forthcoming conference on Stem Cell
Research, organisation of more regular joint workshops on a smaller scale to
address topics of specific interest to sections of our membership such as the
implications of the Human Tissue Bill, Ethical issues in Genetics, Ethics of Drugbased
Research to mention just a few, and provision of expert speakers from
amongst the membership of the Ethics Forum and/or pooling of resources to invite
keynote speakers from outside of Northern Ireland to facilitate identified training
needs of HPSS REC members and our own membership. It is hoped that a fruitful
partnership between our respective organisations can be forged and Council will
keep members updated as discussions progress.
Further information about the new ethical review arrangements are available via
the ORECNI website http://www.orecni.org.uk

Questionnaire
A questionnaire was distributed to the membership in March. Although the
number of replies received was relatively small (~30) a number of trends did
emerge and the information provided has been of assistance to Council in planning
future meetings and activities.
The consensus was that the Forum should hold two weekday evening meetings,
and a full or half-day Saturday conference annually, with the venue alternating
between QUB, RVH/BCH and a venue outside of the Greater Belfast Area (for
example, University of Ulster, or the Craigavon, Antrim or Altnagelvin Trusts).
Members favoured meetings focused on a single topic with a panel of speakers
exploring the topic from various angles, before opening the meeting to plenary
discussion. A number of topics and potential speakers were identified and Council
are actively pursuing some of these. There was also interest in forging links with
other Ethics Associations within the British Isles, with a view to occasional joint
meetings and sharing of resources. This suggestion will be explored by Council.
The majority of respondents favoured the facilitation by the Forum of a
programme of workshops during the year, ideally for 10-20 participants, to explore
topics of particular interest to each grouping in greater depth. Consideration would
also be given to the formation of working groups, meeting regularly and focusing
on emerging developments in regard to specific issues and themes, for example,
end of life decisions, reproductive technology, genetics etc. Council will
endeavour to meet these requests and to identify members with expertise in the
appropriate areas to facilitate such initiatives.
A number of respondents already contribute to delivery of ethics teaching within
QUB and the University of Ulster, particularly through the student selected
component programme for medical students, inter-professional education for
nurses, doctors and pharmacists, and ethics modules within undergraduate and
specialist practice Nursing, Law, Theology and Philosophy. A report on the
integration of ethics teaching within the undergraduate medical curriculum in
Northern Ireland has been compiled by Bob Taylor and will be featured in the
forthcoming issue of the Journal. A number of NHS clinicians have expressed
interest in contributing to undergraduate ethics training, and consideration is also
being given to introduction of an intercalated BMedSc degree in Healthcare Ethics
and Law for QUB Medical students.
Several respondents already possessed a formal qualification in Healthcare Ethics
(certificate, diploma, MA, MPhil), but many of those who did not at present,
indicated that they would be very interested in undertaking an appropriate course.

While this is primarily an issue for the Universities within Northern Ireland, the
Forum will actively support any proposals to enable introduction of such a course.
In regard to publications, preference was evenly divided between email or
hardcopy of the Newsletter (the current issue has been sent by regular post, and
was also emailed to those members who had provided an email address.). More
effective use should be made of the Newsletter to disseminate information
regularly to members, advise them of the matters discussed by Council, and
highlight resources of interest, such as papers published recently in Ethics’
Journals. The majority of respondents favoured receiving a hardcopy of the
Forum’s own Journal. In response to suggestions received, the forthcoming issue
will contain papers presented at recent meetings, but also articles from student
members, invited contributions from specialists in particular fields, and updates on
local, national and international debates/cases of ethical interest.
The Website is accessed relatively infrequently by members at present. In addition
to mission statement and membership application form, contact details of Council
Members and Register of Members’ Interests to facilitate networking, information
about forthcoming meetings, and copies of our Newsletter and Journal, it was felt
that the discussion forum and links to useful sites/sources of information should be
a priority. Council will endeavour to address this matter, and the Secretary will
continue to liaise closely with Karen Agnew, whose assistance in development and
maintenance of the website is much appreciated. In future, access to the discussion
forum, resource materials and Forum publications will be restricted to members
only. Usernames and passwords can be obtained from the Secretary.
Membership Database
The membership database is currently being updated. Although the previous
database compiled over a period of several years contained 270 names, not all
members had remained active in the Forum and were in good standing, and many
contact details, especially email addresses are not correct. In response to the recent
mail-shot 57 members have updated their membership details, and a further 23
members have not updated their membership details but continue to pay
subscription fees by standing order, making a total active membership of
approximately 80. Those who have not already done so are encouraged to renew
their membership and update their membership details as soon as possible.
A new leaflet /brochure is currently being printed, and we would request the
assistance of all of our members in recruiting colleagues to the Forum. Academic
staff are asked to help with publicising the work of the Forum amongst the student
community. Copies of the leaflet can be obtained from the Honorary Secretary.

Recent articles of interest published in the Journal of Medical Ethics:
Gillon, R. Ethics needs principles- four can encompass the rest- and respect for
autonomy should be first among equals. J Med Ethics, 29: 307-312, 2003
Boyle, R.J., Salter, R., Arnander M.W. Ethics of refusing parental requests to
withhold or withdraw treatment from their premature baby. J Med Ethics, 30: 402-
405, 2004.
Towns, C.R., Jones, D.G. Stem cells, embryos and the environment: a context for
both science and ethics. J Med Ethics, 30: 410-413, 2004.
Van Delden, J.J.M. The unfeasibility of requests for euthanasia in advance
directives. J Med Ethics, 30: 447-451, 2004.
Preece, P., Roff, S. Helping medical students to find their moral compasses:
ethics teaching for second and third year undergraduates. J Med Ethics, 30: 490-
493.
Recommended Training Resources
The Ethics OSCE: standardised patient scenarios for teaching and evaluating
bioethics. Produced by EFPO (Educating Future Physicians for Ontario). A series
of twelve scenarios, accompanied by a training materials and a video, focusing on
issues including decisions to forego treatment, confidentiality and truth telling.
http://wings.buffalo.edu/faculty/research/ bioethics/osce.html
Medical Ethics: a case based approach.
Editors: Schwartz, L, Preece, P.E., Hendry, R.A.
2002: Saunders, London
Medical Ethics and Law: the core curriculum.
Editors: Hope, T., Savulescu, J., Hendrick, J.
2003: Churchill Livingstone, London

Legal Briefs: a roundup of some recent significant law cases
! General Medical Council
! Shipman Inquiry
! Coroners Courts
! Misconduct
! Consent
! Mental Health
! General Medical Council
It has not been a good year for the GMC, for the second year in succession. Since
the beginning of 2002, there has been an unprecedented number of determinations
of the Professional Conduct Committee overturned or dismissed by the Privy
Council who, since 2 nd October 2000, are required to judge the decision-making of
the GMC’s tribunals and panels in the light of the Human Rights Act 1998 and the
European Convention on Human Rights. Of the 15 appeals which their Lordships
heard, two appellants had their erasures reduced to lesser punishments and one had
his finding overturned. Twelve others were dismissed.
But the most significant threat to the GMC’s much-prized independence came
from a newly established statutory body, initially called the Council for the
Regulation of Healthcare Professionals (CRHP) and now re-named the Council for
Healthcare Regulatory Excellence (CHRE). In October 2004 it won a test case
establishing its right of referral to the English High Court to a penalty imposed
upon a doctor by the GMC considering it ‘too lenient’ and ‘inadequate’. Council
for the Regulation of Healthcare Professionals v. General Medical Council
and Ruscillo [2004] EWCA Civ 1356. Additional new evidence of misconduct
could also be brought to the attention of the High Court in such a case by the
CRHP if it was truly in the public interest and the GMC’s penalty was ‘manifestly
inappropriate’. The new CHRE intends to exercise it regulatory role even more
robustly in future, on foot of this precedent.
! Shipman Inquiry
The suicide by hanging of Dr. Harold Shipman in January 2004 did little to avert
the attention of Dame Janet Smith’s Inquiry into the murders of his 260 victims.
From the outset, the GMC realised that it could not escape censure, having treated
Shipman too lightly in 1976 when his drug-dependency first came to light in the
criminal courts and failing to ‘protect patients’ by inadequately supervising his
professional career. What came as a profound shock to the Council was the
vehemence of Dame Janet’s criticism, conveyed to the GMC in the form of a

‘salmon letter’ in February 2004, which is used by inquiries to notify interested
parties of their exposed position and inviting supplementary depositions in their
defence. Following personal presentations of the Council’s position before the
Inquiry by Sir Graeme Catto, President, and Finlay Scott, Chief Executive, the
letter accused the GMC of being self-serving, biased in favour of doctors, too
secretive, and of acting through “expediency rather than principle.” Whether the
Council’s rebuttal has mollified the Inquiry’s criticism will be apparent when
Phase 5 of the Shipman Inquiry is published in early 2005. Senior lay Council
members are already rehearsing a Requiem for the GMC.
Seven doctors are facing disciplinary action before the GMC’s Fitness to Practice
procedures, six GPs and one pathologist. The GPs had worked in practices
adjacent to Dr. Shipman’s, a single-handed GP, and were implicated in the
completion of an unusually high number of Cremation Certificates at his request,
which they attributed to a demographic age skew. The death following the
administration of a high dose of morphine on an asthmatic patient was not so
easily explained statistically by the pathologist. However, in October 2004, the
GMC cleared him of serious professional misconduct charges referred by Dane
Janet Smith’s Inquiry. Now retired, he was commended by the GMC for the
‘quality of his testimonials’. The Professional Conduct Committee refused to
speculate on whether any lives might have been saved had he detected the ‘alarm
bells’ ringing in 1995. But the reader may wish to.
! Coroners Courts
2004 has proved to be a critical year in the development of a new jurisprudence for
the Coroners Courts in both the Northern Ireland and the English jurisdictions. It
has undergone a paradigm shift following the House of Lords decision in 11
March 2004, R (Middleton) v. West Somerset Coroner and Another [2004]
UKHL 10. Prior to this judgment coroners and juries were prohibited from
commenting beyond the immediate ‘cause of death’ in a narrow verdict (or
‘findings’ in Northern Ireland). Since the decision in Middleton, our Coroners
Courts have been inquiring into the ‘broad circumstances surrounding a death’, a
much wider remit. Already the Coroner’s extended inquisition has begun to
comment upon ‘systems failures’ in our hospitals and amongst our healthcare
professionals. Under Rule 23 (2) of the Coroners (Procedures and Practice) Rules
(NI) Act 1963, the Coroner has had the responsibility of informing a regulator,
such as the GMC, in order to prevent recurrence of similar systems failures in
future. In the past this was rarely used but now combined with Middleton, Rule
23(2) is likely to be used with increasing frequency to facilitate the Coroner in the
application of his or her preventative role. With its new investigative function, the
GMC may have to shift its attention beyond sanctioning individual doctors, who
are too often juniors, towards a more systematic analysis approach. If the GMC is
unable to do so, the Government may consider abolishing it self-regulation and

eplace the Council with a generic regulator body composed of users rather than
providers.
In the Northern Ireland Court of Appeal an equally progressive judgement was
delivered on 10 September 2004. In Jordan, Re: Application for Judicial Review
[2004] NICA 29 and 30, the Court dealt with the issue of whether to apply the
Human Rights Act 1998 to inquests into deaths occurring before October 2000,
when the Act first came into effect. A backlog of such cases awaiting inquest since
1992 includes the so called ‘shoot-to-kills’ involving allegations of state collusions
in the fatal shootings of paramilitaries. This judgment confirmed the relevance of
Middleton to Northern Ireland inquests. While acknowledging that the Human
Rights Act could not be applied retrospectively, the NI Coroners Courts would
operate any future inquest in a manner compliant with the European Convention
on Human Rights Article 2, ‘The Right to Life’. In so doing, our Northern Ireland
Coroners will assert their independence beyond question. The healthcare
profession will be shown the usual courtesy but they should not expect to be
shown undue deference. They should be warned that the modern coroner is not
medically illiterate just because he is a lawyer.
! Misconduct - sexual
Professional Conduct Committees of the GMC still have a proper interest in the
sexual misconduct of registered medical practitioners, though it is much more
tolerant of some earlier taboos. In the recent ‘Operation Ore’ into the internet
access of child pornography, the police arrested over 3500 people, convicting
1230. As a result of the notification of these criminal convictions involving
doctors, the GMC has amended its ‘sanctions guidance’ in order to be clearer and
more consistent in its approach, speed of action being critical. So far, two doctors
have been struck off and two suspended. Nothing but exceptional mitigating
circumstances might avoid the “only proportionate sanction – erasure”. Of
course, inclusion on the sex offenders’ register for a minimum of five years is
automatic with such a criminal conviction.
! Consent
In Chester v Afshar [2004] UKHL 41, the House of Lords upheld the English
Court of Appeal decision that a patient whose doctor failed to warn her of a risk
inherent in surgery to which he was obtaining her consent and who suffered injury
when the risk eventuated, sufficiently satisfied the test for causation where she
could prove that if she had been properly informed she would not have undergone
the surgery which was in fact performed. The patient in this case had consented to
lumbar surgery from a neurosurgeon but suffered post-operative partial paralysis
of which she had not been warned. Even though the operator was in no way

negligent, he was judged as not having received informed consent. Their
Lordship’s decision was a departure from the long standing principle which
previously would have been expected to hold that the surgeon’s negligent failure
to warn had not caused her injury. In future, do not suppose that a simple consent
form can be considered sufficient to avoid liability in similar circumstances.
! Mental Health
In October 2004, in H.L. v United Kingdom (application no. 45508/99), the
European Court of Human Rights ruled that the human right of liberty of a 55 year
old man, known only as HL, was violated by his being detained informally in a
psychiatric hospital for more than four months. In the instant case, the man was
suffering from a learning disability, autism, but the judgment has wider
implications for other apparently ‘compliant’ patients with dementia, who lack the
capacity to consent or to object to treatment. An earlier judgment by the House of
Lords held that his detention was permissible under common law, using
‘necessity’ as justification. Parliament is likely to amend the English Mental
Capacity Bill on foot of it. The government’s Mental Health Bill for E&W is also
under fire from both the Law Society and the Royal College of Psychiatrist as the
proposed legislation is likely to breach patients’ human rights. An out-patient
engaging in “specific conduct” which has been banned by the community
psychiatric team may result in an involuntary detention. So, a trip to the pub could
cost a patient his or her liberty. In addition, patients with mental health problems
will become even more stigmatised as a danger to the community. The Royal
College has described the draft bill as “extremely complex, confusing and, some
would say, incomprehensible”. It could induce even more confusion in the minds
of the doctors than of the patients.
Readers are advised that the website of BAILII (the British and Irish Legal
Information Institute) is a direct access site which is free of charge. Using its
Search Engine, a particular case may be located using the case citations given
below at http://www.bailii.org
Thanks are extended to Dr John Burton for compiling this very informative
round-up. In the next issue of the newsletter, John will focus on recent law
cases related to paediatric healthcare issues.

Murder or Mercy?
The Forum extends congratulations to Dr Vivienne Crawford and Dr David Bell
from the Faculty of Medicine and Health Sciences on receiving a QUB Teaching
Award for the 2 nd Year Undergraduate Medicine module, ‘Murder or Mercy? : the
euthanasia debate’. Several members of the Forum contribute to this module
including Dr Bob Taylor (RBHSC), Ann Begley (QUB School of Nursing), Rev
Dr Harold Cunningham (Institute of Theology), Marie Lynch (QUB School of
Law) and Dr John Catherwood (QUB Department of Philosophy), together with
the BCH and RVH Hospital Chaplaincy Services, QUB Chaplains, and staff of
paediatric and adult ICUs at RVH, and the NI Children’s Hospice. Well done to
all concerned!! This module will be showcased in our forthcoming Journal.
Composition of Council
A number of vacancies have arisen on Council and we would like to increase
representation from a number of areas, particularly nursing and midwifery, law
and genetics in order to reflect the broad nature of the Forum’s membership. We
are also seeking representation from amongst the academic staff of the University
of Ulster. Nominations, together with names of proposer and seconder, and
confirmation that the person nominated has agreed to their name going forward for
consideration, should be submitted to the Honorary Secretary in advance of AGM
on 8 th December. Our thanks are expressed to Professor Roy McClelland and
Professor Tony McGlennan for their sterling contribution to the work of the
Council since the formation of the NI Ethics Forum. Both have recently indicated
their intention to retire from Council at the forthcoming AGM.
The next issue of the Newsletter will be published in April 2005.
Contributions for inclusion should be submitted to the Honorary Secretary not
later than 31 st March 2005
Dr David Bell, Hon. Secretary,
Northern Ireland Ethics Forum,
Department of Therapeutics and Pharmacology,
School of Medicine, QUB
Whitla Medical Building,
97 Lisburn Road, Belfast BT9 7BL
Tel: 02890 335770
Email: d.bell@qub.ac.uk