Demands and requests for ‘inappropriate’ or ‘inadvisable’ treatments at the end of life: what do you do at 2 o’clock in the morning when …?

Abstract

In an era when healthcare has become increasingly complex and patient expectations are higher than ever before, we can find the decision-making process for patients, potentially at the end of their lives, increasingly difficult. In the shift from paternalism to patient choice, we can struggle to know what to do when faced with a patient, their family, or both requesting or demanding inadvisable, inappropriate, or futile treatments. It can feel as if we are being asked to subject patients to intrusions and interventions that ‘just feel wrong’. In this article, we aim to look at how ethical frameworks, legal statute, case law, and professional guidance, as they apply in the UK, interact when we make these decisions, and we discuss some of the conflicts and challenges that such guidance pose.

What do you do at 2 o’clock in the morning when a patient, their family, or both request a treatment that you feel is inadvisable, inappropriate, not in their best interests, or futile? This question demonstrates the dilemma often faced when making potential end-of-life care decisions. The question, although relating to an acute, urgent situation, could equally be applied to any end-of-life decision where fundamental differences exist between what the clinician and the patient (or their family, or both) feel is appropriate. Should we err on the side of the patient’s autonomous wishes or should we do what we feel, in our professional ‘medical’ opinion, is right for the patient, despite the worry that, should this difference of opinion escalate, we may end up in court?

A lack of understanding on our part may contribute to this dilemma. We may feel comfortable from a clinical perspective in our decision-making, but are we altogether at ease with the legal and ethical perspectives? It can, at times, feel as though we are making decisions driven by fear of litigation, rather than in our patients’ best interests. With an increasing legal and ethical emphasis on patient autonomy,^1,2 are we now in the position of simply asking patients, ‘What do you want us to do?’. With that comes the worry for many that we may be moving away from being professionals, with a lifetime of experience in making these difficult decisions, to becoming simply physiological technicians, acquiescing to potentially unrealistic expectations. As trained professionals, we have a moral imperative to use our training, experience, and knowledge to benefit our patients.

The authors appreciate that there are numerous, often complex reasons why patients and their families make such requests and demands. All are personal and important to them and should be considered sensitively and thoughtfully. Exploring these reasons and recognizing when potential conflicts in opinion are arising is fundamental in preventing escalation of such situations.

In this article, we explore the professional guidance, legal statute, case law, and ethical frameworks that help to steer us when such challenging situations arise. As we will see, however, the guidance can only ever be just that. Putting it into practice is often much easier said than done.

Clinical and professional guidance

Extensive guidance exists to aid decision-making at the end of a patient’s life. Both the General Medical Council (GMC)³ and the British Medical Association (BMA) guidance⁴ in this regard are fundamental reading for any doctor. The former is certainly the benchmark by which any doctor is judged should they unfortunately face a ‘Fitness to Practice Panel’ over any of their clinical decisions taken in this area. It is not the intention of this article to provide a summary of or to repeat this guidance, and the authors cannot stress enough the importance for those who are involved in end-of-life decision-making to familiarize themselves with this guidance.

These end-of-life situations highlight repeated themes of conflicting interests of patients, clinicians, and society. Patients have an interest in receiving care that is consistent with their values and preferences; clinicians in not being compelled to act against their professional judgement; and society in protecting individual rights, fostering professionalism in its clinicians, and ensuring fair allocation of resources.⁵

In essence, the GMC guidance sounds obvious: use ‘specialist knowledge and experience and clinical judgement’ and the ‘patient’s views and understanding of their condition’ to identify which investigations or treatments are clinically appropriate and likely to result in overall benefit for the patient.³

Decision-making for patients with capacity

For competent patients, this is relatively straightforward; patients weigh up their various options and any non-clinical issues that are relevant to them and decide whether to accept or refuse any or all of the options (which, of course, competent patients are ethically and legally entitled to do no matter how irrational we may deem their decisions to be).³

Difficulty can arise, however, if patients ask for treatments we consider clinically inappropriate. The GMC guidance (based upon the case of Burke v GMC)⁶ states that doctors ‘do not have to provide the treatment’.³ In reality, the guidance and good practice dictate that we should do the following: explain why we consider the treatment inappropriate; discuss other options available to them, including advice from a more experienced colleague; and offer a second opinion or offer advice from the local ethics committee or mediation service (if available). If, despite these measures, significant disagreement persists, the advice is that we should seek counsel from our legal colleagues. Navigating through difficult and contentious ethical decisions is, after all, what courts do, and where significant conflict exists, it is the court that is the ultimate arbiter in deciding where a patient’s best interests lie.³ However, this is not without its own problems. Whilst a court can rule upon what is lawful or not, it is rightly reluctant to dictate to doctors that they must provide (or withdraw) treatments that the doctors themselves consider clinically and ethically inappropriate or inadvisable. For example, in the case of Miss B v An NHS Trust, this necessitated transfer of the patient to another unit, where the treatment in question (namely her ongoing artificial ventilation) was subsequently withdrawn.⁷

Decision-making in the incapacitated patient

The above is all very well for competent patients. However, the difficulty for intensive care patients is that by the time ‘end-of-life’ decisions are being made, patients are often, by virtue of their illness, lacking in capacity. In these circumstances, under statutory law in England and Wales (courtesy of the Mental Capacity Act 2005)⁸ and Scotland (Adults with Incapacity Act 2000),⁹ whether and what treatment is provided is determined by what would be of benefit to and in the best interests of the patient. As we shall subsequently discuss, establishing benefit and best interests in practice is exceptionally complicated. Who gets the final say in this can be just as problematic. If the patient has a Lasting Power of Attorney (LPA) in place for their welfare, things are relatively straightforward. Where one exists, the LPA effectively steps into the shoes of the patient in terms of being able to provide consent to receive treatment on behalf of the patient. In the absence of this, however, it is a common myth to assume that loved ones, a named next of kin, or both can consent on the patient’s behalf. They cannot. What they can do (courtesy of the statutory law) is give an indication as to what the former competent patient may have considered to be in their own interests, and it is this information that helps to determine where the patient’s ultimate best interests lie. As the GMC guidance states,³ it is important to be clear about this, as at times relatives may be left feeling that they are being asked to make the difficult decision as to whether or not to treat. If conflict arises between the healthcare team and the loved ones or next of kin (or indeed between members of a healthcare team) as to what is in the best interests of the incompetent patient, then the path for resolution of that conflict is no different from that described above for the competent patient.

At 2 o’clock in the morning, with an urgent decision needing to be made, the number of these ‘conflict resolution’ options available may be few, leaving the on-call physician at a loss as to how best to proceed.

Where the doctor feels that further treatment is inappropriate, the BMA reiterates the GMC guidance; if the treatment would not ‘achieve any clinical benefit to the patient, for example because it is unable to achieve its physiological aim, the healthcare team should not offer it’.⁴ A patient’s wishes should always be discussed with them (assuming, of course, that they have capacity), but the fact that a patient has requested a particular treatment ‘does not mean that it must always be provided’.⁴ We should make efforts to comply with ‘reasonable requests … about the provision of life-prolonging treatment’. However, the decision regarding what treatment to offer rests with the clinician.

But the same guidance also suggests that there may, in fact, be arguments for complying with requests from patients for treatment to be continued or at least provided for a ‘limited period’. For patients holding views that there is ‘intrinsic value in being alive’, provision of life-prolonging treatment would, ‘in virtually all cases, provide a net benefit’.⁴ ‘Virtually all’ in this context seems to imply that withholding treatment because it is not in their best interests would be a rare event.¹⁰

Thus, it appears that there is a degree of contradiction in the professional guidance. The GMC guidance states that we may offer patients treatments that we feel are ‘clinically appropriate’ and of ‘greatest benefit’, which the patient can accept or decline, but for requests we feel are inappropriate, we ‘do not have to provide the treatment’.³ On the contrary, from BMA guidance, if the patient feels there is benefit to receiving those treatments, despite us deeming them inappropriate, inadvisable, or futile, there may be arguments to consider complying with these requests in certain life-and-death scenarios.⁴ Understandably, conflicting guidance can leave clinicians feeling confused, particularly in the early hours of the morning. Sadly, there is rarely a black-and-white answer that fits all situations. Difficult decisions are difficult whether ‘the decision is taken in court rather than at a patient’s bedside’.¹¹

Ethical concepts

Guidelines are all very well but, as any practising doctor is fully aware, there is no escaping the grip that various ethical paradigms have upon our decisions these days. Although not exhaustive, consideration of best interests (BI), futility, sanctity of life, quality of life, and ‘justice rights’ are essential when undertaking complex decision-making.

Sanctity and quality of life

Ethical arguments abound as to whether sanctity of life should take precedent over quality of life, and even the Law Lords have struggled with the conflict between the two.¹² Suffice (for the purposes of this article) to say, that whilst the sanctity of life is one of law’s fundamental principles and one ‘long recognised … in our own society’ and ‘in most civilised societies’,¹² it does not place upon clinicians an obligation to preserve life at all costs. Sanctity of life as an ethical concept has previously been used as justification for not withdrawing treatment. In the case of W v M, it was deemed unlawful to remove artificial nutrition and hydration in a patient in a minimally conscious state, despite the efforts of the patient’s family to persuade the judge that the patient would never have wanted to have lived in such circumstances¹³ (see Table 1). Subsequent to this decision in the case of M v N [2015],¹⁴ the presumption of prolonging life was rebutted on the basis of the known wishes of an incapacitated adult. The inviolability of life has to be weighed against an individual’s right to self-determination and personal autonomy.

Baroness Butler-Sloss addressed whether the introduction of the Human Rights Act (1998),¹⁵ in particular Article 2 (the right to life), imposed a legal obligation for doctors to preserve life at all cost. She ruled that the cessation of artificial nutrition and hydration in two patients in a permanent vegetative state did not contravene Article 2, because it did ‘not impose an absolute obligation to treat if such treatment would be futile’. The State only had a positive obligation to provide life-sustaining treatment if it was in patients’ best interests.¹⁶

Equally, the use of terms such as ‘quality of life’ can be problematic and ambiguous. Despite this, the courts have ruled that the quality of life which could reasonably be expected after treatment is an appropriate factor to take into account when making treatment decisions,⁴ and quality-of-life arguments have been used in sanctioning decisions relating to both treatment withdrawal¹² and provision.¹⁷

But what of ‘futility’ and ‘best interests’ (BI) as referenced by Butler-Sloss LJ in the case above? Just how easy are these concepts for the clinician to get his or her head around at 2 o’clock in the morning?

Futility

Debate has raged in relationship to what constitutes futility, and even the courts have struggled how best to define it.^18–20 Treatment may be physiologically futile, in that it may not achieve its physiological goal, or it may be potentially ‘qualitatively’ futile, in that whilst achieving its physiological goal, it may not leave the patient with a quality of life that they would in fact wish. Additionally, if a patient and their doctor differ as to what is ‘futile’ and what the ‘burdens’ and ‘benefits’ of treatment are, there is unlikely to be agreement on how best to proceed. Increasingly, therefore, futility is being acknowledged as a problematic concept,⁴ and its use may be on the decline. Indeed, a recent consensus statement concluded that ‘futile’ ‘should only be used in the rare circumstances that an intervention … cannot accomplish the intended physiologic goal’, and if defined, ‘clinicians should not provide futile interventions’.⁵ The consensus statement further suggested that ‘Potentially inappropriate’ should be used, rather than ‘futile’, to describe those treatments that have ‘at least some chance of accomplishing the effect sought by the patient but clinicians believe … competing ethical considerations justify not providing them’.⁵

Best interests (BI)

As explained above, ‘best interests’ is the hallmark legal test in determining treatment decisions for the incapacitated. The ‘best interests’ (BI) test was first established in UK law in the matter concerning patient F (Re F).²¹ Although this case pertained to the sterilization of an incompetent woman rather than treatment withdrawal, it was instrumental in hailing BI as the definitive test for medical treatment for the incompetent. Lord Donaldson declared that courts should ask what course of action is best calculated to promote the true welfare and interests of an incompetent patient and that treatment should be based upon whether it was in their best interests or not.²¹ ‘Best interests’ was viewed as equally valid in cases concerning the termination of life-sustaining treatment in the incapacitated, with Lord Goff deeming best interests central to decision making in Airedale NHS Trust v Bland²² and Taylor LJ applying it to withdrawal decisions in children in Re J.²³

The Mental Capacity Act 2005⁸ has meant that ‘best interests’ has progressed from common law cases into statutory law. However, it has not been immune from attack. Taylor LJ acknowledged in Re J that the phrase ‘best interests’ was one ‘easily said but not easily applied’.²³ It has been described as ‘vague rhetoric’ used by courts as a ‘mantra’ that has ‘obscure[d] the complexities of the decision making process’,²⁴ and, echoing Taylor LJ above, best interests is a phrase ‘easy to utter and difficult to interpret’.²⁵

Which factors determine BI was addressed in Re A, when Butler-Sloss LJ defined ‘best interests’ as ‘encompass[ing] medical, emotional and all other welfare issues’.²⁶ In the Aintree University Hospital v James judgement, the key defining point that has shaped subsequent case law on medical treatment was ‘when considering whether a treatment offers a prospect of recovery, “recovery” does not mean a return to full health, but the resumption of a quality of life which the patient would regard as worthwhile’.²⁰ Importantly, therefore, best interests is not simply seen solely in ‘medical terms’, and clinicians must be aware of the other elements of the test, commonly referred to as ‘wider best interests’.

However, defining what constitutes these elements remains problematic.

‘Intolerability’ as a benchmark for BI was voiced in Re J.²³ In determining whether it was in the child’s best interests to withhold life-sustaining treatment, one had to consider whether ‘life would be so afflicted as to be intolerable to that child’. But ‘intolerability’ has not won unanimous favour as the determinative factor of BI. Defining intolerability and determining what would be intolerable and to whom is difficult. What may be viewed as intolerable depends from whose viewpoint it is seen.²⁷ As with quality of life, only patients themselves know what would and would not be intolerable, and as for young infants and neonates, how can one possibly know what they consider to be intolerable?

Several court cases have highlighted the problem in using only one parameter to define the test, including that of Portsmouth NHS Trust v Wyatt (Table 2).²⁸

The Court of Appeal in Burke v The General Medical Council⁶ also dismissed intolerability as a defining factor, declaring it an inappropriate solitary hallmark of best interests and that it was not ‘possible to attempt to define what is in the best interests … by a single test, applicable in all circumstances’.⁶ Likewise, in Aintree v James Court of Appeal ruling, intolerability was viewed as only ‘one of the many circumstances to take into account’.²⁹

If other circumstances should be considered in determining best interests, what should they be and how should they jostle for position in concluding the outcome of the decision? The Code of Practice for the Mental Capacity Act³⁰ gives a useful list of factors to take into consideration when determining a patient’s best interests, and the authors recommend reading the helpful summary in the GMC guidance.³

Attempts have been made in previous cases to put these factors into some sort of ‘balance sheet’.²⁶ This involved listing the pros and cons, the benefits and burdens, and the losses and gains of providing or withholding treatment. If the account is in credit, the application is likely to advance the best interests of the claimant.²⁶ Although this approach sounds logically appealing, the ultimate decision reached in terms of withholding or continuing treatment has not always matched the balance sheet; for example, in the case of W v M (Table 1).¹³

Therefore, despite it being in statute, ‘best interests’ does not appear to represent the perfect test. Perhaps Hedley J’s ruling in Portsmouth NHS Trust v Wyatt best summarizes the problem: ‘The infinite variety of the human condition never ceases to surprise and it is that fact that defeats any attempt to be more precise in a definition of best interests.’²⁸

Justice

Justice is often expressed in terms of what is fair, equitable, or reasonable. It is particularly important in healthcare in decisions relating to allocation of resources.³¹ After the foundation of the NHS in 1948, it was hoped that once problems caused by lack of access to healthcare were dealt with, demand for healthcare would reduce. In practice, as the population has increased and with technologies increasing the possibilities for care, demand for healthcare has always exceeded supply, leading to a situation of rationing, which is ‘rarely explicit and often inequitable’.³²

Scarce resources are rarely used explicitly as reasons to forgo, withhold, or withdraw treatments. There are, however, some who question the merits of this. The following three basic ethical principles in a publicly funded health system have been described:³³ (i) treatments to be provided are decided on principles of distributive justice; (ii) treatments are provided to patients in their best interests; and (iii) competent patients consent to accept treatments offered in their interests or refuse them.

Wilkinson and Savulescu³⁴ describe what they call the ‘elephant in the intensive care room’ and state that it is ethical for doctors ‘not to provide treatment judged to be medically inappropriate or futile, where such treatment is contrary to the interests of the patient’ or ‘where there are insufficient resources to provide treatment’. They also deem it reasonable to withdraw a feeding tube from a permanently unconscious patient, not because it was in the patient’s best interests but because, ‘in a publicly funded health system, society cannot afford to keep people alive with such poor prognoses’.³⁴ Likewise, Savulescu and Clarke³⁵ consider that providing care to patients who are ‘waiting for miracles’ merely discriminated against those whose faith did not accept miracle claims and against atheists and agnostics who otherwise ‘might have legitimate reasons to seek “futile” or very-low-chance of success treatments’.

Clearly, not everyone will be in agreement with these opinions. The GMC advise that ‘you should not withdraw or decide not to start treatment if doing so would involve significant risk for the patient and the only justification is resource constraints’.³

The courts have addressed this issue of distributive justice in cases such as R v Central Birmingham³⁶ (Table 3) and R v Cambridge Health Authority ex parte B [1995] or ‘Child B’³⁸ (Table 4).

In Re J,²³ Lord Donaldson MR commented that there was an ‘absolute undesirability’ that the court would make an order compelling a doctor or health authority to make available scarce resources, without knowing whether others might be ‘more advantageously […] devoted’.²³

From the court rulings, it could be taken that we may make decisions based on distributive justice, and our decisions might be backed by the courts. However, the GMC guidance seems to suggest otherwise,³ and judging from unfavourable media attention, a disparity exists as to what the public (or at least the media), feel is just and fair and what health professionals believe. Making decisions based on justice may not always, in reality, be practicable or straightforward.

Can the law dictate treatment?

In terms of how the courts have viewed decisions taken by doctors in cases where they feel a treatment is inappropriate, the first case to ‘set the bar’ was Re J.²⁷ The court ruled that a doctor can refuse to offer a treatment on the grounds it was medically contraindicated. The court could not ‘insist on a treatment’, and requiring a doctor to adopt a course of treatment that was not in the best interests of the patient would be an ‘abuse of power’.²⁷

The more recent case of Burke v GMC reinforced this view.⁶ The court was clear that ‘doctors could not be forced to administer treatments which they believed to be clinically unnecessary, futile or inappropriate’ and that this ‘applied equally to a competent patient demanding treatment and an incompetent patient whose demands were expressed through an advance directive’. The court stated, ‘Autonomy and the right to self-determination do not entitle the patient to insist on receiving a particular treatment regardless of the nature of that treatment. Insofar as a doctor has the legal obligation to provide treatment this cannot be founded simply upon the fact that the patient demands it.’⁶

In St George’s v P in 2015⁴³ (Table 5) a judgement was made that seemed (at least on the surface) to differ from the above rulings.

An article of this nature would not be complete without reference to the high profile case in 2017, Great Ormond Street Hospital v Yates & Gard.⁴⁶ The case now signifies one of the UK’s most protracted and controversial withdrawal-of-care cases (Table 6).

So how should we practise: clinically or defensively?

The reader would be forgiven for thinking that decisions taken at the end of life are all a little too overwhelming from a legal and ethical perspective, and perhaps we should just get on and treat despite any professional misgivings we may have. The authors feel that this would be a great disservice to the profession and belittle the hundreds of thoughtful, ‘difficult but right’ decisions that are made up and down the country in our daily practice. This area is difficult, and doctors often, by nature, want clear answers in relationship to ‘where they stand’ clinically, legally, and ethically when taking these decisions. The truth is that there is no ‘magic’ answer to be found within legal statute or case law when it comes to what is the ‘right’ decision at the end of life. Law is like medicine; the answers are not always black and white. They vary hugely depending on the individual circumstances of each case and can be heavily dependent upon how the relevant law and guidelines are interpreted within the context of the case. The role of the courts is to determine what is lawful or not rather than to dictate treatments. Despite this, apparent ambiguities in legal ruling can make things more confusing, and the subtleties in differences of opinion between court decisions may be lost on us as physicians.

The advice of the authors, therefore, can only be as follows. Be aware of the professional guidance; it is there to guide us. The law understands that these are some of the most difficult decisions to be made in healthcare, and the answers are not always clear, especially at first glance and especially at 2 o’clock in the morning. But the law is clear on one thing and that is this: pleading ignorance of the principles of the law and the professional guidelines which exist to help steer these decisions is not a defence. Trusts have access to legal opinion, lawyers, and the courts, 24 h a day, and we should use these when necessary. It does not always signal conflict and it can, for some loved ones, demonstrate that careful thought and process has been put into the complex decision-making process which, in itself, can provide some comfort.

It is extremely important to try to preserve the relationship that exists between the healthcare professionals and the patient and their family. If the decision is made to go to court, the ideal scenario would be one of the healthcare professionals and the patient/family going ‘together’ to seek the advice of the court. The doctors should try and explain that in this situation they do not know how to proceed further and they are asking the courts to help. What has to be remembered is that regardless of the court decision, the family and the doctors still need to go back to the patient to either withdraw or continue treatment. Once that relationship is lost it can be extremely difficult to get it back.

Communicate early with patients and their families in relationship to end-of-life decisions. Do not shy away from difficult conversations and, for the sake of the patient and your colleagues coming on shift after you, document and communicate the outcome of these decisions clearly. Try to foresee and plan for potentially inappropriate requests and deal with them sensitively.

Probably the most honest, although some would say unhelpful, answer is not to have allowed the patient to get into this situation in the first place. Ideally, decisions regarding withholding or withdrawing life-sustaining treatments should not be made in the last few minutes or hours of a patient’s life.⁵⁶ If we, as critical care clinicians at two in the morning, feel it is inadvisable to escalate treatment beyond ward care, it is not unreasonable to think or hope that these issues would have already been addressed, either earlier in the patient’s admission or, ideally, earlier in their diagnosis.

Fundamentally, when dealing with such requests the issue is one of trust. Gaining the trust of a patient and their loved ones is fundamental in determining the outcome of any conversation. Loss of this trust is potentially catastrophic and will undoubtedly make the management of any potential end-of-life situation extraordinarily difficult.

Conclusions

The ethical complexities surrounding end-of-life care have meant that it has become one of the most controversial areas in modern medicine. Guidance from professional bodies exists to help us try to navigate our way through this difficult time with patients and their loved ones. Although based upon both common and statutory law, doctors can be left feeling frustrated that such guidance does not always provide the clarity we would hope for, possibly because such decisions are so complex, multifaceted, and unique to each circumstance. As such, we need to approach each request on an individual basis, applying all of the guidance available uniquely. We probably have to accept that the law is not always as black and white as we would hope.

We need to gain a better understanding of the triggers for conflict at the end of life,⁵⁷ how to avoid conflict, and how to communicate and manage it appropriately when it happens. We also need to be mindful of when turning to the courts is a necessary intervention.

Ultimately, there may also need to be fundamental changes in society’s attitudes to illness and death. With that comes a need to be more open to having earlier discussions to allow our patients a better say and understanding about their end-of-life wishes.

Controversially, we may need to look at how far we have moved from our once paternalistic approach in medicine and ask whether we have come too far in our quest for patient autonomy.

Perhaps the take-home message from the Charlie Gard case is not that of the legal principles behind withdrawal-of-care cases in the UK. Perhaps it is the plea, made twice by Mr Justice Francis, that hospitals and staff must at least attempt to make efforts to resolve these tragic differences of opinion via some sort of mediation process.

I recognize, of course, that negotiating issues such as the life or death of a child seems impossible and often will be. However, it is my clear view that mediation should be attempted in all cases such as this one even if all that it does is achieve a greater understanding by the parties of each other’s positions. Few users of the court system will be in a greater state of turmoil and grief than parents in the position that these parents have been in and anything which helps them to understand the process and the viewpoint of the other side, even if they profoundly disagree with it, would in my judgment be of benefit and I hope that some lessons can therefore be taken from this tragic case which it has been my duty to oversee.⁵⁸

The family courts have extensive experience of the use of such mediation services, but we no doubt have a long way to go in terms of developing and using these services in the context of difficult ‘end-of-life’ cases, both in adults and children. But surely, now more than ever, we must.

From Sir Thomas Bingham MR:

Medical science and technology has advanced for a fundamental purpose; the purpose of benefiting the life and health of those who turn to medicine to be healed. It surely was never intended that it be used to prolong biological life in patients bereft of the prospect of returning to an even limited exercise of human life. Nothing in the inherent purpose of these scientific advances can require doctors to treat the dying as if they were curable. Natural death has not lost its meaning or significance. It may be deferred but it need not be postponed indefinitely. Nor, surely, was modern medical science ever developed to be used inhumanely. To do so is not consistent with its fundamental purpose.¹⁶

Acknowledgements

Thank you to Dr Leon Cloherty for the ‘question’, to Dr Maryam Crews for reviewing and editing the manuscript, and to Rebecca Fitzpatrick from Browne Jacobson (LLP) for reviewing the manuscript.

Declaration of interest

None declared.

References