Cases audi transcript — SMP305 lecture transcript

we have to carry I literally can't do it and then my mum's like, yeah, no, that's not when I was a waitres. So if you could all check on Minerva, you should have received er the teaching material for today, the scenario, so just have a check if you can, please. Do you think we're expecting many more? No, just look about the right number. Alright, I'll shut the door. Right, so welcome. This is quite a good turnout for this session. We've had far fewer before now. Um, I understand this is the last session you've got today. It's allocated until 3:15 I believe. Is that what you're expecting? Yeah, we don't normally fill the whole time, so you'll probably get to go at least a little bit early. Um, And were you all expecting a session on ethics? Yeah, I see lots of nods. So to introduce myself, I'm Jim, I'm a registrar, I'm an ST6 in general psychiatry. Um, just to sort of caveat that I'm not an ethicist, I'm not an expert in ethics at all, I'm just a. Jobbing trainee psychiatrist, but I do have an interest in ethics. And this session is normally done by myself and and one of my colleagues Rob, but Rob couldn't come today. Um, we are in the process of trying to rejig this session to make it a bit more interesting, but I think people normally find it quite good, um. So what we'll do, we'll have a little bit of a discussion as a group first of all, like really briefly about some general kind of principles of medical ethics, we won't spend long on it. So this session isn't really about learning about the ins and outs of ethics, it's a bit more applied, so you'll have a scenario on Minerva with some options for what you would do in that scenario, and then you're gonna think through using ethical principles, why you would choose which scenario or why you wouldn't choose certain scenarios. So that's basically what we're gonna do and then we'll sort of, we'll switch it up a little bit probably towards the end and see whether that affects your thinking. Um Normally, and I think we will today, they always put this in the lecture theatre and it's not ideal because we do like to work as small groups really. Sometimes we do it where we sort of ask a shout out as a large group and people just don't like doing that, do they. So I will ask you to kind of gather together in groups of sort of 3 or 4 if possible, as far as you can, uh, and discuss amongst yourselves and then I'll just move around the room and then we'll sort of come together at various points and sort of discuss.

So Who can tell me anything about medical ethics? When you think of medical ethics, what sort of things pop into your head? Sorry, who said that? 4 pillars, yeah, what are the four pillars, who's, I can't see who you are, sorry. Yeah. Just as, yeah, absolutely, 4 pillars, um, so. The four pillars, or otherwise known as sort of principalism, that's kind of an applied ethical framework, so that's a relative kind of modern formulation of, of medical ethics essentially or essentially practical tools to use when thinking about medical ethics. And it was developed I think in the late 70s, early 80s and it was literally a book that was kind of written as a kind of useful manual for people working in medicine or in related areas. Um, can anyone think of any more fundamental sort of schools of thought in ethics generally that might apply to medical ethics? Yeah, consequentialism, and can you tell me a little bit more about that? Is there another name for that? Does anyone know another name? Utilitarianism, yeah. Can you tell me a little bit about it? Yeah, the ends just by the means and what sort of ends are you looking for, what are you trying to maximise? Pleasure, did you say? Yeah, I think that's, I think those are the terms actually, you know, people who developed it, it was, do you know? Bentham, a funny surname, I think. Sort of late Enlightenment thinker, philosopher. Um And John Mill, big influence on kind of liberalism again, sort of late Enlightenment period, at the turn of the 19th century, and I think Mill kind of specifically talked about maximising pleasure. I suppose when we think about utilitarianism or consequentialism in terms of medical ethics, we think about maximising, maximising the goods for the maximum number of people. It's quite an intuitive thought, isn't it? Quite an intuitive idea, I would say. What are some of the downsides do you think of, of consequentialism? Broadly, not necessarily just in medical ethics. Yes, I'd agree with that. Yeah, who's deciding what's good, who's not, yeah? Any other problems? Yeah, I still can't see, sorry, yeah, there you are. Yeah, absolutely, yeah, so you're maximising good for the maximum number of people aren't you, but what about minorities who might not benefit from that? Will they be actively disadvantaged by certain say policy decisions or, yeah, absolutely. There's kind of one other, I mean, ethics is still a very much a live field in philosophy, so, you know, there's there's. Reams and reams and reams of sort of thinking and research on ethics, but can anyone think of any other sort of big schools of thought historically in ethics? It's a little bit like the sort of um not the mirror image, but it's sort of like the opposite almost of consequentialism. Deontology like virtu So virtual ethics is something different, but yes, the ontology or duty ethics or Kantian ethics. Again, sort of enlightenment, er, sort of philosophy, essentially. Can you tell me a little bit about that?

It's about doing what's right. Yeah Yeah, so it's, it's almost, so rather than thinking about the consequences, it's thinking about, about the actions, you know, are the actions right that we're, we're carrying out, and we don't really so much worry about the consequences are, um, so. Can anyone think of any sort of examples in medical ethics, how, how might sort of duty ethics or deontology sort of relate to medical practise? I would say it relates pretty strongly to medical problems. Maybe something like Jehovah's Witness, so like it doesn't matter about. The effect that giving someone uh someone that's a Jehovah's Witness, uh, Give them blood, they might survive, but it's about doing what's right. Yeah, so what duty do you think you'd be maximising or you'd be sort of exhibiting there in that particular scenario? I mean there's probably different ways of viewing it, but I would say it's, it's sort of um respect for autonomy, isn't it? That you're it's a duty, you're, you know, as a doctor you're respecting the patient's autonomy and their values in your decision making rather than thinking necessarily about what the consequences are. You probably would think what the consequences are, wouldn't you, and you'd put measures in place to make it as safe as possible, but. As happens, you know, in reality. Yeah, and I suppose, you know, medicine is a professional field, isn't it? It's professional practise, we have regulators. There's a great big document isn't it called Duties of a Doctor that literally details what the GMC expects your duties to be as a doctor. Have any of you read Duties of a Doctor? No, I haven't either at your stage of training. I forgot what they call it but you have to do that awful like sort of is it situational judgement test or something at the end of, do they still do that for foundation training? Yeah, um. If it's still the same as it was when I did it, admitted several years ago, read Duties of a Doctor, it's really helpful for that, really, really helpful, so yeah, you will end up reading it at some point, even if not at the moment. Yeah, so. To my mind, my limited ethical knowledge, um, you know, principalism, the four principles, and, uh, utilitarianism and deontology are probably the most informative schools of thought really in terms of everyday medical practise, and they're often intention. I mean the, the four principles are always intention. But there are certain sort of decisions that are made that are quite utilitarian, the way services are structured is generally quite utilitarian, and our everyday practise is ruled by duty, so you can see how actually all these things are at play. And then you mentioned virtue ethics as well, um. Does anyone know, I won't pick on you anymore, does anyone know anything about virtue ethics? I don't know a great deal about virtue ethics either, to be honest, but.

to do Yes, exactly. So rather than necessarily thinking about sort of the specific duties and actions, it's, it's thinking about how would a, a virtuous doctor, say, act in this scenario. Um, and it comes from ancient Greece, doesn't it? I think it was Aristotle who developed or initially developed sort of virtue ethics, um. I suspect it probably is still a field of study, um, but it it feels to me a little bit less. Useful perhaps. Or not, I don't know, medical ethics, feel free to disagree, um. Brilliant. OK, so shall we move on to the scenario, um. Forgive the blurb at the top, the blurb says that you have a handout about the principles of medical ethics, which you don't. I've never seen that handout. So if you just have a look at the scenario. And read through it. So split into small groups, kind of 3 or 4 people, and discuss amongst yourselves which of those options A, B, C or D, would you choose at the end and I'll circulate around once you've started chatting. Just to say a trigger warning, if anyone finds this scenario upsetting, um, feel free to have a chat with me afterwards or you can email me as well. It's true of all psychiatry, really.

You get some therapist and if they don't have that. She has collapsed. I think She doesn't need to have a diagnosement for diabetes, right? Yeah, she's a. reasons. I don't have to be diagnosed. No, that's. That. And if it can be, I don't know should be. It could be, I guess. But that's one thing we don't know. you wanna make sure that. Like I would, I would. Because I, I, I, I think because she's at risk to herself, um, due to certain um. to die state that over that that she will die. Um, she hasn't had mental health, um, self help before so providing that help of being happy. but we also, I think don't necessarily know enough information to say that. We've got like 22 ideas, yeah. section was difficult. It makes things pretty terrible wrong about it. What principles it does do the um. What's the novel I do because we're we're doing harm by by that we're also doing harm by breaking trusting it's not harm, but I, I guess from your point of view, like what's the, what's the breach of trust compared to them that I think. I like or condition and they have to be a a racist of themselves or others, so I don't think. With neuropsychotic features and yeah, but you need to meet both of those criteria so she's out of you have to have a a higher. I think there's a she's mental health it's just go back to. So yes, absolutely I agree with you in terms of the non the non-milicious that's that's not it's hard. Yeah. and then they're doing good. Yeah, justice is really it's justice. I. It's just like, would you treat a man the same way or an elderly person the same way? Is it fair to treat a young person? I have different views on euthanasia on most people, so. So. it's like you brought in by a housemate that's that and then autonomy obviously, so it's, I'm not asking you wrong by the way, you know it's you, you're weighing up, aren't you, and you're, and you're kind of, I think it, it's, I just feel like it because she's not known, I think that's quite a big deal to me. That and I'm saying that we don't know if something's like had a small, it's like a it's very much virtue I think that's what good doctors could do to help their patients. Yeah we, yeah, we don't know if this could be a like a short term thing that then resolves. I, yeah, it's, I think I think it's a very short case yeah so I mean. Spoiler alert in this sort of scenario. And the ontologyci. I. So you know I'm trying to. That said, of other matters. I It I drowns reversible irreversible. Like if you let her go home, she'll kill herself dead and there's no root cause. I think it's an unknown person for months I think. I feel a lot of different about that. It's like. the last time so that was what create more information that she had like a screen there was no signs of mental illness. She was having a bad situation and that more about financial. So the first one is we really struggle. So, so to section 2, so not so high balance ability to suspect a mental disorder anyway. essentially. become But then, yeah. I just Yeah.

This sort of scenario it's deliberately very, very, very risk doesn't give you advice, which is a bit low, but that's potentially suicidal, that's what that's what I said it particularly then stop talking it because you need to assess that. It's not necessarily ethic for He was. That Hello, how's it going? conversation. Yeah, but I think it's enough to give because you can just be ill and mentally well you're mentally ill in this case where there's none of that unless they give you indication it's more likely that they're not. In practise, this sort of sex sex, it's very. I don't know the fact that she reluctant to go. in order to make that you need to do. Just Consistent values. This is an emergency. I testing. I. Oh There's a practical scenario she's got capacity. I feel that we're more likely to wins out. You. OK. I. I. over 10. 10 mg. the Oh. It. you I. That's just slipped over right she's got the capacity gonna take yeah, OK, that's nice, nice. It's that's that. So if you think about the I think it's a lot. You're you're you're prioritising the way to go. Yeah way. Yeah. I mean there is no right answer, but I'll disagree in practise. No So you So. It was But think about the ethics then about the. Yeah, yeah. OK. just Yeah, sort of, but I, I talk to these guys. I think.

by respecting their autonomy I know. No. Sunday session without any legal questions you guys. I think yeah, because. If uh. I did not want to. my parents straight. I'm not sure. Yes. It is the ability you suspect them of having then then that's enough. It's, it's, it's on the probability of you can't just say you just have to you have to have a certain like. is. 0. in every situation it's. Yeah. Yeah. Yeah. Oh my God that No. Yeah, but you were asking, you were asking. I think. It's a different, I think it was like a subject. I know. Yeah. I. It. It also diagnosis. Uh. I'm not. just And she was like, you're like on the sides. I. Yeah Oh He said. From. I can. Yeah Yeah yeah. I'm I'm not. Yeah that was good. discussion. have. I myself. I like one of my um friends like like uh his wife coming. you. I I think that's what I said. It's just the two of you to help keep the psychiatrist. I think she was like basically like she was she got to the point where she planned it mostly herself so that she was able to to like. when you fly out and then fly back. What. See If it's tricky. I leave it alone, but obviously like this. Keep. This is way more. I should have. Yes, but I feel like making sure I don't have a. Yes So you can. No, but it shouldn't be criminal. in reality. So like. England. I and you have to guess which ones. And you actually get like rehab you suspect that's how you go out and get. But it was, it sounds counterintuitive. I. exceptions. OK. I I Oh I think people should be able to All things, like as a society we should try and prevent it as a whole but if I get to. No, they don't, they just groan. If I get to 70, I like both of my knees and my mental capability. All of my friends I know, anyway, we, we do that not only it's a, it's actually too easy to get it they probably. It's difficult when there's no chance. That's It's not. Yeah. Yeah. You know this. No, I was just gonna finish that sentence and that's it. but Just the one. I. Yeah. I had a chronic illness, so my whole family just skipping out. But that's. what they say. I mean it's. s So That's no. I I think I. So I it. It'll have to be. Right just to the original. I But it's called salt. I've brought. I think it's probably one of the easiest. today. Why should you have not. What. Yeah. The I. on that. The you. I I Oh. experiencing It's just get examined. That yeah, find that as much. I was I was with a patient. I. And this Yeah, yeah, so, uh, probably not for a chew chew and swallow to be able to chew and swallowing. You know, just a second. Oh, yeah, yeah, yeah, I'm an impulsive. I I. So I You It depends on what. Because that's thank you thank you this is the situation like you are. I. It's very 20. Yeah just just kill me. She's health assessment, it depends what the side effects of the treatment are. Oh, if I lost the ability to swallow now. Yeah. I'm assuming that'd be 6. This is the this is the. the way I wrote my ethics. Um, they said I will because I. in the feed. You've almost got to discuss it in prison healthcare, but I don't think that's discussing. It does not need discussing. I. I think it depends on what. But then I'm not for, I'm not feeling so. But if it was self-chosen, it would, it would save the UK prisons a lot of. I'm just. we don't, we don't know, do we? It depends whether you're male or female, male, right? 5. I. into the area and then you have to go to your cell and then you've got like you've got like. I do. your Like that's no object to the time. Uh, but the uh. Yeah. problem I Uh. something but. I thought you know that name. Everyone starts. I forget. That's yeah. rehabilitation. Even when I'm that. I Red In theory, in theory, all prisoners should be able to I've been for so long. Yeah, so photography. the door. If you get it it's it. A religious I think the charismatic. Uh. there is like I think evolution is where you're basing. It Yeah, I did on the phone. There. Yeah, not your fault. He's odds aren't so. And some things like which. Like injective. I. That It's mostly about their mainstream society. I think. Yeah. it's definitely a. At least you can. I yeah. Yeah. Can. It was, it was. we Yeah, because we walked past a branch of them grew up next to some friends and I used to. I. yeah. It was it was a big design show in London with fans and they can't wear ties and they can't watch the TV like it's yeah I'm not used to getting up. And Yeah, it's so it's. on. It's my favourite. Yeah. Is. That was so good. You know. Yeah. in his view there's no. These conclusions have been described as. I. I think I, I guess it was the. It's OK. It's the home. I can tell you that they have not. It. I. hard. This is. One of my friends like They, they can live in anywhere. Yeah. I. Social media is really interesting. They're not allowed to wear ties. They're not allowed to eat with it. They're not allowed to watch the TV while they eat. They're not allowed to go to the. Because I'm pretty sure it's a long, long line. I was gonna say go back to back to. My return flight is 150. 15 pounds 6515 pounds. So No, my, my right, should we sort of come

back together, um, I got around most of you, but not all of you. I do apologise, um. But I think maybe you're chatting about other things by by now anyway, um, so, so there's a sort of variety of opinions really here, um, unsurprisingly cos there always is, um. I know I spoke to one group who went with option D, partly informed by chat GPT. Um, did anyone else, um, choose option D out of interest? Someone normally does in this session, but does anyone else? Um, who chose option, so individually now, not as a group, who felt option A? Put your hands up. There's no, there's no wrong answer just to say I'm not gonna lambast anyone. Option A is the question, what would you do or what is the most ethical? Most ethical thing. Well, sort of, yeah, this is a session about ethics. In practise you end up thinking about what you would do, don't you, in practise. But ethically, what do you think is the best option? So we've got one for only one for option A. There's normally more. Don't worry, you're not, it's not normally just one person, um, so no one else. How about option B, who's got option B? Yeah, quite a few of you. Um, who's got option C? OK, interesting, yeah, we'll come back to that. Sorry to pick on you, and, and then I know some people chose option D but no, no one else did or were thinking about option D. Did you think option D or was that just what GPT thought?

We did, yes. It's a hard choice, to be honest, it's a hard choice, um. Out of interest, the option D that Chat GPT suggested was um. Remind me, I think it was, it was involves seniors, involves senior psychiatry, er, continuously reassess capacity. Was there anything else that Chatty suggested? No. Yeah. What do people think about that actually as an ethical option? I see some knobs. Yeah. It's kind of unethical to for it on something. I, um, so I think, I think, so yeah, it's a duty, we have a duty as a doctor to work within our competency, don't we? So actually recognising this is beyond your competency as an F2 doctor and involving a senior is, is in keeping with the duties of a doctor. So you could say that deontologically that's the right thing to do. You're not overstepping your, your sort of competence, I suppose, but I, I do agree with you partially. It's not so much to me bobbing on someone else, it's deferring the decision. You're sort of, you're dallying, aren't you? Meanwhile her liver's like chewing over more and more paracetamol, um, the risks of her, the risks are increasing over time, the quicker you give that nap, the quicker, you know, the, the risk of, of liver failure is gonna reduce essentially. So you're, you're sort of hedging your bets, you're keeping her there under no framework, legally, cos she wants to go, doesn't she? So what legal framework have you got for keeping her there? That she wants to leave. None at that point, you're kind of coercing her to stay somehow, um, or you're just not letting her out the door and you're continuously reassessing her and you're, The expectation being that she might change her mind or that she might lose capacity. Potentially, that's my criticism of it, so you're, you're basically. Shirking your duties to come up with a decision, so you're essentially not embracing the, the inherent, um, tension here ethically because there's, there's opposing, you know, clearly opposing principles here ethically. In any of those decisions. Um That said, I think you could justify waiting for a senior psychiatrist to come and give you their view on their capacity, for example. Or it might be that when you call them up they say oh just call them. And then that happens and then that team make the decision. In practise. In practise, that going down option B actually, so this isn't talking about ethics, this is talking about practise now. For what it's worth, I think option B is pro is probably the most sensible as speaking as a psychiatrist who has encountered this sort of time before, option B is probably the most sensible on the face of it. The problem is that a mental health assessment doesn't happen immediately. Um, there are more urgent sections you can use, but they don't give you power to treat, so it'd have to be section 2 or section 3 to actually treat this person against their will under the Act. Um, you'd probably wait till the next day, depending what time this is, if it's like overnight, you know, we'll certainly wait until the next day because they'd have to get a second doctor, um. So it's not going to be a quick decision. And there's also You can treat under the Mental Health Act, but people often resist doing it because people aren't it doesn't happen very often, you don't often treat physical illness under the Mental Health Act, this case specifically you could, and there's case law to support that because you're you're treating a consequence of someone's, Putative mental illness, you know, they wouldn't be detained unless they thought they had a mental illness.

Assessors Um So yeah, so in practise, and I had a similar case to this, although it was different in the sense that it was a, a sort of middle aged person who was very much a frequent attender um. But the A&E regs thought they had capacity to refuse their neck treatment, and I, in the middle of the night, it was one of the registrar, I think it was a new registrar, and I went out to see her and I determined she didn't have, So I disagreed with the A&E doctor, he accepted my opinion. They Consulted the on call anaesthetist, Reg, to come and sedate her, and this had happened before, she'd been sedated in ICU and given that treatment before in the past, however, um, on seeing the anaesthetist, The coercion, I suppose, of events kind of rolling led her to accept the treatment. She had one bag of Mac and then she absconded. And there were no bad consequences from that, so her liver was fine as it happened. And the reason that I questioned her capacity was because. Actually I, I mean I thought it was fair to cut and dry, she didn't have capacity because she couldn't really weigh up at all, you know, she was just dead set um on wanting to dive. And couldn't sort of consider the fact that any of her problems might change, so she had EUPD established over a long period of time, and she had lots of social problems, um. Many of which actually were potentially fixable. Um, but she was resisting support, so she, she really struggled to work with people, but that doesn't mean it's not possible. And she just couldn't put any weight on it at all. The other thing with her, the reason I questioned her capacity is because she was a known quantity and she changed her mind all the time. She was suicidal sometimes, the next day she'd regret it or she'd be able to say, well, actually I'm really split, part of me wants to die, but part of me wants to live. So it wasn't a fixed stable thing in keeping with her values, you know, her, her values are shifting all the time. So it'd be a brave person to say that you have capacity in that case, the one I'm talking about. This is different because it's an unknown quantity so we don't know this person, but you. The consequences here are really severe, aren't they? There's a horrible death potentially waiting for this person, it's not a nice way to die. Really isn't, so there's potentially a horrible death here, it's not certain, it might be that, that she survived anyway without the neck, but there's a, a good chance there that she could die, and I've definitely seen it, I saw it when I was a doctor. Sort of dying from paracetamol or whatever it's really grim. So there's a horrible consequence there. You'd have to have a really sort of high index of suspicion that this person lacks capacity. Um, and you'd have to have a high index of suspicion that the person has a mental disorder because people certainly can be and are suicidal without a mental. Someone's, I I can't remember who it was, but someone said yeah lots of people have capacity and they're suicidal. I'm sure lots are. But in my experience it's a minority, for small minority, in fact I can't think in my psychiatry practise, including liaison Skype, so going to visit people who aren't necessarily going to mental health services in the general hospital. Um I can't think of anyone for whom I would say I was absolutely certain they had no mental disorder when they were expressing suicidal ideas. There's always something. And often it's transient, you know, by the time I'd go and see them with liaison, they weren't be feeling suicidal anymore. So that's the other thing, you know, is this likely to change, are they like to change their mind? So can you really say they've got capacity? That's, that's So Any other thoughts on the ethics of option D that Chatty PD thought? Any other thoughts before we move on? What do people think of option C? I'm glad no one picked option C. There are no wrong answers here, but to my mind option C is the least desirable option. Um.

Unreasonable A housemate Hum. I very much agree with that, and that comes down to a duties thing really, I would say. And Yeah, so I quite agree, I think that's that's the main thing. But it also shows here that you're anticipating if she gets ill, she's going to lose capacity, um. To my mind, you're having a very mechanistic view there of what's right filtered through the Mental Capacity Act, so you're trying to rely on the law, you think about what's legal here, you know, really I want to treat this person. And But You know, and in actual fact, by the time they're, they're sort of losing consciousness or whatever, they're probably not treatable anymore, they're probably going to die in, in reality, but you're just sort of taking quite a sort of mechanistic, sort of legalistic view, well, you know, they've got capacity, you know, so I've got no legal framework, um, that'll treat them if they lose capacity, so then you're just like shoving their apparent, um, autonomy aside, aren't you, er, cos what's changed there, nothing in their attitude has changed, they've just lost consciousness, so that's the ethical, ethical. Problematic thing yeah and then there's also the duties thing about um yeah, about not shirking your duties and putting them onto the housemate he barely knows her um. Which is, would be a really dodgy thing to do actually, you'd get a complaint, probably if you did that, um. Yeah. Obviously if you know if you've exhausted all possibilities, if she had a mental health assessment and wasn't detained and a senior's come along and assessed her again and they think she's got capacity and you end up sending her home and she's got family, then you would safety net and you would talk to family or potentially the housemate, but it's a really uncomfortable thing to do, isn't it? But I think the way Option C is written, there are ethical problems. Yeah, bread. So Not much longer actually, I told you we'd finish early, um, I just want to sort of think about whether. Your thinking would change about this case if we think about altering the age of the person, so. It doesn't actually say what the age this person is, but, um, to my mind I read this and I sort of imagine a kind of youngish person in their twenties. Did you all sort of picture that or yeah. I think there's an alternative version of this where it does actually say their age, but let's say she's sort of 24 or something like that. So my laptop's died. Um, so. Have a chat amongst yourselves again as groups. How would this change if this person were a. 16 year old.

a job. Well, I mean, To Yeah. I think it's like. I thought that. So it's mental capacity she was 16 she was 16, so 16 and 17 year old. Same thing, yeah, well, if it's the same history, it's the same thing. I like more she so. OK. Oh. I. You were just. Yeah. So just the way so uh Section 3 is to be established. So he stu syndrome that might not sort of diagnosis. You have to involve. $500. So essentially postal syndrome. Section to you there just needs to be a, you know, a feasible suspicion it's on balance that. So Is it, is it? It has to be that's yeah, that's what. Yeah. It's, you know, so you can, you know, he's pure, I, I wanted to go there, but so you can have like way more women and I would say granted suicidal, uh, you're able to stay in a hotel. I would say. I think it's just. I. suicidal. Drinks were also. It could be that I'm not. Is the way. Gives you lots of like totally absolute, I had a very short fail my second one and I was like. protection Yeah, so just I I it's the horizon. you can, it doesn't happen very often valid. I know I can't think of any because my personal you can it's, the world evolution and that the risk is. It's really interesting it's a really interesting area. and some mental health nurses as well. It was. Oh. I see. the difficulties in the way it's it's so difficult not to. but generally speaking it's very hard in an emergency situation I was highly suspicion of basket that she's able to. in the way of describing to think about how they're ascribing to each other what weights they're ascribing how they. If your own weight. I stream. But it's nuanced, you can't be that doubt that by in an emergency situation. So if someone is unwilling to even engage with you about what's the option. So they're just shutting it down and so no but I meant I meant it's not gonna I just. It's not really conversation I've got no evidence of it and they seem low and the suicide for a young person's genuine support. No, it's not after that prolonged gen should be because if she's fine legal test. I take it the blonde lady in the will just oh sorry, I meant, yeah, as you explain to me that's, that's the way yeah. Not willing to gauge with this I would I would I would probably, you can't just suspect. emergency situation. I think that is misleading. So you already decided but like she, she's a landlord and off which is when the so yeah, yeah, she wants to move out she's like. It's so jokes like I met you and then we became friends. He told me all about this sneaky girl and I moved into the house and I'm like, it's not this sticky, is it? And then on her phone, it has like like you've got like, like an old one of them came and it was like 11 like printed and I was like no it's not you. Yeah. I I Yes. So. Come back later. I that. Sorry. I just found out my housemate before she got literature 15 and below. Yeah, the year above was just 1. I've been I've I've not seen a powdered substance. That. M. I've never seen. I think a lot. Yeah I know. Apparently he broke his back but surprised that's why I'm hearing from the girls that have never met him, we haven't really. Oh, that's so dangerous why we do that and he was like, well, it's not dangerous. It's the way the way the scared to you and then. Um. So. No, you wouldn't be. Is. you know, so. Oh. I'm on my. It's 75 pounds. I don't know what samples seems like it's more likely derived from somewhere 6 times. OK, so let's just change it again. I don't know whether it changed any of your thinking.

I suppose anyone's kind of got for option A before then possibly making it a young person might have changed it. OK, we'll, we'll come together afterwards, but have a think now if it's a. So same scenario, they've not been talking to you and they just say they want to die, but it's an. 81 year old with um. With controlled but incurable bowel cancer, so they've had some chemo and and it's kind of stayed on due trap a bit, but it's not curable. But they're not saying that's why they want to die, they're coming in and they're just saying they want to die and they want to and they've shut down. Would it change your thinking? to help. be Yeah. the illness to an 18 year old. I just. it doesn't matter. That's not the reason they're shut down and we're talking to you. Well some of the. I like in terms of And So I mean in practise it all gets I don't know nothing related to this and I suppose in that sort of scenario um let's say that's not this now, but what we're talking about sort of fairly common you think actually the the exercise you think they're a bit actually but they've also got parts of the rational needs why they don't want to rely on anymore, um, they've been offered some surgery that might prolong their life and they're declined it. What are the ethical implications there? Yeah. That's I I I know you do. To live. I. surgery It's very much. No. Yeah. Yeah. I mean, I'm also. Yeah. I just feel like. So. Unless there's a certain thing you'd like, I like it in 2 years of your life. Yeah, so how, so how does that differ from that same versus having been at home? They've been engaged with the industry it's all stable now, it's kind of single mission, let's say it's not available. It shrugged the Jewish shrugs. They're really up and they come in, they take part. a bit low. This one. but um and then if you talk to you a beer when we go home. So how is that different between ethnically how is the reaction not ethically exactly the same so what the It. What would you, would you do about it you can't kind of a lot of sleeping on the floor. I think you you sort of have to. But of course it's so stressful. It's so stressful. on one level I think. and actually it's an emergency that would the team wanted to give a chance they were trying to justify it. So I think it so why might. I think just in my formulary. just use what might have changed how it might have. It's so, so this, so this is a 24 year old. So the first scenario is a 24 year old turning up as a prison. So this now is an 81 year old with stable but curable bowel cancer who's turns up take me. the proportionate abortion that they've got a year to live and you're searching them for 2 months that a lot. Yeah, exactly, exactly. other pieces. I like to. diet and that's like the stage where I was looking at it. I section. I mean the thing is, is you admit some of that age, there's a chance that. like You don't get them. it's not the law. The frame it's not an ethical I would always like thumbs up and then it's not a manual and it doesn't really help you because you you thinking about. Oh. in terms of the basics is what acts in the best Which, which I think is in the best interest so best best interest is the concept of. And, and can deal with that, but in this scenarios in context, well, it relates to mental health as well, so best interests is, is a concept, you know, I

suppose it happens in somebody's best interests if they are not capable. I. Is that specifically. I think paracetamol motivation. I might not be able to I can trying to save her and talk to her. Is not within a couple of hours, like if you wanted to assess all this capacity it's easy to do it, you explain what you'd have to probably call some sort of about how likely it would be to, or you'd ask the AE re how likely that's gonna play that look, I would say. possibly, you know, 1 in 10. You didn't give that information to describe what it looks like to dye of paracetam I do describe, you know, how that might want the liver more gorgeously online or something that's not the liver. you'd need to talk about um you know what you'd be offering them, what the track's gonna look like, what the matching's gonna look like you need to talk about what might happen to be on that. You'd need to really go but you have to check that you understand all of that, repeat that so that you understand it, person in it, and then they weigh into two choices and explain to you why, why did you test because that's how you read it. So that is one that nuances that the attack um were you saying sort of the principle the sort of fundamental idea that people's best. Yeah. I don't really into, but yeah. Yeah, she's she wants. Is that what the patient is that what the patients can't we can't we can't. And that the privacy. I think you can you don't have to give treatment. Yeah Yeah. And it's like a whole merexate we'll try it but we'll try. the I. That means it's been out as well. Yeah, real, shall we come back together. They they said I was. Did anybody think that messing around with the age of

the person really made any difference in their, in their ethical thinking about this case? Did anyone think it made no difference really? So no difference at all, it didn't even factor in. Bowel cancer. Why did that factor in? How did it affect the ethics? Well, you never know anything about. B No. If they fully understand capacity. How likely do you think they are to understand that? just Yeah, we were sort of talking about that, you know, the lengths you'd actually have to go to to come to a really firm decision about their capacity. You'd need to have a really in-depth conversation with them and they'd need to be able to engage with you in that, and if they couldn't, you'd need to try again and see if it'd be a longitudinal assessment, meanwhile, their liver is failing. Yeah. Who thought it did change things? The age in general, whether it's the young person or the older adult, did it change things? They've said, no, I don't That. Yeah. Yeah, agreed, I mean that's a legal thing, isn't it? Um, and it's, yeah, it's a form of advanced decision, isn't it?

Yeah We said we might for the 16 year old you want to get family involved. Yeah. Why You wanna consider their role in helping them get a better or how they've got. I mean, you would definitely. Liaison family with You know, you'll be gathering more information, so that's actually option D. Option D is you gather more information, you speak to family, yeah, as quickly as you can. If you can't get through to them, you still have to make a decision, don't you? Um Yeah, just, I know I've discussed this with a couple of groups, but I sort of picked 16 arbitrarily, but the Mental Capacity Act applies from 16 upwards, so Gillet competence doesn't come into it. If there were 15, you might think about Gillet competence, but it doesn't really apply in this situation because Gillet competence, um, doesn't allow a child to legally decline treatment that would be in their best interest. It's only that they can consent to treatment if they're competent, if they're licenced. Does anyone, I mean that's it, that's the end of the session. Does anyone have any sort of final thoughts or?

Has it been interesting? Yeah, so this scenario, so this session's been in this form for about 6 years, um. The way we're thinking of changing it is we're basically making it more complicated, so giving a bit more info, so similar scenario but a bit more information. Somebody who is known to mental health services, probably somebody maybe with a diagnosis of personality disorder or complex PTSD possibly in, in hospital, uh, and maybe they've taken an overdose and they want to leave. Um, you know, what do you do? And then we were gonna, what we're gonna try and do is write some little short briefs for different people's roles, so parent or partner. Or ward nurse or you know the care coordinator in the community, social worker, and we were gonna sort of split you into groups so that you try and put yourself in that professional or or person's shoes and think about, try and think about how you might view it ethically and how that might differ from your views as a doctor. Does that sound too complicated or would that be quite interesting? Say it again. Interesting. We, because we were thinking it'd be a bit more interesting anyway, but it, it also sort of brings in other kind of professional sort of skills like empathy and trying to kind of think about the whole person, think about what their, you know, their relationships, their networks, what those people might think, um, and then also thinking about the ethics of it. I, I'm a bit in two minds. I think it might be, yeah, you're, do you think it's a bit complex? Yeah, I think it's complex, and we're all in medical school looking at it from a doctor's point of view, so it's, it is important to look at family's point

of view. I would have liked some like more riffs on the scenarios, like what if, what if they had this terminal illness, what if they've had any previous suicide attempts. But yeah, loads of people in different roles kind of subtracts. Right Yeah. In a way, but then as I've sort of kind of admitted to kind of most of you going round, the decisions you end up making are often informed by the structures. Within which you're working, your professional role, professional guidance, NICE guidance, what the nurse is saying. You know, you're not sort of making ethically pure decisions, so to speak, not any such thing, but, um, ethical thinking definitely factors into some decision making. Do, certainly as a psychiatrist, um, so we were sort of thinking removing you from that doctor role might help you to think about the ethics, but I, I take your point, I have the doubts, I think it might be a bit overly complicated. Um, and a bit taxing is trying to kind of put yourself in the shoes of what a social worker might think. I mean to be brief, but um. Yeah, anyway, alright, thanks very much, you've all been really good, you've all taken part really well, so thank you, and I'm glad somebody turned up today, that's really good. And we finished 45 minutes early.

I Cheers, see you. I What you form your beliefs on. Cheers. See you. Cheers, bye. Thank you. Thanks. See you. Thank you. See you. Good, cheers, thank you. What is the day. Yeah, that's