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Preface

When Lord Denning was at his most prolific, a law student wrote to The Times
requesting that “his Lordship kindly refrain from changing any more laws before
the law examinations in August”.1 Updating this book has led me to feel some
sympathy for that student. I initially thought that the updating process would
merely be a matter of attending to the occasional new case, such as the Supreme
Court’s rulings on the ambit of conscientious objection to abortion and on the
standard of care for disclosure of medical risks.2 Then, alas on my birthday no
less, the UK electorate voted in favour of leaving the EU. EU law on data
protection (relevant to Chapter 6) and clinical trials (relevant to Chapter 11) is in
a state of flux and received some criticism in the lead up the referendum. In a
televised debate, Boris Johnson expressly cited the law on clinical trials as an
example of EU law from which the UK should depart. Around the same time,
Michael Gove wrote a piece in The Telegraph in which declared that the EU
Clinical Trials Directive had “slowed down the creation of new drugs to cure
terrible diseases” and ECJ judgments on data protection issues had “hobbled”
industry.3 Both politicians were criticising Directives that are due to be replaced
by Regulations with expected effect from 2018. Then as the deadline for
submission of this book approached, the Government announced new schemes
for !HS Redress, the Court of Appeal revisited the controversial case of Cheshire
West, the !HS Litigation Authority became !HS Resolution and the Human
Tissue Authority replaced its ten Codes of Practice with eight new ones—when it
rains, it pours!
The task of updating the text was, fortunately, aided by the removal of some
topics when writing the last edition, including the section on reclaiming the costs
of treatment obtained elsewhere in the EU. The fourth edition also trialled many
new features, such as summary boxes of key points, which have received positive
comment.4 This fifth edition has retained those features and is focussed on
updates.
The aim of this book continues to be to advance understanding of medical law
by applying the moral and contextual framework that is outlined in the first
chapter. As before, it seeks to demonstrate the need for medical lawyers, at all

1
Frances Jane Sieber, quoted in Rosenthal 1976.
2
Doogan v Greater Glasgow and Clyde Health Board [2014] UKSC 68 and Montgomery
v Lanarkshire Health Board [2015] UKSC 11, respectively.
3
Gove 2016.
4
See McAlister 2015.

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ii PREFACE

levels, to delve into philosophical moral reasoning. If successful, readers will be

asking the philosophical questions that are the focus of the final chapter.
I have sought to ensure that the law is accurate as of mid-May 2017.

Acknowledgements I wish to reiterate my thanks to all those listed in the

previous editions. I remain entirely responsible for any errors. I would also like to
thank Mary Herbert, who has kindly commented on my explanation of both
cloning and mitochondrial replacement, and to Emma Cave, Mike Taylor and
David Townend who kindly provided copies of some of their work.
I dedicate this book to my dearest Zoe and our son Orion.
SDP

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TABLE OF CO!TE!TS

PAGE
Preface.....................................................................................................................i

PARA
1. MEDICAL ETHICS
1. I!TRODUCTIO! .................................................................................1–001
2. U!DERSTA!DI!G MEDICAL ETHICS ..................................................1–002
(a) Moral relativism, objectivism and pluralism ...........................1–003
(b) Criteria of moral permissibility ................................................1–005
(i) Utilitarianism.....................................................................1–006
(ii) Rights-based theories and duty-based theories ................1–008
(iii) Virtue ethics .......................................................................1–010
(iv) Mixed objectivist positions ................................................1–012
(c) Religious and issue-perspective approaches ............................1–014
3. COMMO! ARGUME!TS I! MEDICAL ETHICS .....................................1–016
(a) Human dignity ..........................................................................1–017
(b) Slippery slopes..........................................................................1–019
(c) Sanctity of human life and moral status
(i) The sanctity of human life .................................................1–021
(ii) The moral status of human beings ....................................1–023
4. PRESSURES O! MEDICAL LAW A!D THE HUMA! RIGHTS ACT
1998..................................................................................................1–025
5. ADDITIO!AL THEMES A!D PRESSURES .............................................1–026
6. FURTHER READI!G ...........................................................................1–028

2. !HS STRUCTURE A!D RESOURCE ALLOCATIO!

1. I!TRODUCTIO! .................................................................................2–001
2. THE STRUCTURE OF THE !HS I! E!GLA!D ....................................2–002
(a) Commissioning and commissioned bodies ..............................2–003
(b) Special Health Authorities ........................................................2–005
(c) Other specialist bodies..............................................................2–007

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3. ACCESS TO HEALTHCARE A!D RESOURCE ALLOCATIO! ...................2–009

(a) Challenging rationing decisions in the courts ..........................2–011
(i) Judicial review...................................................................2–012
(ii) !egligence and breach of statutory duty ..........................2–014
(iii) The Human Rights Act 1998 .............................................2–016
(b) Ethical rationing strategies .......................................................2–018
(i) Ability to pay .....................................................................2–020
(ii) Age .....................................................................................2–022
(iii) Quality adjusted life-years (QALYs) .................................2–024
(iv) Other issues .......................................................................2–026
4. CO!CLUSIO! .....................................................................................2–027
5. FURTHER READI!G
!HS Structure ..................................................................................2–028
Resource allocation

3. CLI!ICAL !EGLIGE!CE
1. I!TRODUCTIO! .................................................................................3–001
(a) Overview of clinical negligence actions ..................................3–002
(b) Whom to sue.............................................................................3–004
2. DUTY OF CARE .................................................................................3–006
(a) Duty to assist ............................................................................3–008
(b) The primary duty of care of healthcare providers ...................3–010
(c) Psychiatric injury ......................................................................3–012
(d) Other grey areas........................................................................3–014
3. BREACH OF DUTY .............................................................................3–015
(a) The standard of care .................................................................3–016
(b) Application of the standard of care ..........................................3–018
(i) Inexperience.......................................................................3–020
(ii) Departure from guidance ..................................................3–022
(iii) Proving breach ..................................................................3–024
4. CAUSATIO! A!D REMOTE!ESS .........................................................3–026
(a) Materially increasing the risk of harm .....................................3–028
(b) Loss of a chance .......................................................................3–030
(c) Legal causation and remoteness ...............................................3–032
5. FURTHER PROCEDURAL ISSUES .........................................................3–034
(a) The limitation period ................................................................3–035
(b) Funding a negligence claim......................................................3–037
(c) The defence of clinical negligence claims ...............................3–039
(d) The civil justice system after the Woolf reforms.....................3–041
(i) The Pre-action Protocol ....................................................3–042
(ii) Expert evidence..................................................................3–043
(iii) Periodical payments ..........................................................3–044

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6. REFORM A!D REDRESS .....................................................................3–045

(a) Problems with the litigation system .........................................3–046
(b) Types of reforms and no-fault compensation...........................3–048
(c) The Future for !HS Redress....................................................3–050
7. CRIMI!AL !EGLIGE!CE ....................................................................3–052
8. ETHICS A!D OTHER THEORETICAL CO!SIDERATIO!S .......................3–054
(a) Corrective and distributive justice............................................3–055
(b) !egligence as a system of corrective justice ...........................3–057
(c) Further ethical considerations...................................................3–059
(i) The needs of medical accident victims..............................3–060
(ii) Deterring medical accidents .............................................3–062
(iii) Punishing those responsible ..............................................3–064
9. CO!CLUSIO! .....................................................................................3–066
10. FURTHER READI!G
Clinical negligence law and practice...............................................3–067
Criminal negligence
Ethics and other theoretical considerations

4. CO!SE!T I: I!FORMATIO!, VOLU!TARI!ESS A!D

PUBLIC POLICY
1. I!TRODUCTIO! .................................................................................4–001
2. THE DEVELOPME!T OF THE LAW OF CO!SE!T ................................4–002
(a) Burden of proving consent .......................................................4–004
(b) Declaratory procedure and clinical judgment ..........................4–006
3. VALID CO!SE!T ................................................................................4–008
4. I!FORMATIO!....................................................................................4–010
(a) Information and battery ............................................................4–011
(i) Performing an additional procedure on an
unconscious patient ...........................................................4–013
(ii) Questioning the low information threshold.......................4–015
(b) Information and negligence ......................................................4–017
(i) Montgomery v Lanarkshire ...............................................4–019
(ii) Patient questions................................................................4–021
(iii) Causation ...........................................................................4–023
(c) Disclosure from a moral point of view ....................................4–025
(i) Therapeutic privilege.........................................................4–027
(ii) The “right” to ignorance ..................................................4–029
(iii) Practical considerations....................................................4–031
5. VOLU!TARI!ESS ...............................................................................4–032
6. PUBLIC POLICY .................................................................................4–034
(a) Self harm from a moral point of view .....................................4–036

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(b) Public policy and refusing treatment........................................4–038

7. CO!CLUSIO! .....................................................................................4–039
8. FURTHER READI!G
Consent and information..................................................................4–040
Consent and public policy
Consent and undue influence
The ethics of consent

5. CO!SE!T II: CAPACITY A!D ME!TAL HEALTH

1. I!TRODUCTIO! .................................................................................5–001
2. I!CAPACITATED ADULTS ....................................................................5–003
(a) Determining capacity................................................................5–004
(i) The capacity test................................................................5–006
(ii) Unwise decisions and the risk of death or
irreversible harm ...............................................................5–008
(ii) Vulnerable adults ...............................................................5–010
(b) The consequences of incapacity ...............................................5–012
(i) The general legal authority and proxies...........................5–013
(ii) The best interests test ........................................................5–015
(iii) The ethics of relying on the best interests test..................5–017
(c) Refusal of treatment in late pregnancy
(i) The law.................................................................................5–019
(iii) Ethical issues .....................................................................5–021
(d) Sterilisation ...............................................................................5–023
3. CHILDRE!
(a) First person and proxy consent ................................................5–025
(i) Parental consent and parental responsibility ...................5–027
(ii) Judicial consent .................................................................5–029
(b) The competent child
(i) The law ..............................................................................5–031
(ii) Legal evolution and ethical views.....................................5–033
(c) The incompetent child ..............................................................5–035
(i) The limits of parental capacity..........................................5–036
(ii) Disagreement between parents and the medical
profession...........................................................................5–038
(iii) Disagreement between the parents....................................5–040
4. WHE! TO I!VOLVE THE COURT ........................................................5–042
5. DETAI!I!G A!D TREATI!G THE ME!TALLY ILL ................................5–044
(a) Compulsory treatment...............................................................5–045
(b) Compulsory detention...............................................................5–047
(c) Informal admission and the Bournewood gap .........................5–049
6. CO!CLUSIO! .....................................................................................5–051

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7. FURTHER READI!G
The capacity test ..............................................................................5–052
Ritual circumcision
Mental health

6. MEDICAL CO!FIDE!TIALITY A!D DATA PROTECTIO!

1. I!TRODUCTIO! .................................................................................6–001
2. THE GE!ERAL DUTY TO PROTECT MEDICAL I!FORMATIO! ..............6–002
(a) The common law duty of confidentiality.................................6–003
(b) Children, incapacitated adults and the dead.............................6–005
(i) Children and incapacitated adults ....................................6–006
(ii) Dead patients.....................................................................6–007
(c) Data protection law...................................................................6–009
(i) The Data Protection Act 1998...........................................6–010
(ii) The General Data Protection Regulation
(GDPR) ..............................................................................6–012
(d) Data protection law and the law of confidentiality..................6–014
3. PERMITTED DISCLOSURE ..................................................................6–016
(a) Consent and the patient’s interests ...........................................6–017
(b) Public interest ...........................................................................6–019
(i) Communicable diseases.....................................................6–020
(ii) Genetic information...........................................................6–021
(iii) Could there be a duty to disclose under the law of
negligence? ........................................................................6–022
(iv) The public interest and data protection law .....................6–023
(c) Teaching, research and audit ....................................................6–025
(i) Anonymisation: breach of confidentiality .........................6–026
(ii) Anonymisation: data protection law .................................6–027
(iii) Statutory exception to the duty of confidentiality .............6–028
4. ACCESS TO RECORDS
(a) Data protection law...................................................................6–030
(b) Other legal routes......................................................................6–032
5. CO!CLUSIO! .....................................................................................6–033
6. FURTHER READI!G ...........................................................................6–034

7. ABORTIO!
1. I!TRODUCTIO! .................................................................................7–001
2. THE ETHICS OF ABORTIO! ................................................................7–002
(a) The moral status of the fetus
(i) Grounds for moral status ..................................................7–003
(ii) The major moral positions ................................................7–004
(b) Other issues raised by abortion ................................................7–006

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3. GROU!DS FOR LEGAL ABORTIO!......................................................7–008

(a) The “social” ground..................................................................7–010
(i) The time limit .....................................................................7–011
(ii) Establishing social and therapeutic grounds....................7–012
(b) Risk to life and health ..............................................................7–014
(c) Fetal abnormality ......................................................................7–016
(i) Interpreting the fetal abnormality provision.....................7–017
(ii) Ethical issues .....................................................................7–018
4. AFFECTED PERSO!S ..........................................................................7–020
(a) The fetus ...................................................................................7–021
(b) The pregnant woman
(i) Human rights .....................................................................7–023
(ii) Incapacitated women and children ...................................7–024
(c) Fathers and other interested parties..........................................7–026
(d) Conscientious objectors ............................................................7–028
5. OTHER ISSUES ...................................................................................7–030
(a) Drug-induced abortion and contraception................................7–031
(i) The involvement of persons other than doctors................7–032
(ii) Post-coital contraception ..................................................7–033
(b) Selective reduction....................................................................7–035
(c) The living abortus.....................................................................7–037
6. CO!CLUSIO! .....................................................................................7–039
7. FURTHER READI!G
Abortion and human rights ..............................................................7–040
Abortion on grounds of fetal abnormality
The ethics of abortion

8. REPRODUCTIVE TECH!OLOGIES
1. I!TRODUCTIO! .................................................................................8–001
(a) The legislation and regulatory body.........................................8–002
2. THE ETHICS OF ASSISTED REPRODUCTIO!........................................8–004
(a) The moral status of the in vitro embryo ..................................8–005
(b) Reproductive tourism................................................................8–007
(c) Dignitarian concerns .................................................................8–009
3. THE STATUTORY SCHEME ..................................................................8–011
(a) The HFEA and its licensing remit............................................8–012
(i) Membership .......................................................................8–013
(ii) Licensing remit ..................................................................8–014
(b) Access to assisted reproduction................................................8–016
(i) The welfare of the child requirement ................................8–017
(ii) Legally challenging the exercise of discretion..................8–018
(iii) Human rights issues ..........................................................8–019

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(c) Other issues concerning treatment ...........................................8–021

(i) Counselling ........................................................................8–022
(ii) Consent ..............................................................................8–023
(iii) !umber of embryos to be implanted .................................8–024
4. DO!ATIO!, STORAGE A!D IMPORT/EXPORT OF GAMETES A!D
EMBRYOS...........................................................................................8–026
(a) Donation....................................................................................8–027
(i) Selecting a donor...............................................................8–028
(ii) Paying donors....................................................................8–029
(iii) Donor anonymity ...............................................................8–030
(iv) Aborted fetuses ..................................................................8–031
(b) Storage ......................................................................................8–033
(c) Import and export .....................................................................8–035
5. PREIMPLA!TATIO! GE!ETIC DIAG!OSIS A!D TISSUE
TYPI!G ..............................................................................................8–037
(a) Sex selection
(i) The regulatory position .....................................................8–038
(ii) The ethics of sex selection.................................................8–039
(b) Donor selection (saviour siblings)............................................8–041
(i) The ethics of donor selection ............................................8–042
(c) Selecting for other traits ...........................................................8–044
6. SURROGACY......................................................................................8–046
(a) Ethical issues.............................................................................8–047
(b) The law .....................................................................................8–048
7. PARE!TAGE .......................................................................................8–050
(a) The mother................................................................................8–051
(b) The other legal parent...............................................................8–053
(i) The father: married mother...............................................8–054
(ii) The father: unmarried mothers and married
mothers whose husbands do not consent ..........................8–055
(iii) A woman as the other legal parent ...................................8–056
(c) Children without another parent...............................................8–058
8. CO!CLUSIO! .....................................................................................8–060
9. FURTHER READI!G ...........................................................................8–061
Preimplantation Genetic Diagnosis

9. PRE!ATAL !EGLIGE!CE
1. I!TRODUCTIO! .................................................................................9–001
2. TYPES OF ACTIO! .............................................................................9–002
(a) Actions by or on behalf of the child ........................................9–003
(b) Actions by or on behalf of the parents.....................................9–005

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3. ACTIO! BROUGHT BY THE CHILD: PRE!ATAL I!JURY ......................9–007

(a) Legal issues
(i) The 1976 Act......................................................................9–008
(ii) At common law ..................................................................9–009
(iii) Future reforms ...................................................................9–010
(b) Ethical issues concerning the maternal immunity from
suit.............................................................................................9–012
4. ACTIO! BROUGHT BY THE CHILD: WRO!GFUL LIFE ........................9–014
(a) Legal issues
(i) At common law ..................................................................9–015
(ii) The 1976 Act......................................................................9–016
(b) Ethical issues.............................................................................9–018
(i) Strategy One ......................................................................9–019
(ii) Strategy Two ......................................................................9–020
(iii) Other comments.................................................................9–021
5. ACTIO!S BROUGHT BY THE PARE!T: LEGAL ISSUES ........................9–023
(a) Prenatal negligence leading to the birth of a healthy
child...........................................................................................9–024
(b) Prenatal negligence leading to the birth of a disabled
child...........................................................................................9–026
(c) Rees v Darlington .....................................................................9–028
(d) Other legal issues......................................................................9–030
6. ACTIO!S BROUGHT BY THE PARE!T: ETHICAL ISSUES.....................9–031
(a) Autonomy and human dignity..................................................9–032
(b) Other ethical arguments............................................................9–034
7. CO!CLUSIO! .....................................................................................9–035
8. FURTHER READI!G ...........................................................................9–036

10. EMBRYO RESEARCH, EMBRYO!IC STEM CELLS A!D

CLO!I!G
1. I!TRODUCTIO! ...............................................................................10–001
2. THE SCIE!CE...................................................................................10–002
(a) Embryo research .....................................................................10–003
(b) Cloning....................................................................................10–005
(c) Stem cells................................................................................10–007
(d) Chimeras and hybrids .............................................................10–009
3. RESEARCH O! EMBRYOS ................................................................10–011
(a) Ethical issues
(i) Moral status of the human embryo .................................10–012
(ii) Specific types of embryo research...................................10–013
(b) Legal issues
(i) Research on human embryos...........................................10–015

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(ii) The 1990 Act’s position on the moral status of the

embryo .............................................................................10–016
(iii) Embryonic stem cells.......................................................10–017
(iv) Cloned, hybrid and chimera embryos .............................10–018
4. REPRODUCTIVE CLO!I!G ...............................................................10–020
(a) Ethical issues...........................................................................10–021
(i) Arguments against reproductive cloning.........................10–022
(ii) Our duties to the clone ....................................................10–023
(iii) Arguments in favour of reproductive cloning .................10–024
(b) Legal issues.............................................................................10–026
5. MITOCHO!DRIAL REPLACEME!T ....................................................10–028
6. THE I!TER!ATIO!AL DIME!SIO! ...................................................10–030
(a) International instruments ........................................................10–031
(b) Reproductive tourism and regulatory approaches
elsewhere.................................................................................10–033
7. CO!CLUSIO! ...................................................................................10–034
8. FURTHER READI!G .........................................................................10–035

11. CLI!ICAL RESEARCH

1. I!TRODUCTIO!................................................................................11–001
2. RESEARCH A!D ITS CO!TEXT .........................................................11–002
(a) Clinical research and innovative treatment ............................11–003
(b) Controlled trials ......................................................................11–005
(c) Phases of research on medicinal products..............................11–007
3. THE ETHICS OF CLI!ICAL RESEARCH ..............................................11–009
(a) The role and validity of consent.............................................11–010
(i) The therapeutic misconception ........................................11–011
(ii) Duties to participate in research.....................................11–012
(iii) Inducements .....................................................................11–013
(iv) The vulnerable .................................................................11–014
(b) Equipoise and placebos...........................................................11–016
(i) Equipoise and uncertainty ...............................................11–017
(ii) Placebos (sham treatment) ..............................................11–018
(c) Those who lack capacity ........................................................11–020
4. THE REGULATORY POSITIO! ...........................................................11–022
(a) Guidance and the regulatory context......................................11–023
(b) The 2004 Regulations and the EU Regulation.......................11–025
(i) The 2004 Regulations ......................................................11–026
(ii) The EU Regulation ..........................................................11–028
(c) Research Ethics Committees ..................................................11–030
(i) Membership of RECs .......................................................11–031

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(ii) RECs and the law ............................................................11–032

(d) The participant’s consent ........................................................11–034
(i) Voluntariness....................................................................11–035
(ii) Disclosure of information ................................................11–036
(iii) The 2004 Regulations and the EU Regulation ...............11–037
(e) Incapacitated adults.................................................................11–038
(i) The Mental Capacity Act.................................................11–039
(iii) The 2004 Regulations and the EU Regulation ...............11–040
(iv) Research into emergency treatment.................................11–041
(f) Children...................................................................................11–043
(i) Children and the common law ........................................11–044
(iii) The 2004 Regulations and the EU Regulation ...............11–045
5. COMPE!SATIO! ...............................................................................11–047
(a) Liability of RECs and their members.....................................11–048
(b) Obtaining compensation from the researcher/sponsor ...........11–050
6. CO!CLUSIO! ...................................................................................11–051
7. FURTHER READI!G
Duties and incentives for participation..........................................11–052
EU Regulation
Research on children
Research on incapacitated adults

12. TRA!SPLA!TATIO! I: LIVI!G A!D DECEASED DO!ORS

1. I!TRODUCTIO! ...............................................................................12–001
(a) The Human Tissue Act 2004 and the Human Tissue
Authority .................................................................................12–002
2. TRA!SPLA!TATIO! FROM THE DEAD..............................................12–004
(a) Defining death and preparing for cadaveric
transplantation.........................................................................12–005
(i) The law ............................................................................12–006
(ii) Elective ventilation ..........................................................12–007
(b) Acquisition: ethical issues ......................................................12–009
(i) Types of regulatory system ..............................................12–010
(ii) Ethical views on the type of system.................................12–011
(iii) Duties on doctors: required request................................12–012
(iv) Tissue that is not necessary for survival.........................12–013
(c) Acquisition: legal issues .........................................................12–015
(i) Appropriate consent.........................................................12–016
(ii) Other provisions ..............................................................12–017
(d) Allocation................................................................................12–019
(i) Conditional and directed donation .................................12–020
3. TRA!SPLA!TATIO! FROM THE LIVI!G............................................12–022
(a) The ethical issues....................................................................12–023

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(b) The law ...................................................................................12–025

(i) The common law and the lawfulness of removal............12–026
(ii) Section 1 ..........................................................................12–028
(iii) Section 33 ........................................................................12–030
4. CO!CLUSIO! ...................................................................................12–032

13. TRA!SPLA!TATIO! II: PAYME!T, ALTER!ATIVES A!D

PROPERTY
1. I!TRODUCTIO! ...............................................................................13–001
2. ALLOWI!G PAYME!T A!D I!CE!TIVES ..........................................13–002
(a) The law ...................................................................................13–003
(b) The ethical issues....................................................................13–005
(i) Paying living providers ...................................................13–006
(ii) The contemporary debate on paying living
providers ..........................................................................13–007
3. ALTER!ATIVES TO EXISTI!G HUMA! ORGA!S ...............................13–009
(a) Artificial organs, tissue engineering and regenerative
medicine
(i) The technology.................................................................13–010
(ii) The regulatory position ...................................................13–012
(b) Animal organs (xenotransplantation) .....................................13–014
(i) Ethical issues ...................................................................13–015
(ii) The regulatory position ...................................................13–016
4. PROPERTY I! HUMA! ORGA!S A!D TISSUE ...................................13–018
(a) Conceptions of property .........................................................13–019
(b) The law ...................................................................................13–020
5. CO!CLUSIO! ...................................................................................13–022
6. FURTHER READI!G
General ...........................................................................................13–023
Conditional donation and directed donation
Elective ventilation
Opt-in v Opt-out
Property in the body
Xenotransplantation

14. E!D OF LIFE DECISIO!S I: THE LAW

1. I!TRODUCTIO! ...............................................................................14–001
2. TYPES OF E!D OF LIFE DECISIO!S .................................................14–002
(a) The doctor’s involvement .......................................................14–003
(b) The patient’s involvement ......................................................14–005
(c) Intending and foreseeing ........................................................14–007

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3. REFUSI!G A!D REQUESTI!G LIFE-PROLO!GI!G

TREATME!T .....................................................................................14–009
(a) Contemporaneous refusal .......................................................14–010
(b) Advance refusal ......................................................................14–012
(c) Requesting life-prolonging treatment.....................................14–014
4. REQUESTI!G LIFE-SHORTE!I!G TREATME!T A!D ASSISTA!CE
TO DIE .............................................................................................14–016
(a) Administration of life-shortening treatment...........................14–017
(b) Physician-Assisted Suicide (PAS)
(i) The Suicide Act 1961.......................................................14–019
(ii) The Pretty case ................................................................14–021
(c) The DPP’s guidance, other jurisdictions and recent
developments ..........................................................................14–023
(i) Assisting another to travel abroad to commit
suicide, Purdy and !icklinson.........................................14–024
(ii) Other jurisdictions...........................................................14–026
(iii) Brief comments and future reforms.................................14–028
5. !O!-VOLU!TARY E!D OF LIFE DECISIO!S .....................................14–029
(a) Permanent vegetative state .....................................................14–030
(i) The Bland case ................................................................14–031
(ii) Post-Bland cases..............................................................14–032
(iii) The Human Rights Act 1998 and the European
Convention .......................................................................14–033
(b) Futility and other non-voluntary non-treatment.....................14–035
(i) Selective non-treatment of newborns and infants ...........14–036
(ii) !on-treatment of adults in a minimally conscious
state..................................................................................14–038
(c) The Special Case of Re A.......................................................14–040
(i) Balancing the best interests of the twins.........................14–041
(ii) The criminal law..............................................................14–042
(iii) Concluding thoughts........................................................14–043
6. TE!SIO!S A!D CO!TRADICTIO!S ...................................................14–045

15. E!D OF LIFE DECISIO!S II: ETHICAL CO!TROVERSY

1. I!TRODUCTIO! ...............................................................................15–001
2. TWO DISPUTED DISTI!CTIO!S
(a) Effects and double effects ......................................................15–002
(i) The principle of double effect and end of life
decisions ..........................................................................15–003
(ii) Conceptual distinction and moral significance ..............15–004
(b) Acts and omissions .................................................................15–006

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3. VOLU!TARY E!D OF LIFE DECISIO!S .............................................15–008

(a) Advance refusals.....................................................................15–009
(i) The personal identity objection.......................................15–010
(ii) Past autonomy versus present welfare interests..............15–011
(b) Legalising voluntary lethal treatment and PAS......................15–013
(i) Arguments advanced by proponents of
legalisation ......................................................................15–014
(ii) Arguments advanced by opponents of
legalisation ......................................................................15–015
4. !O!-VOLU!TARY E!D OF LIFE DECISIO!S
(a) Criteria and debate..................................................................15–017
(b) Applying this ethical framework............................................15–019
(c) Patients in PVS and the special case of Re A ........................15–021
(i) Patients in PVS................................................................15–022
(ii) Re A..................................................................................15–023
5. CO!CLUSIO! ...................................................................................15–025
6. FURTHER READI!G
Permanent vegetative state.............................................................15–026
Present v prospective interests
The legalisation of voluntary lethal treatment and
physician-assisted suicide

16. A MORAL APPROACH TO MEDICAL LAW

1. I!TRODUCTIO! ...............................................................................16–001
2. MORAL OBJECTIVISM RECO!SIDERED ............................................16–002
(a) Weak moral objectivism .........................................................16–004
(i) Logical analysis of the moral point of view ...................16–006
(ii) Moral contractarianism...................................................16–008
(b) Strong moral objectivism........................................................16–010
(i) Transcendentalism ...........................................................16–011
(ii) !on-moral contractarianism ...........................................16–012
(c) The strong moral objectivism of Gewirth ..............................16–014
3. MORAL APPLICATIO! ......................................................................16–016
(a) Applying specific moral theories ...........................................16–018
(i) Kant..................................................................................16–019
(ii) Gauthier ...........................................................................16–021
(iii) Rawls................................................................................16–023
(iv) Hare .................................................................................16–025
(b) Applying Gewirth’s theory .....................................................16–027
(i) Understanding the generic rights....................................16–028
(ii) Precautionary reasoning .................................................16–030
(iii) Applying the PGC to medical issues...............................16–032
4. THE FUTURE OF MEDICAL LAW ......................................................16–033

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5. FURTHER READI!G
On the justificatory strategies of particular theorists
Gauthier ..................................................................................16–034
Gewirth
Hare
Kant
Rawls
On applied moral theories

BIBLIOGRAPHY

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CHAPTER 1

MEDICAL ETHICS

1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–001
2. Understanding medical ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–002
(a) Moral relativism, objectivism and pluralism . . . . . . . . . . . . . . . . . . . 1–003
(b) Criteria of moral permissibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–005
(c) Religious and issue-perspective approaches . . . . . . . . . . . . . . . . . . . 1–014
3. Common arguments in medical ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–016
(a) Human dignity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–017
(b) Slippery slopes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–019
(c) Sanctity of human life and moral status . . . . . . . . . . . . . . . . . . . . . . 1–021
4. Pressures on medical law and the Human Rights Act 1998 . . . . . . . . . . . . . 1–025
5. Additional themes and pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–026
6. Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–028

1. I!TRODUCTIO!

Should a doctor kill a suffering patient who begs for an early release from life? 1–001
Should a doctor withdraw food and water from an insensate patient who could
survive for years without ever regaining consciousness? Should a doctor perform
an abortion on a woman who does not want to carry a disabled child? Such
questions pulse with significance for the doctor, the patient and the law.
The controversy and complexity of the issues faced by modern medicine is
often deeper than is immediately apparent. Consider the weight to be given to the
free and informed decision of a pregnant woman who steadfastly refuses the
Caesarean section advised by her doctor. If your initial reaction is to support the
woman’s decision in all circumstances as long as she is competent, ask yourself
whether you would still hold this view if the baby was ready to take its first
breath and without a Caesarean section would be dead in the womb within the
next 15 minutes, followed within hours by the death of the woman herself. What
if the pregnant woman is refusing the Caesarean section solely to punish the
baby’s father or a disapproving family member? If your initial reaction is to
support the doctor’s view in all circumstances irrespective of the competence of
the pregnant woman, ask yourself whether you would still hold this view if the
pregnant woman’s decision was supported by her husband, there was only a low
chance that the surgery would save the baby and a high chance that it would
accelerate the woman’s imminent death from secondary lung cancer.1 If your

1
These were the facts of the American case Re AC. At first instance the court authorised the
involuntary Caesarean section. The District of Columbia Court of Appeals refused to stay this

[1]

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