Understanding What Consent for Medical Treatment Means

Informed consent is a choice a patient makes in respect of a proposed advice, be it a

treatment plan or a surgical intervention, after receiving appropriate and adequate
information about the medical condition and the proposed intervention. It is important
that the patient understands the information and uses it to make a decision, which may
be to accept or reject the proposed intervention. The information given to the patient
should include risks and dangers of the proposed intervention. It is for this reason that
informed consent is sometimes referred to as shared decision making or the duty to
disclose. It arises out of respect for the autonomy of the patient. A patient may sue a
health-worker for assault or battery if one touches the patient or a specific part of the
patient without the patient’s express consent.

For a patient’s consent to be valid it must be given freely, willing and when the patient is
of sound mind. In this respect the patient must be competent to consent and the
Information should be given to the patient in a language and terms that the patient can
comprehend. For a patient’s consent to be legally valid it must be based on adequate
information given and should be specific for the proposed procedure or treatment. The
patient’s comprehension of the information given should also be reasonably attested.

There are different main forms of consent; written consent, oral or verbal consent, the
‘no objection’ consent and the implied consent. All these different forms of consent
should be witnessed and one of the witnesses should be a health-worker. For surgical
or invasive procedures or treatment with potentially serious side-effects, it is important
that a patient should be fully informed and the consent should be in writing. Even where
oral consent is obtained, it is wise to make a note of this in the patient’s file. When a
patient withdraws consent, health-workers should not continue with the treatment or
intervention but seek a second opinion and have the patient counseled.

Health-workers should learn the art of effective communication with their patients. This
enables them to get informed consent from the patients. It is virtually impossible for
health-workers to get written consent for all the medical processes but the health-worker
should explain and get a verbal consent or a no-objection consent when taking history
or examining a patient, or when carrying out laboratory investigations or giving
medications with potentially serious side-effects. Patients also need to be informed and
consent obtained when information got from them may be released to third parties. This
is particularly important in forensic consultations and examinations where the findings
may be presented to or discussed in an open court of law or when the patients are
subjects of research.

Doctors may choose to withhold information regarding the risks of a proposed treatment
or procedure or information regarding a particular diagnosis or prognosis of a disease, if
in the opinion of the doctor, the information may harm the patient. This is known as
therapeutic privilege and it is based on the principle that a doctor should always act in
the best interests of the patient and do no harm to the patient. Some courts have

1
accepted the principle of withholding information from patients but one school of thought
considers this principle paternalistic and not in accord with the respect for a patient’s
autonomy. To withhold information from a patient may increase the patient’s anxiety and
may undermine the patient’s confidence in the doctor. The onus is on doctors who
withhold information from patients to prove to court, when faced with litigation, that they
believed on reasonable grounds that giving the patient that particular information would
pose a significant risk of serious harm to the patient’s physical or mental health. It is not
enough that the patient may be alarmed or distressed by the information.

The Rights of Patients

In 1981 in Lisbon, Portugal the World Medical Association during its 34 th Assembly
adopted a declaration on the principal rights of the patient. These rights were to
guarantee fairness and justice to, and autonomy of the patient. The declaration was
also a call to all the stakeholders to recognize and uphold these rights. These rights are
a legal and moral ground for improving the standard of care for the patient.

The rights of the patient are based on the Universal Declaration of Human Rights and
are largely hinged on the dignity of the person and the equality of all human beings.
These are what the health worker and healthcare provider owes to the patient as a
human being. Patients’ rights or Patients’ Bill of Rights vary in different countries and in
different jurisdictions but are all based on the best interest of the patient. Some of these
have been passed as laws.

Every patient has a right to medical care of good quality, including the right to
appropriate care without discrimination. Treatment of patients should be in accordance
with generally approved medical and time honored ethical principles. And every patient
has a right to be treated in accordance with his or her best interests by a health worker
who is free to make clinical and ethical judgments without outside interference.

A patient has a right to freedom of choice. This means that the patient has the right to
choose freely his or her healthcare provider, be it the health worker or institution and the
patient has the right to ask for the opinion of another healthcare provider at any stage.
Diagnostic procedures or treatment against the patient’s will can be carried out only in
exceptional cases, if specifically permitted by law and conforming to the principles of
medical ethics.

A patient has the right to self-determination, to make free decisions regarding his or her
health. This means that a mentally competent adult patient has the right to give or
withhold consent to any diagnostic procedure or therapy as well as the right to
information necessary to make that decision. A patient is entitled to understand clearly
the purpose of any test or treatment, what the results imply, and what would be the
implications of withholding consent. A health worker will, however, inform the patient of
the consequences of his or her decisions.

2
A patient has the right to receive information about his or her health as recorded in the
medical charts or records and to be fully informed and updated about his or her health
status. Information may, in exceptional circumstances, be withheld from a patient when
there is good reason to believe that this information will have a serious hazard on the
patient’s life or health. And the patient has the right to choose who, if any, should be
informed on his or her behalf.

All information about a patient’s medical condition, including diagnosis, prognosis and
treatment, and all other information of a personal kind must be kept confidential, even
after death. All identifiable patient data must be protected. The protection of the data
must be appropriate to the manner of its storage. Human substances from which
identifiable data can be derived must likewise be protected.

Confidential information can only be disclosed if the patient gives explicit consent or if
expressly provided for by law. Information can be disclosed to other health care
providers on a strictly “need to know’ basis unless the patient has given explicit consent.
Third parties may, however, have a right of access to information that would inform
them of their own health risks.

If the patient is unconscious or unable to express his or her will, a healthcare provider
should endeavor to obtain, whenever possible, informed consent from a legally entitled
representative. However if this is not possible, but a medical intervention is urgently
needed, consent of the patient may be presumed, unless it is obvious and beyond any
doubt on the basis of the patient’s previous firm expression or conviction that he or she
would refuse consent to the intervention in that position. Healthcare providers should,
however, try to save the life of a patient unconscious due to a suicide attempt.

Every person has a right to health education that will assist him or her in making
informed choices about personal health and about the available health services. The
education should include information about healthy lifestyles and about methods of
prevention and early detection of illnesses and the personal responsibility of everybody
for his or her own health should be stressed. Health workers have an obligation to
participate actively in educational efforts.

A patient’s dignity, right to privacy, values and culture must be respected at all times in
medical care and teaching. The patient is also entitled to humane terminal care and
should be provided with all available assistance to make death as dignified and as
comfortable as possible.

3
Relevance of the Hippocratic Oath

An Oath is a solemn pledge or promise to uphold an undertaking. The Hippocratic Oath

is an Oath historically taken by health practitioners to uphold specific standards of their
profession. The true author of the Hippocratic Oath is unknown but has been attributed
to the Greek physician and teacher Hippocrates of Kos. The original Oath, written in
Ionic Greek, between the fifth and third centuries Before Christ, is the earliest
expression of medical ethics and professionalism. In its original form, it required a
physician to swear by a number of Greek gods of healing to uphold specific ethical
standards. The earliest surviving version is on a fragment of papyrus and thought to
have been written in 275 Anno Domino. The Oath, however, has been modified
numerous times. Today it acts as a moral compass for the health practitioner.

As the practice of medicine has changed, so have the oaths taken. There are modern
and more relevant versions of the original Oath that have been adopted by the World
Medical Association (WMA) and national medical associations. One of the most
significant revisions, drafted in 1948 by the World Medical Association and referred to
as the Declaration of Geneva, was a result of concern over the state of medical ethics
then. The Declaration of Geneva is used across the world by physicians and in many
countries it is actually part of the professional code and some of it is legally binding. The
WMA took up the responsibility of setting ethical guidelines for the World’s physicians. It
is from the original Oath that many of the medical ethical codes of conduct have been
derived.

The 2017 version, a modern successor to the Hippocratic Oath for physicians, has been
approved by the WMA. Of this version, the then President of the WMA said “The life of
physicians today is completely different to what it was in 1948 when the original
Declaration of Geneva was adopted….We hope that the declaration approved today will
be used by all physicians around the world to strengthen the profession’s determination
to maintain the highest standard of health care for patients.”

In the 1948 version of the Oath, the physician pledged to maintain the uttermost respect
for human life from the time of conception. In the 2017 Oath the physician pledges to
maintain the utmost respect for human life. In the older version the physician pledged
even under threat not to use the medical knowledge contrary to the laws of humanity
but in new version the pledge is not to use the medical knowledge to violate human
rights and civil liberties even under threat.

The initial Oath described the relationship between the physician and his mentor; and
the relationship between the physician and his fellow physicians. It contained a pledge
to share knowledge. In the 1948 version the physician’s pledge was to maintain the
honour and noble traditions of the medical tradition while the 2017 version pledges to
foster the honour and noble traditions of the medical profession. In the 2017 version, the
physician pledges to give his or her teaches, colleagues and students the respect and
gratitude that is their due.

4
That the physician must always act in the best interest of the patient and to do no harm
was a cardinal issue in the oath. In the words of the Oath “I will use treatment to help
the sick according to my ability and judgment, but never with a view to injury and wrong-
doing. The phrase “First do no harm” does not appear in the original Oath; it is believed
to have been coined much later. An equivalent phase “Practice two things in your
dealings with disease: either help or do not harm the patient” is found in later medical
literature. One doctor interpreted this to mean not over diagnosing, not over treating and
shared decision making.

The Oath, as adopted by the World Medical Association, contains the pledge “I will not
permit considerations of age, disease, creed, ethnic origin, gender, nationality, political
affiliation, race, sexual orientation, social standings, or any other factor intervene
between my duty and my patient”.

The 2017 version of the Oath puts emphasis on the patient autonomy with a clause, “I
will respect the autonomy and dignity of my patient.

In a later version of the Oath physicians pledged “not to treat a fever chart, a cancerous
growth, but a sick human being”, making patients, and not tests, the focus of the
physician.

The original Oath forbade the provision of poisonous drugs including drugs that could
cause abortion. There was no place for euthanasia in the Oath. The prohibition of
abortion is however not found in revised versions of the Oath as many practitioners now
prescribe abortions, if only for the sake of the mother’s life or health.

The Oath also mentions the special position of the doctor with regard to his patients,
especially women and girls as it contained a pledged to abstain from abusing the bodies
of men or women, bond or free.

“And whatever I shall see or hear in the course of my profession……..I will never
divulge, holding such things to be holy secrets.” Holding the patient’s information sacred
is at the heart of the trust and respect between the physician and the patient

A modern version of the Oath requires doctors to look after their own health in the
clause “I will attend to my own health, well being, and abilities in order to provide care of
the highest standard.

Doctors today have different opinions about the Oath. To some doctors the oath is a rite
of a passage but to others it is to a serious and appropriate initiation into medicine.
Some doctors find the ethical principles and medical guidelines developed from the
original Oath as more appropriate for the current practice of medicine. Some health
practitioners are so audacious to suggest a common charter

5
Understanding the Hippocratic Oath

The Hippocratic Oath is a solemn pledge or promise, historically taken by health

practitioners, to uphold specific standards of their profession. The true author of the
Hippocratic Oath is unknown but has been attributed to the Greek physician and
teacher Hippocrates of Kos. The original Oath, written in Ionic Greek, between the fifth
and third centuries Before Christ, is the earliest expression of medical ethics and
professionalism. In its original form, it required a physician to swear by a number of
Greek gods of healing. The earliest surviving version is on a fragment of papyrus and
thought to have been written in 275 Anno Domino. The Oath, however, has been
modified numerous times. Today it acts as a moral compass for the health practitioner.
It is from the original Oath that many of the present medical ethical codes of conduct
have been derived.

As the practice of medicine has changed, so have the oaths taken. There are modern
and more relevant versions of the original Oath that have been adopted by the World
Medical Association (WMA) and national medical associations. One of the most
significant revisions, drafted in 1948 by the World Medical Association, and referred to
as the Declaration of Geneva, was a result of concern over the state of medical ethics
then. The Declaration of Geneva is still used across the world by physicians, and in
many countries it is actually part of the professional code, and some of it is legally
binding.

In 2017 the WMA approved a modern successor to the Hippocratic Oath. At the
approval of this version, the President of the WMA said “The life of physicians today is
completely different to what it was in 1948 when the original Declaration of Geneva was
adopted….We hope that the declaration approved today will be used by all physicians
around the world to strengthen the profession’s determination to maintain the highest
standard of health care for patients.”

In the 1948 version of the Oath, the physician pledged to maintain the uttermost respect
for human life from the time of conception. In the 2017 Oath the physician pledges to
maintain the utmost respect for human life. Today some countries have legalized
abortion and euthanasia and the wording of the 2017 pledge clearly reflect these
changes.

In the older version the physician pledged, even under threat, not to use the medical
knowledge contrary to the laws of humanity but in new version the pledge is not to use
the medical knowledge to violate human rights and civil liberties, even under threat. This
has broadened the ethical responsibilities of the physician.

The initial Oath described the relationship between the physician and his mentor and
the relationship between the physician and his fellow physicians. It contained a pledge
to share knowledge. In the 1948 version the physician’s pledge was to maintain the
honour and noble traditions of the medical tradition while the 2017 version pledges to

6
foster the honour and noble traditions of the medical profession. In the 2017 version, the
physician pledges to give his or her teaches, colleagues and students the respect and
gratitude that is their due.

That the physician must always act in the best interest of the patient and to do no harm
was a cardinal issue in the oath. In the words of the original Oath “I will use treatment to
help the sick according to my ability and judgment, but never with a view to injury and
wrong-doing. The phrase “First do no harm” does not appear in the original Oath; it is
believed to have been coined much later. An equivalent phase “Practice two things in
your dealings with disease: either help or do not harm the patient” is found in later
medical literature. One doctor interpreted this to mean not over diagnosing, not over
treating and shared decision making.

The 2017 version of the Oath puts emphasis on the patient autonomy with a clause, “I
will respect the autonomy and dignity of my patient.” In one version of the Oath
physicians pledged “not to treat a fever chart, a cancerous growth, but a sick human
being”, making patients, and not tests, the focus of the physician.

The Oath, as adopted by the World Medical Association, contains the pledge “I will not
permit considerations of age, disease, creed, ethnic origin, gender, nationality, political
affiliation, race, sexual orientation, social standings, or any other factor intervene
between my duty and my patient”. Non-discrimination, justice and fairness are today
core values of medical ethics derived from these wordings.

The Hippocratic Oath today

Doctors in virtually all universities take the Hippocratic Oath or one of its versions when
they graduate. This is often a solemn and moving ceremony. However doctors have
various views and attitudes about the Hippocratic Oath. While some doctors consider
the oath as a rite of passage, others do not remember taking it. Some doctors even
think the oath is irrelevant. Nevertheless the oath is considered by some doctors as a
serious and appropriate initiation into the medical profession. One doctor said “The oath
reminds me of the longstanding tradition of medicine, which evolved from ancient times,
of its ancient mysteries, and the importance of continuing that noble tradition.”

To one doctor the oath is a constant reminder of what practicing medicine is all about
and it’s role a safety valve and mitigating factor. To another doctor taking the
Hippocratic Oath was more than a ceremony; it gave him a feeling of entering into a
special profession in which the practitioner must do his or her best possible to support
patients. To another the oath set out the responsibilities of the physician and what was

7
expected of the physician. The Oath, to one practitioner, helps physicians where they
are not sure of what to do and also helps them put patients at the heart of the decisions
made. To most clinicians the oath may still chime as a guide for best practice.

Although to some clinicians the oath is inspirational, some, however, do not believe that
doctors should take an oath at all as the health profession in most places is regulated
by law and elaborate guidelines have been developed. One doctor, who did not take the
oath when she graduated later confessed, following her work experience, that pledging
the oath was a valuable experience for doctors

Some doctors find the ethical principles and medical guidelines developed from the
original oath as more appropriate for the current practice of medicine. One health
worker put in this way “The oath is a useful record of how medical ethics have
developed. But the good practical guidelines developed go into more detail, have
evolved through case law and disciplinary hearings, and are regularly reviewed.” Some
health practitioners are so audacious to suggest a common charter. It is however vital
that all physicians understand the principles of medical practice as envisaged in the
original Oath.

One of the difficulties with the original oath is that medicine is constantly changing, as
are people’s values and believes. The original oath forbade the provision of poisonous
drugs including drugs that could cause abortion. There was no place for euthanasia in
the oath. The prohibition of abortion is however not found in revised versions of the oath
as many practitioners now prescribe abortions, if only for the sake of the mother’s life or
health.

“And whatever I shall see or hear in the course of my profession……..I will never
divulge, holding such things to be holy secrets.” Holding the patient’s information sacred
and confidential is at the heart of the trust and respect between the physician and the
patient. This is a value upheld in all clinical guidelines today.

A modern version of the Oath requires doctors to look after their own health in the
clause “I will attend to my own health, well being, and abilities in order to provide care of
the highest standard. One doctor said that doctors should not be expected to sacrifice
their lives for patients or to make their patients their first concern. This was not to say
that doctors should abandon their patients but rather that doctors should not be
expected to make all the sacrifices and work literally to death.

The Oath also mentions the special position of the doctor with regard to his patients,
especially women and girls as it contained a pledged to abstain from abusing the bodies
of men or women, bond or free. Doctors who have not strictly adhered to this have
faced the full wrath of the law and of the disciplinary bodies.

A suggestion was floated that experienced doctors should consider retaking the oath. “It
would be like reaffirming marriage vows; an opportunity to reaffirm the physician’s belief
in making the patient the first consideration.” In the revised 1964 oath, the physician

8
vows to “always act to preserve the finest traditions of the calling and long to experience
the joy of healing those who seek medical help.”

Medico-legal grounds for Abortion

In 1938 five officers (soldiers) of the Royal Horse Guards in England enticed a 14 year
old girl into their London barracks with a promise to show her a horse with a green tail.
In the barracks, the five soldiers took turns to rape the girl and she become pregnant as
a result. Her parents took her to St. Thomas’s Hospital requesting for an abortion. The
Consultant at the hospital declined the request on the grounds that the rapists were
officers and apparently gentlemen and the girl therefore could ‘be carrying a future
Prime Minister of England’. And the Consultant also stated that ‘girls always lead men
on’.
The girl was then taken to St. Mary’s Hospital, another hospital in London, and was
referred to see the Consultant Dr. Aleck Bourne, an eminent medical practitioner. He
carefully considered the case noting that the girl was not mentally defective and not of
the prostitute type. Bourne concluded that, though a plea of danger to life could not be
substantiated, termination of the pregnancy was justified because of the risks to her
physical and mental health.
On 14th June 1938, he openly terminated the girl’s pregnancy by performing a surgical
curettage (cleaning the uterus) and then deliberately informed the police. In his own
words Dr. Bourne stated “I decided to bring forward a test case in which there would be
no real danger life…but in which one might strongly suspect great danger to health. I
was also concerned to establish in the eyes of the Law that mental health was just as
important as physical health, and in certain cases perhaps even more’
In England abortion was prohibited under the Offences Against the Person Act of 1861
and prosecutions for abortion were relatively common. Most of the people who were
prosecuted under this act were women with no or little medical training, the so-called
backstreet abortionists. Dr. Bourne was charged under this act. His defense lawyers
called several of his colleagues who testified that there were significant risks of both
physical and psychological damage if the pregnancy had continued. In his defense, Dr.

9
Bourne told court that he could not draw a line between danger to life and danger to
health; if one waited for danger to life the woman would be past assistance.
The Judge took the view that if there was unlawful abortion, then there should be
situations in which abortion was lawful. He extended the meaning of the life of a woman
to include her health and in guiding the jury he stated that ‘if the doctor is of the
opinion on reasonable grounds that the probable consequences will be to make
the woman a physical and mental wreck, the doctor is operating for the purpose
of preserving the life of the mother.’ Dr. Bourne was acquitted.
One week after his acquittal, Dr. Bourne wrote ‘The Attorney General admitted that
abortion is legally recognized when life is in danger. Now we know it is it is also
admitted when there is serious danger to health….the majority of the profession would
feel they are on safer ground if the precedent established were incorporated in a new
Act passed in days when much more knowledge of medicine and surgery and
psychology is available that when the law was passed in 1861. Another writer called for
the law to be amended in an open and straight forward way to meet the demands of
justice and humanity. Indeed in many jurisdictions the law has now been amended
allowing doctors to undertake therapeutic abortions when they honestly believe the
woman’s health is at risk if the pregnancy is allowed to continue. Abortion laws have
now been amended to allow doctors to undertake therapeutic abortions when they
honestly believe the woman’s health is at risk if the pregnancy is allowed to continue.
The Abortion Act 1967 of the United Kingdom for example allows induced abortion
when continuing the pregnancy poses a greater risk to the life or physical or mental
health of the woman, or her existing family or children, than if the abortion is carried out.
Dr. Bourne was however opposed to this act. He campaigned for the society for the
Protection of the Unborn Child, believing the new legislation to be too liberal. In his
memoirs, Dr Bourne wrote:
“Those who plead for an extensive relaxation of the law against abortion have no
idea of the very many cases where a woman, during the first three months,
makes a most impassioned appeal for her pregnancy to be ‘finished’, later, when
the baby is born, is thankful indeed that it was not killed while still an embryo.

10
During my long years in practice I have had many a letter of the deepest gratitude
for refusing to accede to an early appeal.”
In another landmark ruling a Judge stated that abortion would be unlawful if the person
performing the abortion did not honestly believe on reasonable grounds that the
abortion was necessary to preserve the woman from serious danger to her life or
physical or mental health, or if the person did not honestly believe that in the
circumstances the abortion was in proportion to the danger averted.

When to Withdraw Life Support

Anthony (aka Tony) David Bland, an 18-year-old Liverpool Football Club supporter,
travelled on 15th April 1989 to watch Liverpool play Nottingham Forest at the
Hillsborough football ground in the FA Cup semi-final. A crowd crush occurred during
the game and 94 Liverpool supporters died that day, in what has now become known as
the Hillsborough disaster.

Tony suffered crushed ribs and two punctured lungs, causing an interruption in the
supply of oxygen to his brain. As a result, he sustained irreversible brain damage. Tony
could open his eyes but he did not seem to focus on anything and he couldn't
communicate or respond to the people around him. Several attempts were made by the
team of doctors, along with Tony’s father, sister and mother, to try to elicit some
response from him and for some signs of interaction. However, all attempts failed. He
showed no sign of being aware of anything that took place around him. The doctors did
not know if Tony was aware of the people around him and the things they were saying
and doing to him. His condition was diagnosed as Persistent Vegetative (PVS) or a
persistent non-responsive state. The medical team treating him stated that there was no
reasonable possibility that he would ever emerge from his vegetative state. He was in a
coma for nearly four years. He never regained consciousness

A permanent vegetative state is a clinical condition of unawareness of self and the

environment in which the patient breathes spontaneously and the heart functions
normally and the eyes show cycles of opening and closing, simulating sleep and

11
wakefulness. It is sometimes considered a state of wakeful unawareness. The diagnosis
of this condition is made three months after a non-traumatic brain injury or twelve
months following trauma to the brain. The diagnosis is made if or when the patient
shows no behavioral evidence of self or the environment. Patients with a diagnosis of
permanent vegetative state may live for many years if artificial nutrition and hydration is
maintained. Stopping food and water leads to death within fourteen days due to
starvation and dehydration.

Tony’s parents did suffer seeing their son in a comma for four years. The hospital, with
the support of his parents, applied for a court order to allow him die with dignity. Prior to
the case of Tony, English case law on non-treatment of patients was restricted to
newborn babies’ where disabled neonates were legally allowed to die. In one such case
a baby born with congenital abnormalities had obstruction of her intestines, which if left
untreated without surgery, would be fatal. The parents felt that it would be in the child’s
best interest if she were left to die. Although this decision was upheld by court, the court
of appeal overturned it on the grounds that in this particular case the prognosis was that
the child would have had a reasonable quality of life.

In another case, another baby born with a genetic abnormality was rejected by the
parents. The doctor wrote in his notes that “Parents do not wish the baby to survive.
Provide nursing care only”. The baby died 69 hours later. The doctor was charged with
murder but was acquitted. From this case it can be seen that doctors who deliberately
withdraw life-prolonging treatment can be charged with murder if the patient
subsequently dies.

The doctor looking after Bland made a request to withdraw all treatment including food
and water to the Coroner four months after Bland was injured. The Coroner threatened
the doctor with a murder charge. The doctor was visited by the police who also told him
that he would be charged with murder if he withdrew treatment and the patient died.

An application was subsequently made to court to lawfully discontinue all life sustaining
treatment and medical support measures including ventilation, nutrition and hydration by

12
artificial means and not to subject anybody to any criminal or civil liability should the
patient die. Court granted the request on the grounds that it was in the patient’s best
interest for treatment to be withheld and this was in accordance with good medical
practice. Tony became the first patient in England to be legally allowed to die by the
courts of law through the withdrawal of life-prolonging treatment including food and
water. On December 21st 1993, Tony Bland’s death was classified as an accidental
death but a second inquest later classified all the 96 Hillsborough disaster deaths as
unlawful killings.

13