Informed consent for medical student involvement in patient care: an updated consensus statement.

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

Health care providers' early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service.

BACKGROUND: In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law. AIM: To explore the early experiences of health care providers (HCPs) who do and do not provide AD services seven months after legalisation of AD to provide the first empirical account of how the AD service is operating in New Zealand's distinctive healthcare environment and cultural context. DESIGN: Qualitative exploratory design using semi-structured individual and focus group interviewing with a range of HCPs. RESULTS: Twenty-six HCPs participated in the study. Through a process of thematic analysis four key themes were identified: (1) Difference in organisational response to AD; (2) challenges in applying the law; (3) experiences at the coal face; and (4) functionality of the AD system. CONCLUSION: A range of barriers and enablers to successful implementation of AD were described. Adoption of open and transparent organisational policies, ongoing education of the workforce, and measures to reduce stigma associated with AD are necessary to facilitate high quality AD service provision. Future research into the factors that influence responses to, and experience of AD; the impact of institutional objection; and the extent to which HCP perspectives evolve over time would be beneficial. In addition, further research into the integration of AD within Maori health organisations is required.

What do health care professionals want to know about assisted dying? Setting the research agenda in New Zealand.

BACKGROUND: New Zealand recently introduced law permitting terminally ill people to request and receive assisted dying (AD) in specified circumstances. Given the nature and complexity of this new health service, research is vital to determine how AD is operating in practice. OBJECTIVE: To identify research priorities regarding the implementation and delivery of AD in New Zealand. METHODS: Using an adapted research prioritisation methodology, the researchers identified 15 potential AD research topics. A mixed-methods survey of health professionals was undertaken where respondents were asked to rate the 15 topics according to the relative importance for research to be conducted on each issue. Respondents could also suggest additional research areas, and were invited to participate in a follow-up interview. RESULTS: One hundred and nineteen respondents completed the survey. 31% had some experience with AD. The highest rated research topic was the 'effectiveness of safeguards in the Act to protect people'; the lowest rated topic was research into the 'experiences of non-provider (e.g., administrative, cleaning) staff where assisted dying is being provided'. Respondents suggested 49 other research topics. Twenty-six interviews were conducted. Thematic analysis of interview data and open-ended survey questions was undertaken. Six research themes were identified: general factors related to the wider health system; the experiences of health care providers at the bedside; medico-legal issues; the impact of AD; experiences on the day of dying; and the overall effectiveness of the AD system. Key issues for stakeholders included safety of the AD service; ensuring access to AD; achieving equity for 'structurally disadvantaged' groups; and ensuring the well-being of patients, families/whanau, providers and non-providers. CONCLUSIONS: Based on early experiences of the implementation of the AD service, health professionals provide important insights into what research should be prioritised post-legalisation of AD. These findings can be used to shape the research agenda so that research may inform law, policy and best practice.

Medical students and informed consent-response to "Consent for Teaching".

Nil.

Beyond Criminalisation: Abortion Law Reform in Aotearoa New Zealand.

With the enactment of the Abortion Legislation Act 2020, New Zealand radically transformed its approach to abortion. Abortion is no longer a crime, and is instead regulated under general health law, adopting a gestational model. Whilst some claim that reform was overdue, critics have described the new legislation as the 'world's most extreme abortion law'. This article investigates these claims through the lens of reproductive justice, a movement that emerged alongside the global campaign for recognition of reproductive rights. First, it outlines the tenets of reproductive justice, before critiquing New Zealand's previous law, and considering arguments for its modernisation. It then describes how a growing number of jurisdictions have decriminalised abortion, with increasing pressure on other countries, including England and Wales, to similarly undertake law reform. Finally, it examines the main provisions of New Zealand's law. It concludes that, to the extent that the new law enables access to timely, equitable, and publicly funded abortion services, it is consistent with the tenets of reproductive justice. By placing women at the centre of the law, it improves the welfare of women, but particularly marginalised women. However, it suggests that the current 20-week gestational test is arbitrary, with the originally proposed 22-week threshold preferable.

The End of Life Choice Act: a proposed implementation and research agenda.

AIM: This article outlines the End of Life Choice Act 2019. It highlights some of the key implementation issues to ensure the system operates safely and equitably after the Act comes into force. It also identifies priorities for research to ensure issues are detected and provision of assisted dying (AD) is monitored. METHOD: We reviewed the End of Life Choice Act, assisted dying implementation literature and governmental reports. RESULTS: Effective system implementation depends on infrastructure, oversight and funding. In terms of service provision, we make recommendations about training for all health practitioners and providing practitioners; the nuances of discussing the "wish to hasten death"; conscientious objection; cultural safety for Maori; and minimising the complexity of delivering assisted dying practice. Structured research is needed to understand how the assisted dying system is operating. CONCLUSION: This article contributes by identifying core issues for practitioners, patients and policymakers. Implementation is an ongoing process that continues after the Act starts. Data are required to know whether access is equitable, who is choosing to make use of the law, whether providers are well informed and whether the safeguards are working as intended. The implications of how the Act is implemented are significant for patients, whanau, health professionals and society.

Doctors' rights to conscientiously object to refer patients to abortion service providers.

After five decades of restrictive laws, New Zealand is on the cusp of law reform that may result in abortion being treated as a health, rather than a criminal, matter. Given this possible liberalisation, a pressing issue is the way in which 'conscientious objection' (CO) will be accommodated within the new legislative landscape. In this context, CO constitutes a health provider refusing, on the grounds of personal conscience, to provide care that, although legal and potentially clinically appropriate, conflicts with their personal moral views. Currently, New Zealand law permits significant concessions for conscientious objectors. This paper argues that in the light of current reform, the justification for permitting CO should be revisited. It claims that even if it is conceded that some form of CO should be respected, a pragmatic compromise must be adopted so that both provider's and women's rights are sufficiently protected. We argue that the current legal situation in New Zealand is unbalanced, favouring the rights of providers at the expense of women's timely access to abortion care. At a minimum, providers with a CO should be required to ensure an indirect referral to another provider who is willing to refer the woman to abortion services.

Incidental findings during a surgical procedure-current practice and ethical implications.

AIM: Sometimes during an elective surgical procedure, an abnormality is found which is unrelated to the scheduled procedure. In many instances, immediate treatment of this unexpected pathology is in the patient's medical interests, however, specific patient consent has not been obtained. This study investigates current surgical practice when confronted by an incidental finding (IF), as well as surgeons' views on informed consent in this context. METHOD: An online survey was sent to all practicing surgeons and surgical trainees within New Zealand. Respondents were presented with hypothetical scenarios involving IFs and asked to decide whether or not they would proceed with treatment. Opinion was sought on the factors influencing such decisions and the need for a clause within surgical consent documents to prompt discussion about IFs. RESULTS: 151/450 (33.6%) surgeons and trainees responded. Immediate treatment was more likely with IFs of greater clinical significance, lower-risk procedures and where there was prior consent for IF treatment. A proportion of surgeons did not follow these trends. Although a great deal of variation exists in the way that IFs are dealt with in the consent process, the majority of respondents (111/129, 86%) favoured a clause within a consent form that prompts discussion and seeks consent for the treatment of IFs. CONCLUSION: Responses to the IF scenarios were generally consistent with good practice. While variation in decision-making is to be expected, some decisions were concerning. Most surgeons agree that a clause within the consent form should trigger a discussion of IFs during the consent process.

Incidental findings during a surgical procedure-patient and public perspectives.

AIM: During a surgical procedure, incidental findings (IF) may be found and often the immediate treatment is in the patient's best interest. Due to the nature of IFs, specific patient consent cannot be obtained under such circumstances. The dilemma is whether the surgeon should proceed or delay until consent is obtained, as there are significant ethical and legal implications. Following an earlier study of surgeons' preferences for IF management, this report investigates patient and public preferences. METHOD: A questionnaire presented hypothetical scenarios involving IFs and samples of patients and public respondents reported their preference to proceed with treatment or have their surgeon wait to obtain consent. Opinion was sought regarding factors influencing their decisions and if general surgical consent procedures should cover IFs. RESULTS: A sample of 331 respondents from the general public and 368 elective surgery patients were surveyed. Results showed an overall preference to proceed with treatment in 75.1% of the hypothetical scenarios, which increased with IF severity and decreased with procedural risk. Thematic analysis of open-ended questions revealed a number of factors influencing preferences with avoidance of further surgery being most common. Results showed most respondents preferred for information provided in general consent forms though not all were comfortable about this. CONCLUSION: Patient and public preferences to proceed with treatment in hypothetical scenarios were generally consistent with surgeons' reported practice when faced with IFs. The data suggest that an IF clause in the consenting process could help surgeons make clinical decisions best aligned with individual patients' preferences.

Minors and Contested Medical-Surgical Treatment.

Use of the best-interests test as the legal standard to justify medical treatment (or its cessation) in respect to legally incompetent adults or minors has come under sustained critique over the years. "Best interests" has variously been alleged to be indeterminate as well as susceptible to majoritarian ideology and inherent bias. It has also been alleged to be inferior to rights-based approaches. Against the background of several particularly hard cases involving minors discussed by Gillett in a prior article in this journal, this article considers some of these critiques. It concludes that these critical accounts make significant contributions to enabling a more procedurally and substantively robust consideration of what might be in a child's best interests. However, it is argued that none of these accounts alone provide a superior framework that would justify jettisoning the concept of best interests. Further, it is suggested that best interests still has an important role in achieving patient-centered decisionmaking in this context. It concludes by suggesting a taxonomy of considerations when determining best interests.

Non-invasive Prenatal Testing: The Problem with "Fast Cars".

Prenatal screening and its technological counterpart, prenatal diagnosis (PND), have been the subject of extensive debate since their inception, particularly given PND's inextricable links with abortion. Despite this, prenatal screening policy and practice has evolved over the last few decades and is now well established. However, a new permutation of prenatal testing, first performed in 2011 and subject to rapid commercialisation, potentially heralds a new era. This article provides an introduction to non-invasive prenatal testing and outlines some of the ethical and legal issues associated with the early clinical integration of this rapidly evolving technology.

Re-visiting Re X: hysterectomy, removal of reproductive capacity and the severely intellectually disabled child in New Zealand.

The law governing parental consent to any surgery performed on an intellectu- ally disabled minor that results, directly or indirectly, in the loss of reproductive capacity was first considered in New Zealand in the High Court case of Re X in 1991. The decision was remarkable in several respects, not least because it reflected a genuine attempt to obtain a representation of interests beyond those of the particular child and parents involved. However, legal and socio-political developments in the intervening years, both locally and internationally, suggest that a review of the decision is timely. This article questions whether, in light of these events, Re X should be revisited and concludes by suggesting a possible legal response.

Regulation of cognitive enhancement devices: commentary.

Maslen et al. (2013) have provided us with a comprehensive overview of the current legislation regulating non-clinical cognitive enhancement devices (CEDs) in the European Union and have proposed a specific model whereby CEDs would be regulated in the same way as medical devices. An alternative model would be to require manufacturers to quantify risks only. Irrespective of the purported 'benefits' of a product, this would allow the consumer freedom of choice to use the product at their will and allow the periodic review of worthwhile indications and unexpected adverse events. Although this departs from the standard Cochrane-type assessment, it takes into account the facts that (i) the evaluation of clinically used cognitive enhancement techniques may not be as rigorous as one might expect, (ii) variations and case-by-case use might be widespread, and (iii) independent variables of significance and useful endpoints may not be obvious ab initio. We consider cerebrospinal fluid diversion techniques which are widely used clinically to enhance cognition in patients with normal pressure hydrocephalus despite any large-scale clinical studies demonstrating substantial benefit, and the real risks of paralysis and death from these invasive procedures. The risks of CEDs which have been available for some time need to be kept in perspective: are the risks really more than using conventional cognitive enhancement techniques such as imbibing too caffeinated drinks? Furthermore, the loss of Europe as a market for CEDs which do not comply with the proposed regulatory model implies a potential gain in the market for other parts of the world. This could impact on the ability of companies in Europe being able to compete in an evolving market demand for CEDs. Legislation to regulate CEDs should be guided by the principle of 'do no harm' and allow for innovation and competition.

The practice of surrogacy in New Zealand.

BACKGROUND: Commercial surrogacy is prohibited in New Zealand by the Human Assisted Reproductive Technology Act 2004 (HART Act). However, altruistic clinic-assisted surrogacy is permitted. Couples wishing to attempt altruistic surrogacy must apply for approval to a statutorily appointed ethics committee. One of seven principles that underpin the HART Act stipulates that the needs, values and beliefs of Maori (NZ's indigenous population) should be considered and treated with respect. AIM: This paper reviews the outcomes of surrogacy applications since the HART Act was established and the uptake of surrogacy by Maori. METHODS: The authors examined the demographic data provided to the ethics committee by way of surrogacy applications and the outcome data provided by fertility clinics. This paper reviews the outcomes for surrogacy applications: the number accepted/declined, the number of live births, those applications discontinued and uptake by Maori. RESULTS: Of 104 applications for surrogacy between 2005 and 2010, 4 (3.8%) were declined. By July 2011, of 100 approved, there have been 26 (26%) live births; 52 (52%) were discontinued, and 22 (22%) remain ongoing. Maori are much less likely to utilise surrogacy. Of the 104 original applications, 9 (8.6%) Maori women were willing to act as a surrogate, and 2 (1.9%) were intended mothers. 7 (6.7%) Maori were partners of a surrogate, with 2 (1.9%) intending mothers having Maori partners. CONCLUSIONS: The process of surrogacy applications is comprehensive and robust, resulting in few being declined. Further research is required to discover why applications are discontinued and why, despite explicit attempts to meet the needs of Maori, few utilise surrogacy.

Preimplantation genetic diagnosis for susceptibility conditions: a new frontier or a logical extension?

A susceptibility or "lower penetrance" condition is a condition to which a person may be predisposed by virtue of a particular gene mutation they carry within their genetic code. Genetic testing for susceptibility to late-onset conditions, an increasingly available phenomenon, has recently been associated with preimplantation genetic diagnosis (PGD). Performing PGD for conditions that occur later in life and that may be preventable or, if not, may be treatable, or that may never even develop, is highly contentious. It constitutes a significant departure from traditional PGD, going beyond testing for serious heritable disorders that are apparent at birth or in very early childhood or late-onset diseases that are certain to manifest themselves. It is likely that, as technology advances, there will be a growing demand for PGD to detect these types of conditions. This article considers the issues raised by susceptibility testing. It questions whether embryonic testing for late-onset susceptibility conditions is more appropriately a matter for regulatory restraint or reproductive liberty.