Tony Bland Research Articles

Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness

In 1993, the UK High Court decided that Tony Bland was unaware of himself and his environment, had no interest in medical treatment and allowed withdrawal of treatment. Subsequently, the...

Permanent vegetative state: comparing the law and ethics of two tragic cases from Italy and England.

In April 1989, in England, Tony Bland aged 17 was trampled and crushed by a stampede at the Hillsborough football stadium ground – a disaster in which 95 people were killed. His lungs were crushed and punctured and the supply of oxygen to his brain was temporarily interrupted. Nearly three years later, in January 1992, in Italy, Eluana Englaro aged 21 lost control of her father's car whilst driving at night on an icy road and crashed into a lamp post, fracturing her skull and neck. When these young people were admitted to hospital, both of them were found to have suffered devastating anoxic brain damage and both were later diagnosed as being in a persistent vegetative state. Their illness narratives have several commonalities, but they also diverge in significant ways. In this article we shall be exploring the views of the relatives, the public, and the health professionals, how their voices were heard, and how the values underpinning these differing accounts were interpreted by the courts of law. We shall critically evaluate the ethical and legal justifications for the final decision to allow these unfortunate young people to die from the withdrawal of nutrition and hydration. We shall also consider the influence and interventions of the Church and the State in these two countries and how the law in England and in Italy resolved the moral and legal issues. From this analysis we shall reflect on what would appear to be the most humane and reasonable way forward.

Best interest. A review of the legal principles involved: Part 2(a)

The ways in which people are allowed to act on another person's behalf have been the subject of discussion for a while. In 1993, the case of Tony Bland (1993) focused the minds of the judiciary on the idea of withholding or withdrawing the treatment offered to people who were judged to be in a permanent vegetative state. This topic is vast and for some, confusing. The aim of this two-part article is to explore the various threads of the law and the debate, with a view to elucidating on the legal position. An exploration of the responses of the professional regulatory bodies is included to illustrate how important it is that all health providers understand the law and apply it correctly in all circumstances so that patients' needs are met at all times, and their autonomy and dignity is recognized and respected.

Withholding and letting die

In the case involving Tony Bland, the spectator who was crushed in the Hillsborough stadium disaster, the House of Lords recognised that there was a distinction between killing and letting die (Airedale, 1993). To let nature take its course when the prognosis is appaling for the patient and there is no longer a duty to keep a person alive at all costs, is not contrary to the law. On the contrary to take action to end a person's life may be murder or manslaughter.

Medical murder by omission? The law and ethics of withholding and withdrawing treatment and tube feeding

When is it lawful and ethical to withhold or withdraw treatment and tube feeding? In recent years, the courts have handed down important decisions and medical bodies have issued professional guidelines on withholding and withdrawing treatment and tube feeding. A major criticism of these decisions and guidelines has been that while they prohibit the intentional hastening of a patient’s life by an act (‘active euthanasia'), they permit the intentional hastening of a patient’s death by omission (‘passive euthanasia'); and they prohibit actively assisting suicide, but permit passively assisting suicide. By focusing on the landmark decision of the Law Lords in the Tony Bland case, and on the guidelines on withholding and withdrawing treatment and tube feeding issued by the British Medical Association, this paper considers whether this criticism is sound, and concludes that it is.

The Practice of Euthanasia

John Keown's informed and powerful argument against euthanasia features both an excellent exposition of its pitfalls and a strong confrontation with a question that remains controversial abroad: Are there circumstances in which withdrawal of treatment should be considered euthanasia? American readers of this book, who consider the question settled and are unfamiliar with cultural and legal differences in the way European countries and the United States have dealt with end-of-life issues, may be puzzled at first as to why this University of Cambridge lecturer in the law and ethics of medicine wants to address this question. But Keown's exposition will make even such readers, who believe we have wisely avoided many of the dilemmas Great Britain and other European countries are forced to face, realize that there are some dilemmas we have not escaped. To evaluate euthanasia, Keown examines its actual practice. He carefully provides evidence to show that legalization of voluntary euthanasia cannot be regulated and that it leads increasingly to involuntary euthanasia and to patients who are not ready to die or whose suffering could be alleviated by palliative medicine. Such a study relies heavily on the Dutch experience, since not only has the practice been legal in the Netherlands for some time, but two Dutch government-sanctioned studies (in 1990 and 1995), in which physicians participated anonymously and with impunity, have shown us what the actual practice entails. The Dutch studies play down a fact they cannot help but reveal, namely, that thousands of patients have their lives ended without their consent. The studies report 3,600 deaths in 1995 from assisted suicide and euthanasia and officially acknowledge between 900 and 1,000 involuntary deaths. But they refuse to describe as euthanasia, or involuntary (when a competent patient does not give consent) or nonvoluntary (when the patient is deemed unable to give consent) euthanasia, the 1,350 patients in 1990 or the close to 2,000 patients in 1995 whose physicians gave them large doses of pain-killing medication with the primary aim of ending their lives. In the course of my own studies of euthanasia in the Netherlands, I asked Paul Van Der Maas, the principal investigator of the Dutch government-sanctioned studies, why, if patients had consented to the drug overdose, these should not be considered euthanasia cases. He conceded they could be--the only difference was that the patients took longer to die. When asked why, if patients were put to death who had not consented (about a third of the patients), these cases were not considered nonvoluntary or involuntary euthanasia, Van der Maas could not give a reason, but he was not willing to consider recategorizing them. When one realizes that in one-quarter of the cases in which Dutch physicians give medications intending to end patients' lives, they do so without the patient's consent, that a third of Dutch doctors admit to having done so, that half of Dutch doctors feel free to suggest euthanasia to their patients, and that 60 percent of Dutch euthanasia cases are not reported to the authorities, one is inclined to agree with Keown that this is a system out of control. Keown is also concerned, however, that the data on the many thousands of Dutch cases where treatment (including tube feeding) was withdrawn without patient consent do not permit us to know whether the doctor was merely stopping a futile or burdensome treatment or intended instead to end the patient's life--referred to as This is an issue that has also troubled Keown in his own country because British law since the landmark Bland case has condoned passive euthanasia. Most of the concluding chapters of Keown's book deal with his concern with passive euthanasia and reflect some of the differences in approach to end of life care between Europe and the United States. In 1989, Tony Bland was left in a persistent vegetative state after being crushed by a crowd at a soccer game. …

The law on dying.

The law on dying.

Causing death or allowing to die? Developments in the law.

Several cases which have been considered by the courts in recent years have highlighted the legal dilemmas facing doctors whose decisions result in the ending of a patient's life. This...

Looking living death in the face

When the House of Lords ruled that Tony Bland should be allowed to die, most of us believed that he was practically dead already. Tony was a tragic victim of the Hillsborough disaster. He was in a persistent vegetative state (PVS), which meant that he seemed to be awake with his eyes open but had no level of awareness. The only reason he remained alive was because he was artificially fed. We were assured there could be no mistake about the diagnosis and no hope of recovery. This Monday's Horizon programme Living Death undermined those assurances, telling us that persistent vegetative state is an unreliable diagnosis. It claimed that some patients, far from being awake but unaware of their environment, may have been misdiagnosed and may be aware and thinking inside their paralysed bodies. There are estimated …

Persistent vegetative state: what decides the cut-off point?

Advances in medicine and technology have allowed us early and effective diagnosis and treatment of many disease processes, with new and developing interventions ensuring this progression. However, in some illnesses and conditions, despite appropriate treatment, deterioration in the person's condition ensues. This may occur following a cardiopulmonary arrest, where resuscitation may have been 'successful' at the time, but the brain has suffered irreversible anoxic damage. It has been seen that only 10-25% of patients survive to discharge following a cardiac arrest (Broadway 1993), and the consequences of cardiopulmonary resuscitation can not only be costly but can leave the patient in a persistent vegetative state (PVS). PVS, however, does not confine itself to these patients alone, and can present following other cerebral traumas, including head injuries. This is therefore especially pertinent to intensive care nurses, who may find themselves caring for such patients in a critical care setting. Growing public awareness of this altered health state due, for instance, to the Tony Bland case in the UK in 1993, has highlighted a need for greater knowledge of the consequences of the condition and the proposed management of patients in PVS. This paper attempts to describe the course of this syndrome, and considers some of the ethical and moral issues surrounding the care and treatment of patients with PVS. The issues surrounding euthanasia are briefly explored together with the attitudes of those caring for these patients.

Withdrawing artificial feeding from children with brain damage

Over the past few decades the American legal system has repeatedly confronted the legal dilemmas of stopping treatment for patients in a persistent vegetative state. From 1975 to 1990, 33 cases reached the higher courts. At least half of these concerned the withdrawal of artificial feeding. The British legal system has also had to address the same questions—first in the case of Tony Bland, crushed at Hillsborough football stadium, and now more recently in the case of Thomas Creedon, a 22 month old child who is said to be severely brain damaged and unable to hear, speak, or see.1 As legal systems are increasingly confronted with these cases, it is important to consider the basic medical, ethical, and legal principles that have unfolded over recent years. The most critical factor from a medical perspective is when the persistent vegetative state (lasting longer than one month but potentially reversible) becomes permanent (irreversible). Recent American standards developed by the Persistent Vegetative State Taskforce discuss a range of 3-12 months, depending on the aetiology of the condition and the age of the patient.2 3 European authorities such as …

Euthanasia: a contemporary nursing issue.

Euthanasia remains a contentious issue. The medical profession has difficulty in coming to terms with euthanasia because of professional and ethical conflicts. There has been little guidance from the UKCC on the issue of euthanasia. Nurses may be in a better position to examine the issue more objectively. There is an opportunity for the nursing profession to take a leading role in developing policy.

Guidelines are set for persistent vegetative state

The official solicitor, Peter Harris, has issued guidance for health authorities and NHS trusts in Britain, reminding them to seek the High Court's approval before withdrawing artificial feeding and hydration from patients in a persistent vegetative state. His practice note, issued last week, follows the second case in which the court has sanctioned the withdrawal of feeding for patients in the persistent vegetative state. The celebrated case of Tony Bland, the survivor of the Hillsborough football stadium disaster, went to the House of Lords last year and established that such patients need not be kept alive indefinitely. In …

Informed consent and living wills

The text of this paper was originally presented to the RCN Cancer Nursing Society Conference which was held in June 1993. It was written in response to a request to cover the topics of informed consent, ethics and the multidisciplinary team and living wills. Clearly, this is an extremely broad range of topics so, in order to introduce some coherence into the paper, the 'Tuma' case is used to connect the themes of cancer nursing, informed consent and working in a multidisciplinary team. The topic of living wills and its parent concept, that of advance directives, constitute a particular aspect of informed consent. These ideas are introduced via two recent legal judgements concerning 'T' and Tony Bland. The focus then moves from legal to moral concerns, ending with a brief critique of the whole idea of living wills.

RCN support for members who cared for Tony Bland.

The Royal College of Nursing has offered support to members who were caring for Tony Bland, the football fan who died last week nearly four years after being crushed in the Hillsborough Stadium disaster.

On Not Starving the Unconscious

The Hillsborough football disaster in 1989 left Tony Bland in what doctors call a ‘persistent vegetative state’ (‘PVS’). His heart still pumped, he breathed, and most of his other vital organs worked, all unassisted. His eyes opened and shut; he yawned and moved reflexively; he reacted to loud noises with a start. But as far as doctors could tell he could not perceive, think or feel, and would never regain consciousness in this life. The English High Court, the Court of Appeal and (last month) the House of Lords all ruled that all food, water and antibiotics might be withdrawn from Tony Bland and sedatives administered so that he would die peacefully and soon.The judges were keenly aware of the moral, legal and social dilemmas which the case occasioned. In general they took the view that the law should closely reflect what is ‘morally right’ in such areas, or at least ‘what society accepts as morally right’. They thought there were three principles to be balanced and applied in this case; the sanctity of life; the autonomy of the patient; and the duty of care. The principle of the sanctity of human life was said to be deeply embedded in our law and ethics, in Britain and throughout the world, included in international human rights documents, and strongly felt by people of all religions and none.

Tough time ahead after Bland ruling.

Nurses caring for Tony Bland face an 'extremely difficult' time after the House of Lords confirmed he will be allowed to die, RCN General Secretary Christine Hancock has said.