COVID-19 – What does the Bible say about epidemics? Some uncomfortable truths

There have been many excellent prayers spoken and sermons preached on the COVID-19 pandemic in the last few weeks.

They have emphasised such themes as the sovereignty of God, the frailty of man and the call for Christians not to fear but rather to be good citizens, voices of calm and agents of compassion in the crisis.

As the Bible tells us we need to keep things in an eternal perspective through these ‘light and momentary troubles’ (2 Corinthians 4:17) and remember that our true treasure is in heaven not on earth. (Matthew 6:19-21)

This is not easy to hear for those of us who are sitting in our self-isolation bunkers watching 20 years of savings disappearing in two weeks and wondering if the company which employs us will even exist in two months’ time.

It’s not just the physical threat of the virus but the fact that this is hitting a world which, even before this pandemic surfaced, was already mired in debt (global debt is now a record 322% of GDP) and had already used all its fiscal ammunition.

Most of us have never encountered an event causing such widespread social and financial devastation before.

This is why it is essential that as Christians we keep our cool and act as the agents of Christ in what we say and do.

After all, we know that God will never leave us or forsake us (Hebrews 13:5) and that nothing can separate us from the love of God that is in Christ Jesus our Lord (Romans 8:38, 39). To live is Christ and to die is gain, as the Apostle said. (Philippians 1:21)

But we also need to do some hard thinking about our global predicament – perhaps starting with asking what the Bible teaches about epidemics.

We know from science that epidemics are caused by infective agents (bacteria and viruses) that are passed from one person to another and from history that they are not uncommon occurrences.

Wikipedia documents hundreds that have occurred throughout history – resulting in hundreds to millions of death. This history of epidemics page illustrates this graphically. Epidemics are nothing new.

Just how deadly they are will depend on a variety of factors – the severity of the illness they cause, the infectiousness of the agent, the level of immunity in the population and the existence of vaccines and treatments.

Coronavirus is neither the worst nor the least we have encountered. But it is nonetheless very serious.

It causes an illness that requires hospitalisation in about 20% of people, of whom about a quarter will require ventilation. Its mortality cannot be known with certainly yet but is probably somewhere between 1 and 4%. 

It is moderately infectious (as easy as Ebola to catch) and there is no pre-existing immunity in the human population and as yet no vaccine. Nor is there any specific curative treatment – just symptomatic treatments like pain relief (if you can find any paracetamol in the shops) and supportive treatments like oxygen and ventilation/ECMO. It has a particular predilection for the old and infirm.

Thus far it has killed over 10,000 people worldwide, but the numbers are rising rapidly as we all know. 

However, it still ranks far below the worst epidemics in history listed below, all of which killed over one million people.

As you can see, the four worst epidemics in history in terms of lives lost were the Plague of Justinian, the Black Death, the Spanish Flu and the AIDS Epidemic, all of which claimed over 20 million lives. 

So we have quite some way to go yet.

So what does the Bible teach us about epidemics? And how should this shape our response as believers?

To understand this we need to look past viruses and bacteria to the spiritual realities that lie beyond.

We know that God is utterly sovereign over everything that happens in the universe. As the book of Daniel reminds us, Kings cannot rule, lions cannot bite and fire cannot burn without his permission.

God is sovereign over all things human, biological and physical and especially the rise and fall of nations (Daniel 2:21, 4:25, 5:21).

God was the author of the plagues of Egypt in Exodus 7-12 and is equally the author of the plagues described in the book of Revelation.

God is our Saviour but he is also our judge and his judgement is played out not just at the end of time but during the course of history.

Through the prophet Ezekiel God speaks of his ‘four dreadful judgements’ (14:21) – sword, famine, wild beasts and plague – which he sends both against Jerusalem (14:21) and ‘any country’ which sins against him (14:13).

Deuteronomy 28 lists the curses of disobedience which the Lord warns will strike Israel if she falls into apostasy and these include infectious diseases (28:21-22, 58-63).

The books of the Prophets in the Old Testament outline in great detail what will happen to each nation and empire in the course of history as a result of societal sin (yes nations, as well as individuals, will be judged) and in passages like Amos 4 God makes it very clear that he himself was the source of the famine, drought, blight, locusts and plague (4:10) which Israel had suffered. God is sovereign.

‘When disaster comes to a city has not the Lord caused it?’ (Amos 3:6)

When Solomon prays to the Lord in 2 Chronicles 6:12-42 asking him to deliver Israel from war, drought, famine and plague (28-31) God in his reply (7:13) makes it very clear that he himself is the author of these afflictions:

‘When I shut up the sky so that there is no rain, or command locusts to devour the land or send a plague among my people…’ (2 Chronicles 7:13)

Jesus makes it very clear that the time between his first and second comings will be characterised by war, earthquakes, famines and also ‘pestilences’ (Luke 21;10-11).

The fourth horse of the apocalypse and its rider, named Death and Hades, were given power ‘to kill by sword, famine and plague and by wild beasts of the earth’. (Revelation 6:8)

All four horses of the apocalypse and indeed all the plagues described in the book of Revelation are released by Jesus Christ himself. It is the Lamb of God himself, who opens the seven seals (Revelation 6:1), orders the blowing of the seven trumpets (8:1,2) and orders the pouring out of the seven bowls of God’s wrath (16:1).

Many Christians today prefer to blame human beings or Satan for these kinds of cosmic events – but whilst they are most definitely involved – it is God himself who is both author and judge. Satan has to ask God’s permission to afflict Job (Job 2:4-8) or to sift Peter (Luke 22:31) – he is like a dog on a leash.

So it should not surprise us when we look at the epidemics described in the Bible - those events which seem most likely to be caused by infective agents like viruses and bacteria – that it is God, or one of his angels, who invariably is named as the active agent.

I have listed below seven major plagues described in the Old Testament. You will observe that in each case God or the Angel of the Lord is described as the active agent. Furthermore, in five of the seven it is Israel which is the object of judgement. The Assyrians and Philistines fill the other two slots.

Furthermore, each plague constitutes retribution for some specific national sin – be it insubordination, sexual immorality, idolatry or something else.

So, how should we respond as Christians to the coronavirus?

We must pray of course for the Lord's wisdom: for faith to see God's plan through it all, for hope in our security in Christ Jesus, and for strength to be the body of Christ in ministering to those in need.

There are great opportunities to show compassion to those who are suffering and many churches are already leading the way in this.  

But if we fail to see that God is also sovereign over this event – that he has not only allowed it but also caused it and that this ‘plague’ is an act of judgement and a mark of our sin as nations – we will have badly misunderstood.

‘I am the Lord, and there is no other. I form light and create darkness, I make weal and create woe; I the Lord do all these things.’ (Isaiah 45:6,7)

Yes, God is our healer. He will bind us up. He is loving and compassionate. But he is also the ultimate author of human suffering because he is also our judge and uses it to wake us up from our spiritual slumber. As CS Lewis said:

‘We can ignore even pleasure. But pain insists upon being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is his megaphone to rouse a deaf world.’

How are we deaf? It is interesting that this epidemic seems to be hurting rich Western countries the most. That, in general terms the oldest and most wealthy of us on the planet are currently being hit the hardest.

This virus threatens to outsmart us and overwhelm even our incomparably vast medical, financial and social resources. We are fighting it with all our wealth, ingenuity and scientific knowledge – and it is right to do so – but we are ultimately in God’s hands. It is he who by a subtle turn of the screw can choose to contain it or let it loose. We are putty, or dust, in his hands.

And so alongside all the good things we are doing and must do to contain, mitigate and turn back this virus, we need to ask what God might be saying to us as the wealthy and profligate post-Christian West – an end-stage culture which has turned its back on God and gone its own way.

It was Ezekiel who said of his own people many centuries ago:

‘Now this was the sin of your sister Sodom: She and her daughters were arrogant, overfed and unconcerned; they did not help the poor and needy. They were haughty and did detestable things before me. Therefore, I did away with them as you have seen.’ (Ezekiel 16:49,50)

These words could equally well describe the Western world today.

One of the most interesting of the plague accounts listed above is that surrounding the census, described in 2 Samuel 24 and 1 Chronicles 21.

King David takes a census of the fighting men of Israel contrary to God’s command. As a result, God sends an angel to bring a plague upon Israel. 70,000 people die throughout the length and breadth of the country – from Dan to Beersheba (2 Samuel 24:15).

But when the angel is about to destroy Jerusalem itself God calls a halt, and says ‘Enough! Withdraw your hand’. (24:16)

David sees the angel who is at that time at the threshing floor of Araunah the Jebusite and asks that God punishes him instead of the people (given that the census was his fault).

God’s response is to ask David to build an altar on the site, which he then purchases for 50 shekels, and sacrifices burnt offerings, fellowship offerings and prayers which leads God to call off the plague.

The place where these events happen is deeply significant.  We are told in 2 Chronicles 3:1-2 that the threshing floor of Araunah was on Mount Moriah – the place where God provided a ram substitute to Abraham for his son Isaac and where David’s son Solomon would later build the Temple. We know it as the Temple Mount today.

On Mount Moriah a ram dies in place of Isaac. On the threshing floor of Araunah animals are sacrificed in place of the people of Jerusalem. On the Temple Mount sheep and goats are later sacrificed in place of the people of Israel. Each substitutionary death averts the wrath of God.

All of these three events point forward prophetically to Jesus’ death on the cross for our sins, taking the punishment that we deserved.

The Lamb of God – Jesus Christ - becomes our Saviour dying in our place.

What will happen with the coronavirus epidemic is in God’s hands. We do not know at this point how many lives it will claim and if we will personally be included in that number.

But we need to remember that the Lamb who gave his life in order that we might stand before God with confidence on the day of judgement, is the same Lamb who pulls off the seals of judgement in the book of Revelation to unleash the four horsemen of the apocalypse.

We know that, regardless of how serious it is and how many people die, the coronavirus plague will eventually pass and become just another event in history. But are we reading the signs?

Sadly, in the context of Revelation most people on earth missed the signs. We are told that in the face of these warnings they failed to repent:

^‘The rest of mankind who were not killed by these plagues still did not repent of the work of their hands; they did not stop worshiping demons, and idols of gold, silver, bronze, stone and wood—idols that cannot see or hear or walk. Nor did they repent of their murders, their magic arts, their sexual immorality or their thefts.’ (Revelation 9:20,21)

Murders, magic arts, sexual immorality and thefts. It is not difficult to see how these descriptions might apply today in our post-Christian West in the shadow of the sexual revolution and all its societal consequences.

Not only did they fail to repent but later, when things got worse, they like the Egyptians before them, ‘cursed the name of God, who had control over these plagues’. (Revelation 16:9)

Yes, we must do all we can humanly do to constrain and mitigate this epidemic (see my recent blog post on how fundamental proper virus testing is to this) but if we do this without reading this event as a warning from God we will have missed the point. We need to see it through the eyes of Scripture as well as through the eyes of science.

God’s words to Solomon were very clear:

‘When I shut up the heavens so that there is no rain, or command locusts to devour the land or send a plague among my people, if my people, who are called by my name, will humble themselves and pray and seek my face and turn from their wicked ways, then I will hear from heaven, and I will forgive their sin and will heal their land.’ (2 Chronicles 7:13,14)

That is what we need to do as a church and as a nation – humble ourselves, pray, seek the face of God and turn from our sins. We are living in an end-stage culture and this is only the beginning of what will befall us if we close our ears and eyes to the signs. It is not too late but we need to act now before it is.

In Matthew’s Gospel we are told, that Jesus began to preach with the words, ‘Repent for the Kingdom of heaven is near.’ It has never been nearer than now. It is time to repent.

'Test, test, test' is the key to coronavirus epidemic control - the clear lesson from East Asia

How many people will die in the UK as a result of the COVID-19 pandemic? According to the scientists it will be between 20,000 and 500,000 depending very much on how we respond.

A team at Imperial College has produced a paper which this week has prompted the government to embark upon a range of new measures to stop the spread of the disease.

If we do nothing and just let the virus pass through the population unhindered – in the hope of producing so-called ‘herd immunity’ - then 81% of people would be infected and 510,000 would die from coronavirus by August.

If we adopt a mitigation strategy - trying to slow its spread to prevent a massive peak in cases that would overwhelm the NHS many time overs – we can expect 250,000 deaths.

But a suppression approach – breaking the chains of transmission in order to stop the epidemic in its tracks – would reduce total deaths to thousands or tens of thousands.  

The government has now concluded that suppression is the only viable line of approach. Their chief scientific adviser Patrick Vallance told a committee of lawmakers this week that 20,000 deaths would then be ‘a good outcome in terms of where we would hope to get to with this outbreak’.

Why has China done so much better than us?

But this raises a huge question. If 20,000 deaths is a ‘good outcome’, and the best we can hope to achieve, then why have there been only 3,000 deaths in China where the outbreak actually started?

On a population basis (the UK has 67 million people and China 1,435 million) the UK equivalent deaths to that in China would be just 140 had we handled it as successfully as them. 20,000 is over 140 times this figure.

So, what have the Chinese done differently? And what, by implication, have we failed to do?

The control of the spread of coronavirus in China is remarkable but real. Today’s figures show a total of 80,000 cases but only 10-20 new cases a day. There are still also 10-20 deaths a day from the virus in China but these are almost all people who were infected weeks ago. Things have tailed off massively.

But China has also achieved this fall-off much more quickly than other countries. 80,000 cases in China amounts to 56 cases per million population which is a better measure of how badly the virus has affected any given country.

By contrast Italy, with 31,000 cases to date, has 521 cases per million, almost ten times the China figure.

In fact, today on 18 March (and these figures are obviously increasing daily) there are 32 countries or territories with a higher density of cases than China. Some of these are small population states like Luxembourg, Andorra and San Marino, but others include Spain, Germany, France, Switzerland, Netherlands, Norway, Austria, Belgium and Denmark.

The two anomalies are the US and UK – today with 20 and 29 cases per million population respectively – but we know from the number of deaths alone in these two countries that the true number of those infected is much higher than this. Vallance said yesterday that a ‘reasonable ballpark’ current figure for the UK was 55,000 cases, not the 1,900 actually reported.

The reason the US and UK total case figures are so low is because we are doing so few tests for the virus. I’ll come back to that.

China’s remarkable success in controlling the virus is documented in the Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) dated 16-24 February. You can read the whole report here but there is an excellent summary here.

The diagram reproduced below from page 29 of the report (you can view it more easily here) shows the number of cases against time in China along with the major interventions made to try and slow the disease.

The outbreak was first announced on 30 December and the new coronavirus was isolated on 7 January and its gene sequence publicly shared on 10 January. The number of new cases per day peaked at around 3,000 just over two weeks later on 26 January but had fallen to fewer than 500 cases daily by 14 February.

A paper published on 16 March in Science shows that the virus first got away on the Chinese because they were unable to identify and isolate the very early cases.

They estimated that 86% of all infections were undocumented prior to the 23 January 2020 travel restrictions. The transmission rate of undocumented infections was only 55% of documented infections, presumably because those affected had less severe symptoms, yet, due to their greater numbers, undocumented infections were the infection source for 79% of documented cases. These findings explain the initial rapid geographic spread of the virus.

However, after the initial stage China got quickly on top of the outbreak through a vigorous programme of widespread testing followed by isolation of those affected, backed up by travel restrictions.

Testing for coronavirus in China and the UK

China has a policy of meticulous case and contact identification for COVID-19. For example, in Wuhan more than 1,800 teams of epidemiologists, with a minimum of 5 people/team, traced tens of thousands of contacts a day. Contact follow up was painstaking, with a high percentage of identified close contacts completing medical observation. Between 1% and 5% of contacts were subsequently laboratory confirmed cases of COVID-19, depending on location.

But the effort outside of Wuhan was also huge. In Shenzhen, for example, the infected named 2,842 contact persons, all of whom were found, when testing was completed for 2,240 it was found that 2.8% of those had contracted the virus. 

Within weeks following the identification of the virus, a series of reliable and sensitive diagnostic tools were developed and deployed. By 23 February, there were ten kits for detection of COVID-19 approved in China by the NMPA and several other tests had been entered in the emergency approval procedure. Overall, producers have the capacity to produce and distribute as many as 1,650,000 tests/week.

In stark contrast, based on figures available on 13 March, the UK had carried out around 30,000 Covid-19 tests, at a median of 1,600 tests per day so far in March. 

The World Health Organization director-general, Tedros Adhanom Ghebreyesus, said this week that he had a simple message to countries on how to deal with the coronavirus outbreak sweeping the globe: ‘Test, test, test.’

Speaking during a news conference on Monday he urged countries to test more suspected cases, warning that they ‘cannot fight a fire blindfolded’. 

But fighting the fire blindfolded is essentially what the UK and US have been doing – simply because there are not enough testing kits. This was admitted by UK government adviser Professor Chris Whitty this week.

On 6 February, the World Health Organization said it had already shipped 250,000 tests to more than 70 laboratories around the world.

But as WHO shipped hundreds of thousands of tests, broader US testing struggled to begin. The US kits, developed by the CDC, were found not to be working as expected, which eventually required test kits to be re-manufactured. In fact, earlier this week it was reported that the US lags almost all developed countries in testing for the virus.

Whilst the abundance of testing kits in China meant that everyone with a fever or who had had contact with an infected person was tested, the shortage of testing kits in the UK has meant that tests are not even available for doctors on the frontline or for high-risk patients at risk. In fact, the only people being tested until very recently were those with severe symptoms admitted to hospital.

What this means is that those with less serious cases of COVID-19 have been able to roam free to spread disease, and frontline people (doctors and other health professionals), who are unwell but do not actually have the virus, are being unnecessarily quarantined for 14 days along with their families when they could be treating patients.

A pandemic out of control

It is now over two months since China initiated its control programme and countries seem now to be in two groups – those where the virus appears to be propagating largely out of control (mainly Western Europe) and those in East Asia where there has been success in getting on top of its spread.

The diagram (below) demonstrates this dramatically.

Cases (and deaths) in Europe and the US are spiraling out of control but in Singapore, Japan and Hong Kong – using more of a Chinese approach - the curve is considerably flattening over time.

Just today an article in Science attributed South Korea’s astounding success so far to the most expansive and well-organized testing program in the world, combined with extensive efforts to isolate infected people and trace and quarantine their contacts.

South Korea has tested more than 270,000 people, which amounts to more than 5,200 tests per million inhabitants. By contrast, the US has so far carried out 74 tests per 1 million inhabitants, data from the US Centers for Disease Control and Prevention show.

South Korea’s experience shows that ‘diagnostic capacity at scale is key to epidemic control,’ says Raina MacIntyre, an emerging infectious disease scholar at the University of New South Wales, Sydney.

Reports last week from Italy described doctors opting not even to assess high-risk patients, let alone tube and ventilate them, because they were simply overwhelmed by the numbers (see frightening twitter thread here and also Lancet paper from 13 March here). Spain is following closely but other countries including Germany, UK, Netherlands and Switzerland, are only a week or two behind.

It is a fundamental principle of medicine that there is no treatment without diagnosis. We need more testing kits rapidly deployed. It is incredible that even at this late stage we don’t really know who has the disease and who doesn’t.

There are already many types of testing kits available and capable of mass production (see also here). Can the UK government expedite the approval process as China so successfully did to bring them on stream?

Of course, all the other measures to prevent spread, which the UK has already implemented and with which we are well familiar, are absolutely necessary and right. And we need many more doctors, oxygen and ventilators to provide support for the rising tide of severe cases.

The figures for China are that 20% of all cases needed hospitalisation and oxygen often for weeks and 25% of these (5% overall) needed ventilation or ECMO. When we consider that the UK until recently only had 4,000 ventilators, 80% of which were already occupied, we can start to appreciate how serious this is.

But it is also clear that had we deployed more rigorous testing, contact tracing and isolation in the early stages of this pandemic we would not be in the position we are now.

We pride ourselves in the UK on both our standard of medicine and on the NHS. But we are lagging far behind those in China and other East Asian countries in our management of this crisis.

Whether it is too late to rectify this only time will tell. Will we end up in the UK with 20,000 deaths, 250,000 or 500,000?

What is clear is that many times more than 140 will die (the number of deaths the UK should have if equivalent to China on a population basis). That total will be passed in the next few days and advisors are predicting that new cases per day will not peak for another 10 to 14 weeks. The peak of the death rate will be two to three weeks after that.

It is clear that, as of this week, the UK government is now much better informed and pulling out all the stops to beat this challenge (helpful summary here). As we all work together we pray that these efforts will be successful and that the UK death toll is much closer to 20,000 than 500,000.

Severely brain-damaged patients are commonly misdiagnosed, often aware and may well recover, says authoritative new report

People with severe brain damage are difficult to diagnose reliably, not uncommonly recover and are often much more aware than we think. Specifically:

      Four in ten people who are thought to be unconscious are actually aware

      One in five people with severe brain injury from trauma will recover to the point that they can live at home and care for themselves without help

      The term PVS should be dropped and that pain relief should be given to patients affected

These are the startling conclusions of a new US practice guideline for managing prolonged disorders of consciousness (PDOC) issued earlier this week.

The guideline is acutely relevant to the UK, where on 30 July 2018, the British Supreme Court made a landmark decision, that food and fluids can be withdrawn from patients with PDOC provided that both doctors and relatives agree it is in a given patient’s ‘best interests’.

According to Prof Derick Wade, a consultant in neurological rehabilitation based in Oxford,  there could be as many as 24,000 patients in the NHS in England alone either in permanent vegetative state (PVS) or minimally conscious state (MCS), most of them in nursing homes.

People with PVS are awake, with eyes open, but do not exhibit behaviour suggesting they are aware either of themselves or their surroundings. Those with MCS show definite signs of awareness of self or surroundings, but often, these behaviours may not be obvious or may not happen regularly. These signs include tracking people with their eyes or following an instruction to open their mouths, but the behaviours are often subtle and inconsistent.

A summary of the guideline, together with an accompanying literature review on which it was based, was published online on 8 August 2018 in the medical journal Neurology. An accompanying press release summarises the main points.

The new guideline updates the earlier 1994 AAN practice parameter on persistent vegetative state and the 2002 case definition for the minimally conscious state (MCS), some of the recommendations of which ‘probably no longer hold true’ according to lead author Joseph Giacino.

The guideline carries weighty authority because it has been issued by the American Academy of Neurology (AAN), the world’s largest association of neurologists and neuroscience professionals, with over 34,000 members.

Experts carefully reviewed all of the available scientific studies on diagnosing, predicting health outcomes and caring for people with disorders of consciousness, focusing on evidence for people with prolonged disorders of consciousness—those cases lasting 28 days or longer.

The majority of those with PDOC are young people who have suffered head injuries or older people with hypoxic brain damage (lack of oxygen to the brain, for example during a cardiac arrest).

Errors in assessing awareness

As neuroscientist Adrian Owen's research demonstrates through the extraordinary testimonies in his book 'Into the Grey Zone', reviewed here by Chris Willmott, some patients with PVS and MCS have far more awareness than we might possibly imagine.

The guideline, based on the latest research, states that about four in ten people who are thought to be unconscious are actually aware. This 40% rate of misdiagnosis is because underlying impairments can mask awareness, argues Giacino, and can lead to inappropriate care decisions as well as poor health outcomes.

‘An inaccurate diagnosis can lead to inappropriate care decisions and poor health outcomes. 

Misdiagnosis may result in premature or inappropriate treatment withdrawal, failure to recommend beneficial rehabilitative treatments and worse outcome. That is why an early and accurate diagnosis is so important’, he argues.

It is therefore essential that assessments of these patients are carried out only by real experts.

The guideline states, ‘People with prolonged disorders of consciousness after a brain injury need ongoing specialized health care provided by experts in diagnosing and treating these disorders.

Problems with diagnosis

To get the right diagnosis, a clinician with specialized training in management of disorders of consciousness, such as a neurologist or brain injury rehabilitation specialist, should do a careful evaluation. This should be repeated several times early in recovery—especially during the first three months after a brain injury.’

The guideline enlarges on this as follows (see here for the accompanying academic references):

‘The range of physical and cognitive impairments experienced by individuals with PDOC complicate diagnostic accuracy and make it difficult to distinguish behaviours that are indicative of conscious awareness from those that are random and nonpurposeful.

Interpretation of inconsistent behaviours or simple motor responses is particularly challenging. Fluctuations in arousal and response to command further confound the reliability of clinical assessment.

Underlying central and peripheral impairments such as aphasia, neuromuscular abnormalities, and sensory deficits may also mask conscious awareness.

Clinician reliance on nonstandardised procedures, even when the examination is performed by experienced clinicians, contributes to diagnostic error, which consistently hovers around 40 percent.

Diagnostic error also includes misdiagnosing the locked-in syndrome (a condition in which full consciousness is retained) for vegetative state and minimally conscious state (MCS).’

But it is not only diagnosis that is problematic. Prognoses too can be widely mistaken.

Difficulties in predicting outcomes

‘The outcomes for people with prolonged disorders of consciousness differ greatly. Some people may remain permanently unconscious. Many will have severe disability and need help with daily activities. Others will eventually be able to function on their own and some will be able to go back to work.’

 According to the guideline, approximately one in five people with severe brain injury from trauma will recover to the point that they can live at home and care for themselves without help. Those with a brain injury from trauma have a better chance of recovery than those with a brain injury from other causes.

What about treatment?

Treatments do exist

‘Few treatments for disorders of consciousness have been carefully studied. However, moderate evidence shows that the drug amantadine can hasten recovery for persons with disorders of consciousness after traumatic brain injury when used within one to four months after injury.’

There are also advances being made in the treatment of some acute brain injury because of brain cooling techniques, intracranial pressure monitoring and neurosurgery.

Commenting on the new guideline, an editorial in Neurology, agrees that the term PVS should be dropped and that pain relief should be given to patients affected.

Authors Joseph Fins and James Bernat, argue in their review titled ‘Ethical, palliative, and policy considerations in disorders of consciousness’ that PVS should be renamed as ‘chronic vegetative state given the increased frequency of reports of late improvements’.  

They also advocate ‘routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness’ and ‘applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients’.

Conclusions

The publication of the new guideline, casts further doubt on last week’s UK Supreme Court decision and will no doubt lead to further criticism.

I have argued previously that doctors should not be starving and dehydrating non-dying brain damaged patients to death in any circumstances at all. The fact that a substantial number of these patients are misdiagnosed, feel pain and will later recover only makes the case more strongly.

This state of affairs was predicted in 1993 by Andrew Fergusson, former CMF General Secretary, when he argued that the Law Lords in the case of Hillsborough victim Tony Bland (pictured above) had made three key false assumptions: that food and fluids is treatment and not basic care; that death is in some people’s ‘best interests’; and that it is not euthanasia when food and fluids are withdrawn with the explicit intention of casing death by starvation and dehydration.  Andrew’s whole article, ‘Should tube feeding be withdrawn in PVS?’ is well worthy of further study by all with an interest in this area.

The new guideline, issued by the American Academy of Neurology, has been jointly published by the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living, and Rehabilitation Research and has been endorsed by the American Academy of Physical Medicine and Rehabilitation, American College of Surgeons Committee on Trauma and Child Neurology Society.

I wonder how our own British medical organisations (and in particular the BMA and Royal College of Physicians) will respond. Given that they backed the Supreme Court decision, they most certainly ought to be asked for comment.

New draft guidance from the BMA will enable doctors to dehydrate and sedate to death large numbers of non-dying patients with dementia, stroke or brain damage

This story was broken on 13 August 2018 by the Daily Mail. 

Is it justifiable to withdraw food and fluids from patients with dementia, stroke and brain injury who are not imminently dying?

New ‘confidential’ draft guidance from the British Medical Association (BMA) - the doctors’ trade union - says ‘yes’ provided that a doctor believes it is in the patient’s ‘best interests’.

The 77-page ‘confidential’ document, which is currently out for ‘consultation’ (although only to a few selected individuals), has been prepared by the BMA in conjunction with the Royal College of Physicians (RCP) and the doctors’ regulatory authority, the General Medical Council (GMC).

I understand from the BMA that it will not be open for public consultation at any point before publication in the autumn.

The draft guidance builds on case and statute law and on previous practice guidelines and has huge implications for the care of some of the most vulnerable people in England and Wales.

It comes complete with a six-page executive summary, flow charts and tick box forms to smooth the decision-making process.

The guidance says it is based on the current legal position which it defines as follows:

·         Clinically assisted nutrition and hydration (CANH) - essentially food and fluids by a fine tube through the nose or through the skin into the stomach -  is a form of medical treatment

·         Treatment should only be provided when it is in a patient’s 'best interests'

·         Decision makers should start from the presumption that it is in a patient’s best interests to receive life-sustaining treatment but that presumption may be overturned in individual cases

·         All decisions should be made in accordance with the Mental Capacity Act 2005 (see also my blog post on the recent Supreme Court judgment)

It focuses on three categories of patients where CANH is the ‘primary life-sustaining treatment being provided’ and who ‘lack the capacity to make the decision for themselves’: those with ‘degenerative conditions’ (eg. Dementia, Parkinson’s etc); those who have suffered a sudden-onset, or rapidly progressing brain injury and have multiple comorbidities or frailty’ (eg. stroke); previously healthy patients who are in a vegetative state (VS) or minimally conscious state (MCS) following a sudden onset brain injury.

It makes it crystal clear that it does not cover patients who imminently dying and ‘expected to die within hours or days’ but rather those who ‘could go on living for some time if CANH is provided’.

So in summary, the guidance decrees that dementia, stroke and brain injured patients who lack mental capacity but are not imminently dying can be starved and dehydrated to death in their supposed ‘best interests’.

Who makes these decisions? If there is an advance directive for refusal of treatment (ADRT) then the patient does (or at least has). If there is an appointed health and welfare attorney then they do, and if it’s not the case that ‘all parties agree’ then it falls to the Court of Protection. But in the remainder of cases – which must by any reckoning be the vast majority – it is ‘usually a consultant or general practitioner’.

No second opinion need be obtained unless there is ‘reasonable doubt about the diagnosis or prognosis, or where the healthcare team has limited experience of the condition in question’ and even if the patient is suffering from PVS or MCS ‘it is not necessary to wait until (investigations) have been completed’ if there is not ‘sufficient evidence’ that they will ‘affect the outcome of the best interests assessment’ (Executive Summary para 14).

In other words, the diagnosis and prognosis are irrelevant if the decision is made that death is in the patient’s ‘best interests’. This is especially disturbing given that PVS and MCS are extremely difficult to diagnose, many patients have some degree of awareness and some later wake up.

And how are best interests to be determined? Decision makers must take into account ‘the individual’s past and present views, wishes, values and beliefs’ and in order to do this should consult ‘those engaged in caring for the patient or interested in his or her welfare’. This would ‘usually include family members and could also include friends and colleagues’.

So, what determines ‘best interests in a given case’?

It boils down to whether CANH is able to ‘provide a quality of life the patient would find acceptable’ (ES p23). Otherwise continuing to provide CANH is ‘forcing them to continue a life they would not have wanted’ (ES p16).

So, by a subtle twist, providing basic sustenance (food and fluids by tube) to someone who ‘would not have wanted’ to be in this ‘condition’ is a form of abuse. How very convenient.

The issue here, of course, is that most normal people do not think that they will find life with dementia, stroke or brain injury ‘acceptable’ and CANH – food and fluids - does not reverse these conditions just as it does not reverse cancer, diabetes, disabliity or mental illness.

This is precisely because CANH is not actually ‘treatment’ but rather part of basic care. But it does not follow that they should therefore have their lives ended. In fact, research shows that people who are sick value the quality of life they have left much more than they would expect to when well. 

British parliaments have consistently refused to legalise euthanasia or assisted suicide for people with a quality of life they would not find ‘acceptable’ or would not ‘have wanted’. But the BMA is saying that to end these lives by starvation and dehydration, rather than with a lethal injection or drinking poison, is perfectly acceptable.

This is actually nothing other than euthanasia by stealth – euthanasia by the back door. 

It might, and has, been argued that starving and dehydrating people to death over two to three weeks is actually less compassionate than killing them quickly with lethal drugs.

What safeguards are there against abuse of this new guidance? Very few it appears.

There is a section reminding doctors that the GMC requires ‘a second medical opinion’ from a suitably qualified ‘senior clinician’ where it is proposed ‘not to start, or to stop CANH and the patient is not within hours or days of death’. This clinician should (note not must) ‘examine the patient and review the medical records’.

A ‘detailed record’ of the decision-making process should be kept and a ‘model proforma’ (see below) is ‘recommended’.  Decisions should be subject to ‘internal audit and review’ and ‘external review’ by the Care Quality Commission and Healthcare Inspectorate Wales but health professionals need to ‘contribute to’ ‘relevant national data collection’ only if it ‘exists’.

So, no legal, or even ethical, obligations – just suggested ‘best practice’.

Quite how oversight or accountability will be possible is unclear as the death certificates need not make any reference to the fact that the patient died from starvation and dehydration after a feeding tube was removed. Instead ‘the original brain injury or medical condition should be given as the primary cause of death’ (2.11). And so, the doctor’s tracks are perfectly covered.

The body of the draft guidance contains a flow chart (page 19) outlining the decision-making procedure.  

The simple ‘recommended’ ‘checklist’ (appendix 4), which could be filled out in a few minutes, could be the only record that remains in the patient’s notes (see inserts).

What is largely disguised here in a lengthy and turgid 77-page document that few doctors or carers will ever read is a simple mechanism for ending the lives of dementia, stroke and PVS patients who are not imminently dying and who otherwise could live for months, years or even decades.

A decision is made by a GP or hospital consultant, on the basis of information about the patient gathered from relatives or carers, that they would not ‘have wanted’ to live this way.

A simple tick-box form is completed, the tube is removed and the patient in question is dehydrated, starved and sedated to death. The true cause of death is not recorded in the death certificate.

I’m not suggesting that large numbers of doctors will not undertake these assessments and decisions with integrity and diligence. But the problem is with the protocol itself. Also, it will only require a few to cut corners out of laziness or driven by malice, ideology or vested interest. This mechanism of ending vulnerable people’s lives – essentially a conveyor belt from nursing home and hospital bed to the morgue – is open to the most extraordinary abuse at every level by health professionals, family members and health institutions who might have an interest, financial or emotional, in a given patient’s death.

Imagine the busy nursing home filled with dependent but non-dying stroke, dementia and brain injured patients whose relatives seldom visit. Feeding tubes have been placed by staff because they are far more convenient than standing over patients and feeding them with a spoon. Wards are understaffed and the patients are difficult to care for.

A visiting GP makes a decision that it is not in a certain patient’s ‘best interests’ to live. Relatives are consulted and agree that their ‘loved ones’ would not ‘have wanted’ to live like this.  A ‘second opinion’ is obtained. Forms are filled out. The tube is removed and the patient moved to a side room to receive ‘palliative care’ consisting of deep sedation until they have died two to three weeks later from dehydration.

The death certificate is falsified with only the underlying condition being recorded. No data are collected and there is no proper internal audit. Everyone is too busy and distracted. No questions are asked or answers given. They are not required as this is all ‘good practice’ approved by the BMA. The police do not investigate. The CPS does not prosecute. The courts are not involved. Parliament turns a blind eye as it lacks the stomach to review the relevant legislation. It is easier to leave it to the doctors and their professional ‘guidance’.

This is a recipe for euthanasia by stealth, but all in the name of autonomy and ‘best interests’ – the very worst kind of doctor paternalism justified on the grounds that the patient would ‘have wanted’ it.

There are conceivably tens of thousands of patients in England and Wales who are vulnerable to the use and abuse of this ‘guidance’. It will be almost impossible to work out what has happened in a given case and there are no legal mechanisms in place for bringing abusers to justice.

How did we get here? This whole process has transpired by a small series of steps – each following logically from the one before and endorsed in case law, statute law, regulations and guidelines going back to the Law Lord’s decision on Hillsborough victim Tony Bland who was the first to die in this way. But the trickle is about to become a flood.

Once we accept that food and fluids by tube is ‘medical treatment’ rather than basic care and that providing this basic sustenance to someone with a medical condition they would not find ‘acceptable’ is not in their ‘best interests’, then we are inviting professionals to devise a simple scheme whereby the starvation of large numbers of non-dying but expensive and ‘burdensome’ patients can be achieved simply and efficiently, and largely undetected, without involving the courts.

When it came to light a few years ago that some doctors were misusing a palliative care tool called the Liverpool Care Pathway to starve, dehydrate and sedate non-dying patients to death there was a national outcry.

One might have expected to see a similar reaction to this draft BMA guidance.  But thus far there has been not a whimper.

I am astounded that no MP or prominent doctor has yet raised any concerns about it. I wonder how long it will be.

You can read CMF’s official response to the BMA draft guidance here.

Organ donation opt out plans in England – not nearly as clear cut as it might seem

All adults in England will be presumed to be organ donors unless they have explicitly opted out, the government has announced.

The new plans follow a public consultation launched last December. Wales has had a similar opt-out system since 2015 and Scotland also plans to introduce one.

New legislation which will be introduced in parliament this autumn is intended to come into effect in spring 2020 giving people a 12-month transition period to make decisions about organ donation preferences.

According to the BBC, ‘Max's Law’ is named after Max Johnson, from Cheshire, who was saved by a heart transplant.

His search for a suitable heart was followed in a series of front-page stories in the Daily Mirror, as the newspaper campaigned for the change in the law.

Last year, Prime Minister Theresa May wrote to the ten-year-old, saying she chose the name after she heard his ‘inspirational story’.

Groups excluded from ‘presumed consent’ will include under 18s, people lacking the mental capacity to understand the changes, and people who have not lived in England for at least twelve months before their death.

People who do not wish to donate their organs will be able to record their decision on the NHS Organ Donor Register, by calling a helpline, visiting the NHS Blood and Transplant website or on a new NHS app.  

If people do not opt out they will be considered to be a potential organ donor but donation will not proceed if the family ‘objects strongly’.

A clear-cut case?

About 17,000 people responded to the government consultation. Of these, 72% said that the proposed change in the law would make no difference to their decision about organ donation. 13% said that the change would make them opt in, while 15% of respondents said that they would opt out.

Around 5,100 people in England were waiting for a transplant at the end of March 2018 but although 80% of people in England would consider donating only 37% have so far signed up.

The government claim that the new plans will result in an extra 700 organ transplants taking place every year in England.

The Royal College of Physicians, Kidney Care UK and the British Heart Foundation all back the proposals along with the British Medical Association.

It is therefore understandable that media coverage of the plans has been overwhelmingly favourable – so why do I have reservations?

Simply because, as the CMF advocacy team have argued many times before (see here, here, here, here and here)  the case for an opt-out system for organ donation is not nearly as clear cut as it might seem.

Marginalised voices

First, there is lots of opposition from authoritative voices who are now being marginalised in the rush to embrace it.

Professor John Fabre, former President of the British Transplantation Society, has led a chorus of critics warning that the evidence shows an opt-out approach is counter-productive.

Speaking to BBC Radio 4, Prof Fabre said it could be predicted ‘with a high level of certainty that it is not going to increase donor numbers in the way that we all want’.

Former National Clinical Director for Transplantation Professor Chris Rudge has said: ‘The only evidence I have seen is that it won’t make any difference and it is not the answer to the problem, but there is a risk that it may make things worse.’

Hugh Whittall, Director of the Nuffield Council on Bioethics, said he was concerned that the Government was asking how the law should be changed, rather than if it should be.

Keith Rigg, consultant transplant surgeon at Nottingham University Hospitals NHS Trust, felt that full results from Wales should be studied before such a move was considered in England.

These authorities have reservations because there is no clear evidence that opt-out actually works in increasing organ donation rates.

Lack of evidence

Before implementing an opt-out system, Fabre said, it is important to ask: ‘Does it actually make a difference?’ He concluded: ‘It actually doesn’t’.

Rigg again: ‘There is no clear evidence that this has resulted in an increase in organ donations and transplants where it has been introduced.’

Whittall: ‘The government should not be making this change until there is evidence that it works, and until we are confident that it won’t undermine people’s trust in the system in the long-term.’

In a September 2017 review, the BBC reported: ‘In Wales, where an opt-out system was introduced in December 2015, there has actually been a small dip in the number of deceased donors, from 64 in 2015-16 to 61 in 2016-17. This resulted in a drop in organ transplants from 214 to 187 respectively.

This is not to say the opt-out scheme is having a negative effect - some fluctuation is to be expected - but so far, despite the claims, we don't have any evidence that it is having a positive effect.’

Opt-out schemes don't consistently translate to increased organ donor rates. In Sweden, such a scheme has been in force since 1996 but it remains one of the lowest-ranked countries for organ donation in Europe. Luxembourg and Bulgaria also have opt-out systems and low rates of organ donation.

In France and Brazil, variations on a ‘presumed consent’ system actually led to a decline in the rate of organ donation.

A better way

Spain is often cited as an opt-out scheme success story.

‘Presumed consent’ legislation was passed in 1979 but donor rates only began to go up ten years later when a new national transplant organisation was founded which co-ordinates the whole donation and transplantation process.

In other words, it was not opt-out but rather other changes, like better infrastructure, more funding for transplant programmes and more staff working to identify and build relationships with potential donors before their death that really made the difference.

As Rafael Matesanz, an expert on the Spanish situation has recently argued: ‘Spaniards consider insignificant the impact of the type of consent on the donation activity. To the contrary, infrastructure, organization around the process of deceased donation, and continuous innovation are deemed the  keys for success… it was not until ten years after the (opt-out) Law approval that donation took off.’

In September the Nuffield Council on Bioethics confirmed that the evidence for introducing presumed consent is absent and highlighted instead the alternative option of investing more in Special Organ Donation Nurses. Where specialist nurses are available to speak to the family of the deceased they either donate or authorise donation in 68% of cases. Where they are absent the figure is just 27%.

Counterproductive

The positive spins on the impact of presumed consent also ignore the implications of people signing the opt-out register.  During 2016-17, 174,886 people in Wales, around 6% of the population, were signed up to the opt-out register. In the first two quarters of 2017-2018 this increased to 178,062.

This means that nearly 175,000 people have now effectively been removed from being possible donors when previously their families, as their living representatives, might have been happy to donate organs at their death, in the absence of express direction to do otherwise.  

The potential for presumed consent to alienate people, precipitating withdrawal from the donation system is real. In giving oral evidence to the National Assembly Health and Social Care Committee in Wales, organ transplant specialist Dr Peter Matthews, who was based in Morriston Hospital in Swansea, made the following statement:

‘My own experience is that the British psyche has a particular view that what it should do is donate organs as an altruistic gift, and if it is felt that the state is going to take over the organs, then there is the potential that people who may have been willing to become a donor will not do so. We have seen two cases in Morriston where patients who were on the organ donation register, on hearing about this, said to their families that if the state was going to take their organs, they were no longer willing to give them. We lost two donations because of that. So, there is a potential backlash.’

Organ donation should be a gift

This underlines the fact that organ donation should be an altruistic gift. Opt-out is not ‘presumed consent’ because no consent has been given.

Consent which is presumed is not actually consent at all. It amounts rather to the body after death becoming the property of the state and the state taking organs rather than the donors or their families giving them.

At a time when so much emphasis is placed on autonomy and free choice, this runs in the opposite direction. I’ve looked at this in more detail here.

Costly

In their 2008 report ‘The potential impact of an opt out system for organ donation in the UK’ the Organ Donation Taskforce looked at the costs for introducing a UK wide system of presumed consent.

They estimated that the cost of doing so would be ‘approximately £45 million in set up costs for IT and communications. There would be £2 million per year in IT running costs and an additional £5 million every few years to refresh public messages.’

Ths money would be far better spent employing trained specialist nurses in organ donation and developing an infrastructure like that of Spain.

Too many unanswered questions

There are simply too many unanswered questions about the opt-out system to be going precipitously down this road. 

There are strong voices against it because there is no evidence it will work, better ways forward exist, its coercive nature risks alienating potential donors, it undermines the idea of donation as a gift and it will be very costly to implement.

It seems that the government is ignoring the facts in its haste for a headline win based on ideology rather than facts. They should think again and refrain from whipping their uninformed MPs through the lobbies to force opt-out onto the statute books.

Dignity in Dying’s response to this week’s Supreme Court ruling reveals its real agenda

The former Voluntary Euthanasia Society, rebranded ‘Dignity in Dying’ (DID) in 2006, in order to disguise its real objectives, has always been quick to emphasise that it only supports a change in the law to allow so-called ‘assisted dying’.

By this it means allowing mentally competent adults with less than six months to live to end their lives by being assisted to drink a lethal draft of barbiturate. ‘Assisted dying’ is, more accurately, assisted suicide for the terminally ill.

Both the Marris bill, which was defeated in the House of Commons in 2015, and the Falconer Bill, which ran out of parliamentary time in the House of Lords several months earlier, applied this ‘assisted dying’ formula. So did the Conway case, recently rejected by the Court of Appeal. All were understandably backed by DID.

DID, therefore, have always maintained that they oppose assisted suicide or euthanasia for the chronically ill, disabled people and those who lack mental capacity. You have to be a mentally competent adult with under six month’s life expectancy to qualify.

It was therefore interesting to see them so actively involved in the recent Supreme Court case involving a man (Mr Y) who was left in a minimally conscious state (MCS) following a heart attack.

The Supreme Court ruled on Monday 30 July, that it is no longer necessary for cases involving patients suffering from PVS (permanent vegetative state) or MCS to go to the Court of Protection before CANH (clinically assisted nutrition and hydration) can be stopped, provided that both doctors and relatives are in agreement that this is in the patient’s ‘best interests’.

The judgement built on legal precedent dating back to the case of Hillsborough victim Tony Bland in 1993 – namely that death is some people’s ‘best interests’ and that deliberate dehydration is a legitimate means of achieving it.

The effect of this week’s ruling is that patients with PVS and MCS can now be dehydrated to death over a period of 2 to 3 weeks without recourse to the courts providing doctors and relatives agree that they would not have wanted to go on living with this degree of disability.

But adults with PVS or MCS lack mental competence and are not dying. They can breathe without ventilators, respond to painful stimuli and often live for years, if not decades, provided their basic requirements for food and fluids are met.

They most certainly do not fall in the category of patients that DID have previously targeted and by no stretch of the imagination can their deaths from dehydration therefore be called ‘assisted dying’.

It is therefore most revealing that the barrister representing Mrs Y in the case, was none other than Victoria Butler-Cole, the chair of trustees of DID’s sister charity ‘Compassion in Dying’ (CID).

On the day that the Supreme Court handed down its decision other staff and trustees of DID were also very active on the media in support of the decision. These included chief executive Sarah Wootton, director of legal strategy and policy Davina Hehir and trustee Jonathan Romain.

In the Netherlands, where voluntary euthanasia is legal, death by deliberate dehydration (by withdrawing or withholding food and fluids) is categorised as an end of life decision with the ‘explicit intention of ending life’. This is because that is what it actually is, and the Dutch are not known for beating about the bush. It is a method of killing.

Other decisions in this category include euthanasia (achieved with a lethal injection of barbiturate), assisted suicide (as above), deliberate morphine overdose (as used recently in Gosport to kill over 450 people) and continuous deep sedation (whereby a patient is sedated until they eventually die from dehydration).

These practices, apart from euthanasia itself, all represent ‘euthanasia by stealth’. In other words they are methods of deliberately ending a person’s life that fall short of administering a lethal injection. But they have the same intention. The key issue morally and ethically is the intention to end life.

DID’s behaviour around this Supreme Court case is not new but has in fact been part of pro-euthanasia strategy for over 30 years.

Dr Helga Kuhse, a leading campaigner for euthanasia, said in 1984: ‘If we can get people to accept the removal of all treatment and care - especially the removal of food and fluids - they will see what a painful way this is to die and then, in the patient's best interest, they will accept the lethal injection.’ (Fifth Biennial Congress of Societies for the Right to Die, held in Nice, Sept. 1984).

So we should not be surprised by this week’s events. Rather, they demonstrate the full extent of DID’s (and CID’s) agenda and the lengths they are prepared to go in order to achieve it. Including dehydrating non-dying disabled people to death - which I suggest could be described neither as dignified nor compassionate.

The great tragedy is that although patients with PVS or MCS lack some or in severe cases all awareness, they still respond to pain. And as neuroscientist Adrian Owen's research demonstrates in his book 'Into the Grey Zone' some of them have far more awareness than we might imagine.

Therefore, we can expect as this new ruling takes effect, for reports to surface about brain-damaged patients suffering pain and distress from thirst while they are being dehydrated to death.

You can be sure that this will then be used as an argument to bring in lethal injections in order to achieve the desired end more quickly and with the minimum of fuss. 

After all, it will be argued, that is what these patients would have really wanted.