vulnerable population

Managing ethical issues in patient care and the need for clinical ethics support

Evan Doran1,4 BA, Grad Dip Health Soc Sci, PhD, Associate Research Fellow

Jennifer Fleming1 BA, MHA, PhD, Postdoctoral Research Fellow

Christopher Jordens1 BA(Hons1), MPH, PhD, Associate Professor

Cameron L Stewart2 Bec, LLB(Hons), PhD, Professor

Julie Letts3 MBioeth, Manager, Clinical Ethics and Policy

Ian H Kerridge1 MPhil(Cantab), FRACP, FRCPA, Director

1Centre for Values, Ethics and Law in Medicine, University of Sydney, Medical Foundation Building, 92–94 Parramatta Road, Camperdown, NSW 2006, Australia. Email: [email protected]; [email protected]; [email protected]

2Centre for Health Governance, Law and Ethics, University of Sydney, New Law Building, Camperdown, NSW 2006, Australia. Email: [email protected]

3Office of the Chief Health Officer, NSW Ministry of Health, 73 Miller Street, North Sydney, NSW 2060, Australia. Email: [email protected]

4Corresponding author. Email: [email protected]

Abstract Objective. To investigate the range, frequency and management of ethical issues encountered by clinicians working in

hospitals in New South Wales (NSW), Australia. Methods. A cross-sectional survey was conducted of a convenience sample of 104 medical, nursing and allied health

professionals in two NSW hospitals. Results. Somerespondentsdidnotprovidedataforsomequestions,thereforethedenominatorislessthan105for

some items. Sixty-two (62/104; 60%) respondents reported occasionally to often having ethical concerns. Forty-six (46/105; 44%) reported often to occasionally having legal concerns. The three most common responses to concerns were: talking to colleagues (96/105; 91%); raising the issue in a group forum (68/105; 65%); and consulting a relevant guideline (64/105; 61%). Most respondents were highly (65/99; 66%) or moderately (33/99; 33%) satisfied with the ethical environment of the hospital. Twenty-two (22/98; 22%) were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) were moderately satisfied. Most (72/105; 69%) respondents indicated that additional support in dealing with ethical issues would be helpful.

Conclusion. Clinicians reported frequently experiencing ethical and legal uncertainty and concern. They usually managedthisbytalkingwithcolleagues.Althoughthisapproachwasconsideredadequate,andtheethicsoftheirhospitalwas reported to be satisfactory, most respondents indicated that additional assistance with ethical and legal concerns would be helpful. Clinical ethics support should be a priority of public hospitals in NSW and elsewhere in Australia.

Whatis knownaboutthe topic? Clinicians working in hospitalsin theUS, Canadaand UK have accessto ethics expertise to help them manage ethical issues that arise in patient care. How Australian clinicians currently manage the ethical issues they face has not been investigated. What does this paper add? This paper describes the types of ethical issues faced by Australian clinicians, how they manage these issues and whether they think ethics support would be helpful. What are the implications for practitioners? Clinicians frequently encounter ethically and legally difficult decisions and want additional ethics support. Helping clinicians to provide ethically sound patient care should be a priority of public hospitals in NSW and elsewhere in Australia.

Received 14 February 2014, accepted 22 September 2014, published online 17 December 2014

Journal compilation � AHHA 2015 www.publish.csiro.au/journals/ahr

CSIRO PUBLISHING

Australian Health Review, 2015, 39, 44–50 http://dx.doi.org/10.1071/AH14034

HEALTH POLICY

Introduction

Clinical ethics support (CES) is the emerging field of theory and practice concerned with enhancing the ethical quality or ‘ethicality’ of clinical practice within hospitals and other health- care institutions.1,2 ‘Ethical quality’ has several interrelated meanings. It can mean that clinical practices are consistent with social norms, such as patient autonomy; it can mean that ethical conflicts over patient care are minimised or appropriately resolved; it can mean that ‘moral distress’ among clinicians is adequately managed; and it can mean that a health organisation has an ethically reflective and engaged culture. With varying emphases between individual services, these elements of ethical quality are the main goals of CES.

CES is typically delivered by a multidisciplinary ethics com- mittee, an individual ethicist or some combination of the two. It aims to provide ‘expert’ ethical input into an organisation’s policies and staff education, and assist with ethically difficult decisions about patient care. CES was initially introduced to help resolve ethical dilemmas and conflict, but it has since evolved to a more ambitious preventative model of fostering an ‘ethical environment’, where the ethical aspects of patient care are routinely and openly considered throughout an institution.3–5

CES services are an established feature of healthcare in the US and Canada and are becoming so in the UK and elsewhere in Europe and Asia.6–18 The growth of such services internationally is often taken to indicate a growing perceived need among clinicians for assistance with the many ethical and legal issues they face.14–17 Although clinicians have always faced complex ethical decisions, the need for CES is driven by factors that have increased the ethical complexities of patient care, such as greater social andvalue plurality, technologicaladvancesand heightened patient autonomy.19–21 Clinicians have traditionally dealt with ethical issues by keeping their own counsel, turning to trusted colleagues or professional codes of ethics or seeking guidance from religious authorities.22 According to advocates of CES, it is no longer sufficient in a morally pluralistic world to rely on professional opinion and codes to ensure ethically sound patient care: ethical quality requires ethical expertise.23–26

CES services are currently available in some Australian hospitals, but they have not been widely adopted. According to the few available studies of such services in Australia, their operation has contributed to better patient outcomes, clinician satisfaction and improved ethics literacy across their host insti- tution. 27–29 Given that observational and experimental studies of CES conducted in the US have also shown positive results,30–35 it is possible that many Australian clinicians and their patients are missing out on valuable support. This can lead to conflict that is avoidable orunresolved,moraluncertainty and distressandalack of ethical scrutiny of clinical and administrative policies, pro- cesses and decisions.

Herein we report the results of a survey that was conducted as part of a project aimed at developing CES services within public hospitals in New South Wales (NSW), Australia. The project began with a qualitative study in one NSW public hospital, which found that most clinicians regarded their hospital ethical envi- ronment as ‘mostly right’, but that difficult ethical issues fre- quently arose and clinicians were receptive to the idea of CES.36

The aim of the survey was to build on these findings by asking

clinicians in the same hospital and an additional NSW hospital about the ethical issues they face, the ethical environment in which they work and whether they supported the idea of addi- tional ethics support.

Methods The survey

We conducted a cross-sectional survey of a convenience sample ofclinicalstaff(medical,nursingandmidwiferyandalliedhealth) in two departments in two large NSW public hospitals. All data were collected using a self-completed questionnaire. The ques- tionnaire included both closed questions with fixed response options and open-ended questions, and required, on average, 15–20 min to complete.

Respondents were asked how often they thought about the ethical and legal implications of their clinical work, whether they had experienced uncertainty or concern about such issues in specified situations during the previous 12 months, how often they experienced uncertainty or concern about certain aspects of patient care (e.g. aggressive treatment), their response to such concern and the frequency and focus of discussions related to ethical issues in their work.

Using a four-point Likert scale, we asked respondents to indicate how strongly they agreed or disagreed with two sets of statements. One focused on the ethical environment of their hospital, the other on their department. Participants’ responses toeach setofstatements were combinedto formaprimaryscale to indicate their degree of satisfaction with these ethical environ- ments. A total score across all items was calculated. Scores were divided into three equal strata: a score of 7–13 indicated low satisfaction; a score of 14–20 indicated moderate satisfaction; and a score of 21–28 indicated high satisfaction. To be deemed highly satisfied, an individual would have agreed or strongly agreed to most positively worded items. Each scale was evaluated using Cronbach’s a to determine whether it measured the same underlying latent variable (i.e. degree of satisfaction).

The questionnaire also included open-ended questions asking how clinical ethics could be improved at their hospital and within theirdepartment,and fixed-responsequestionsaboutexisting and preferred means of ethics support. Demographic information was also solicited, including age, gender and profession.

Survey administration

Respondents could complete the survey online or as a pen-and- paper questionnaire. The online survey was distributed via an email from the research team that contained a hyperlink to the questionnaire. The email assured anonymity, described the sur- vey and provided an estimate of the time it would take to complete. An email reminder was sent 2 weeks following the initial mail out. The pen-and-paper questionnaire was distributed topotentialrespondentsinpersonbytheclinicalsupportofficeror thenursingunitmanager.Clinicianswerealsoinvitedtocomplete the survey at a pre-arranged meeting.

Data analysis

Data were summarised using descriptive statistics. Proportions are shown as percentages rounded to the nearest whole number. Responses were further analysed on the basis of gender, age,

The need for clinical ethics support Australian Health Review 45

profession and hospital. Associations were tested using Pearson Chi-squared analysis and odds ratios (OR) with 95% confidence intervals (CI). In some analyses, age and profession were dichot- omised (21–40 years vs >40 years and medical vs non-medical, respectively). ORs are used to show significant associations, and we report only statistically significant associations (P � 0.05).

This study was approved by the Hunter New England Human Research Ethics Committee (10/12/15/4.12) and the NSW Hu- man Research Ethics Committee (HREC/10/HNE/373).

Results

From the two hospitals, 105 clinicians participated in the survey. The denominator is less than 105 for some items because: 1 – answering was conditional on the basis of preceding question (e.g. If Yes, then. . .?); and 2 – a small number of respondents did not provide data for some questions. Values are presented with denominator.

Respondent characteristics are listed in Table 1.

Response rate

We were unable to determine how many clinicians received or sighted the email invitation, or were made aware of the pen-and- paper survey, so were unable to calculate a response rate.

Do clinicians experience concern about ethical and legal issues?

Over half (58/103; 56%) the respondents reported that in the past 12 months they had often considered the ethical implications of their decisions, but a much smaller proportion reported having often been uncertain or concerned about ethics (Table 2). Com- bining ‘often’ and ‘occasionally’, over half (62/104; 60%) the respondents reported being concerned about what is ethically the ‘right thing to do’ and the majority (74/104; 71%) reported being concerned about the ethics of the decisions and actions of others.

Respondents were also asked about the legal implications of their decisions (Table 2). Less than half (44/104; 42%) reported often thinking about the legal implications of their decisions. Again, smaller numbers of respondents reported often being uncertain or concerned. Combining ‘often’ and ‘occasionally’, 46 (46/105; 44%) respondents reported that in the past 12 months theyhad been concerned about what is legallythe right thing todo and 57 (57/105; 54%) reported being concerned about whether what other clinicians were doing was legally right.

What situations are associated with ethical difficulties?

Respondents were given a list of situations and asked whether they had experienced ethical and/or legal uncertainty or concern relatedtoaparticularrelevantsituation.Experiencingbothethical and legal uncertainty was the most commonly reported category foreachsituation.Table3combinesthosereportingethicaland/or legal concern in relevant situations. Concern in two situations showed a significant difference according to age. Younger respondents (21–40 years) were more likely to report ethical and/or legal concern at a patient refusing recommended treatment than older respondents (86% vs 61%; OR 3.9, 95% CI 1.4–11.5). Younger respondents were less likely to report being concerned about carrying out an advance directive (8% vs 35%; OR 0.2, 95% CI 0.3–0.9).

Respondents were asked about the specific causes for their ethical concern or uncertainty. The most frequently indicated cause(s) for concern were: (1) whether the patient is receiving the treatment they really want (63/102; 62%); (2) the quality of the

Table 1. Respondent characteristics (n = 105) Note, seven respondents did not provide data for the first four characteristics; 13 did not provide data for the last. Unless indicated otherwise, data show the

number of respondents in each group

Age (years) Mean ± s.e.m. 43 ± 1 Range 21–70+

Years in profession Mean 16.5 ± 1.2 Range 1–40+

Gender Female 81 Male 17

Occupation Medical 32 Nursing 45 Allied health 21

Area of employment Oncology 30 Midwifery 23 Haematology 23 Obstetrics and gynaecology 10 MFM 2 Neonatology 1 Palliative care 1 Other 2

Table 2. Frequency of ethical uncertainty and concern Data show the number of respondents in each group, with percentages in parentheses

How often do you face a clinical situation where. . . Often Occasionally Rarely Never

Ethical . . .you will think about the ethical implications of your clinical decisions 58 (56%) 36 (33%) 9 (9%) 0 . . .you are uncertain or concerned about what is ethically the right thing to do 13 (12%) 49 (47%) 41 (39%) 1 (1%) . . .you are uncertain or concerned about the ethics of the decisions and actions of others 13 (12%) 61 (58%) 29 (28%) 1 (1%)

Legal . . .you will think about the legal implications of your clinical decisions 44 (42%) 34 (33%) 18 (17%) 8 (8%) . . .you are uncertain or concerned about what is legally the right thing to do? 12 (11%) 34 (32%) 47 (45%) 12 (11%) . . .you are uncertain or concerned whether what others are doing is legally right? 8 (8%) 49 (47%) 40 (38%) 8 (8%)

46 Australian Health Review E. Doran et al.

information the patient is being given, and how (62/103; 60%); (3) whether the treatment is too aggressive (59/102; 58%); (3) beingrestricted by resources in providing the care or treatment it was believed a patient needs (57/102; 56%); (4) patient pre- ferences and whether choice is being respected (52/102; 49%); (5) concern that the personal values of clinical staff may be inappropriately influencing patient care (27/100; 27%); and (6) concern regarding the appropriateness and quality of care generally (22/101; 22%). There were no significant differences according to gender, age, profession or hospital.

What are the most common ways of dealing with ethical difficulties?

Respondents were asked what they do when they are uncertain or concerned about the ethical implications of a clinical situation. Most (96/105; 91%) indicated they would ask for the opinions of colleagues; approximately two-thirds indicated they would raise the issue in a group forum (68/105; 65%) or consult a relevant guideline (64/105; 61%); 39 (39/105; 37%) indicated they would meet with the patient and/or family and allow them to decide; 29 (29/105; 28%) indicated they would consult with a clinical ethics committee or other source of ethics expertise; and 23 (23/105; 22%) indicated they would discuss the situation with their partner or close friend. There were no significant differences according to gender, age, profession or hospital.

What is the perceived adequacy of current ways of dealing with ethical difficulties?

Respondents were asked ‘How often is what you usually do not helpful in addressing your uncertainty or concern?’. Sixty-nine (69/105; 66%) respondents indicated that their actions were ‘never’ or ‘rarely’ helpful, 18 (18/105; 17%) indicated that their actions were ‘occasionally’ helpful and four (4/105; 4%) reported that their actions were ‘always’ helpful.

How do clinicians evaluate the ethical environment of their hospital?

Respondents were asked to agree or disagree with set of state- ments about their hospital. As indicated in Table 4, a large

majority of respondents agreed to strongly agreed with the positive statements and disagreed with the single negative state- ment (‘This hospital is too ready to accede to external political demands’). The statements were scaled and a summary score estimating the individual’s satisfaction with the ethics of their hospital was derived (see Methods). The scale was evaluated using Cronbach’s a (0.87). Sixty-five (65/99; 66%) respondents indicated they were highly satisfied with the ethical environment of the hospital, whereas 33 (33/99; 33%) indicated moderate satisfaction. Only one respondent indicated low satisfaction. There were no significant differences between medical and non-medical respondents or according to hospital.

How do clinicians evaluate the ethical environment of their department?

Respondents were asked to indicate their agreement with a set of statements about their department (Table 4). The ethical envi- ronment of the department was also explored by scaling the statements and by estimating individual respondent satisfaction. The scale was evaluated using Cronbach’s a (0.82). Twenty-two respondents (22/98; 22%) indicated they were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) indicated moderate satisfaction.Two respondents indicated low satisfaction. There were no significant differences between medical and non-medical respondents or according to hospital.

Do clinicians indicate a need for clinical ethical support?

Respondents were asked whether they believed that clinicians are usually comfortable handling the more common clinical situa- tions involving ethical issues. Most (71/105; 68%) answered ‘Yes’; nine (9%) answered ‘No’ and 17 (16%) answered ‘Don’t know’. When they were asked ‘Are there some ethically complex or challenging situations where more support might be helpful?’ most (72/105; 69%) responded ‘Yes’. These respondents were then asked to identify what they felt may be helpful.

What types of support are preferred?

Table 5 shows what types of support respondents indicated would be most helpful. The three most commonly preferred

Table 3. Proportion of respondents reporting uncertainty or concern in relevant situations Data show the number of respondents in each group, with percentages in parentheses

In the past 12 months did you experience uncertainty or concern related to the following situations?

Yes (ethically, legally or both)

Neither

A patient refusing recommended treatment 67 (73%) 25 (27%) Disagreement among staff about care or treatment 61 (70%) 26 (30%) A patient requesting treatment of borderline necessity or benefit 58 (69%) 26 (31%) Ordering and/or participating in aggressive treatment of a terminally ill patient 40 (62%) 24 (38%) A patient requesting treatment outside hospital guidelines 49 (60%) 33 (40%) The handling of a medical error or incident 53 (58%) 39 (42%) Making the decision to withdraw or withhold treatment 25 (43%) 33 (57%) A request for late termination of pregnancy 18 (43%) 24 (57%) A patient request to withhold information from his/her family 36 (42%) 49 (58%) A family request to withhold information from a patient 30 (37%) 51 (63%) Staff withholding information from a patient and/or family 19 (24%) 60 (76%) Carrying out an Advanced Directive 12 (21%) 44 (79%) Carrying out a Do Not Resuscitate order 11 (20%) 43 (80%)

The need for clinical ethics support Australian Health Review 47

types of support were protocols and guidelines (44/72; 61%), having ethics or legal issues covered in routine clinical meetings (42/72; 58%) and having an ethics or legal expert available for advice (39/72; 54%).

Discussion

Most of the clinicians surveyed for this study were sometimes to often troubled by the ethical and legal implications of their own clinicaldecisionsandthoseoftheircolleagues.Respondentswere most concerned about situations that are known to be ethically and legally sensitive, such as end-of-life care, medical errors and patient privacy.37–42 Patient autonomy appeared to be the most common source of concern. The five situations that were most commonly reported to be troubling were (in rank order) a patient refusing recommended treatment, disagreement among staff, a patient requesting a treatment of uncertain value, aggressive treatment of a terminally ill patient and a patient requesting treatment outside hospital guidelines. The first, third and last of these situations are related to managing patient preferences and

choice.Patientautonomywasalsoprominentinwhatrespondents indicated were the specific causes of their uncertainty and con- cern: whether the care a patient is receiving is really what the patient wants, concern about the information a patient is being given and concern about patient preferences being respected and staff inappropriately influencing care.

The majority of respondents appeared to be satisfied with the ethical environment of their hospital and their department. At the hospital level, most respondents indicated being highly satisfied that policies and procedures were ethically appropriate; patients’ interests generally have priority and the values upheld at the hospital mostly reflected their own personal and professional values. Although fewer clinicians indicated being as highly satisfied with their department as they were with the hospital, most still indicated a general satisfaction with the ethics of their department and that ethical issues are attended to appropriately, openly and inclusively.

Most respondents indicated that they were generally comfort- able dealing with the ethical issues they face and, similar to the findingsofotherstudies,6,42 whentheyareuncertainorconcerned

Table 4. Respondents’ degree of satisfaction with the ethical environment of their hospital and department Data show the number of respondents in each group, with percentages in parentheses

Statement Strongly agree Agree Disagree Strongly disagree

Hospital The policies and procedures of this hospital are generally ethically appropriate 19 (19%) 76 (76%) 5 (5%) – The interests of this hospital are rarely put before the interests of the patient 14 (14%) 55 (56%) 27 (28%) 2 (2%) Patients at this hospital are generally treated equally 23 (23%) 67 (68%) 8 (8%) 1 (1%) The values upheld at this hospital mostly reflect my professional values 14 (14%) 79 (80%) 5 (5%) 1 (1%) The values upheld at this hospital mostly reflect my personal values 12 (12%) 78 (79%) 8 (8%) 1 (1%) My conscience is rarely troubled by the care patients receive at this hospital 9 (9%) 79 (80%) 10 (10%) 1 (1%) The values upheld at this hospital mostly reflect values of the community 10 (10%) 71 (73%) 16 (16%) – This hospital is too ready to accede to external political demands 4 (4%) 43 (47%) 42 (46%) 3 (5%)

Department When an ethical issue arises it will be openly discussed 24 (24%) 67 (68%) 7 (7%) – If I am concerned that a patient’s best interest isn’t being met I am able to air my view 23 (23%) 68 (69%) 6 (6%) 1 (1%) Ethical issues are usually handled appropriately 18 (18%) 77 (79%) 3 (3%) Ethical issues are often overlooked 1 (1%) 14 (14%) 73 (75%) 9 (9%) We talk about ethics as much as is necessary 8 (8%) 72 (74%) 17 (18%) – We could handle ethics issues better than we currently do 2 (2%) 47 (49%) 47 (49%) – If an ethical issues arises all staff are able to voice their view 9 (9%) 67 (70%) 19 (20%) 1 (1%) There should be more discussion of the ethical aspects of our clinical practices 11 (12%) 54 (57%) 29 (31%) 1 (1%)

Table 5. Types of support respondents believed would be most helpful Data show the number of respondents in each group, with percentages in parentheses

Types of support believed to be helpful with ethically complex or challenging situations n = 72

Having protocols/guidelines in place that outline appropriate responses to ethical/legal issues 44 (61%) Having ethical/legal issues as a routine element of grand rounds or morbidity and mortality meetings 42 (58%) Having an individual ethics and/or legal expert available for advice 41 (57%) More ‘in-service’ training or education on the ethics and law of patient care 39 (54%) Having regular educational seminars on ethics and law 37 (51%) Having a member(s) of the clinical team trained in ethics who can provide ethical advice when needed 37 (51%) Having an advisory group (made of clinicians, lawyers, ethicists, patient representative) 34 (47%) Having an internet based resource (storing relevant literature, case studies, policies etc.) 33 (46%)

48 Australian Health Review E. Doran et al.

they are most likely to talk to their colleagues. Raising an issue of concern at a group forum was also commonly reported, as was consulting a relevant guideline. Although these actions were generally considered helpful, over two-thirds of respondents indicated that additional clinical ethics or legal support would behelpful.Protocolsandguidelines,havingclinicalethicsfeature in routine clinical meetings, continuing education and training and having an individual clinical ethics or legal expert available for advice appeared to be most preferred options for further support. A clinical ethics committee was among the least pre- ferred options.

Although talking to colleagues or consulting a relevant guide- line or policy can help address ethical uncertainty or concern, it does indicate that clinicians are largely relying on traditional approaches to dealing with ethical issues. As discussed in the Introduction, these approaches are increasingly considered inad- equateforensuringethicalqualityinthecontextofamoresocially and morally diverse contemporary society. Given that the social factors that make clinical work more ethically and legally com- plex are evident in Australia, the scarcity of CES means most Australian clinicians are currently left to navigate their way through complex ethical issues with little specialised support.

Ethical tensions and difficulties that may arise anywhere in a hospital (from the bedside to the boardroom) are not always recognised and acted on as such and, even where recognised, may be considered too hard and avoided. Left unrecognised or over- looked, ethical issues can block communication, create uncer- tainty or distress about treatment goals and ultimately undermine qualitycare.Aclinicalethicssupportserviceprovidingassistance with policy development, staff education and difficult cases can foster an ethically aware environment where issues are addressed and uncertainty and distress minimised.

Clinician satisfaction with the ethical environment does not indicate that ethical quality is consistently achieved. As one prominent clinical ethicist has observed: ‘Doctors and other healthcare professionals are seldom widely educated in ethics, and no matter the length of their experience, they are by no means guaranteed to have ‘ethical perspicacity’.’43 The majority of the clinicians we surveyed appeared to recognise this by indicating that additional support would be helpful in working through ethical and legal concerns that face themin their day-to-day work.

Limitations

Responses to this survey were drawn from a non-random sample in which female respondents were clearly over-represented. The findings are also susceptible to social desirability bias (i.e. respondents may have tended to provide what they saw as the most socially appropriate response, instead of what they truly believe). These considerations reduce the generalisability of the findings.

Conclusion

The results of our survey support our qualitative findings reported elsewhere,36 namely that most clinicians see the ethical environ- ment of their hospital and department as ‘mostly right’, that troubling ethical and legal issues frequently arise and that, although these are considered to be generally adequately man- aged, further support in dealing with these issues would be

welcome. CES can take the form of an individual clinical ethicist, a multidisciplinary clinical ethics committee or a hybrid of the two.Whichtypeofsupportisthemostsuitableandwhatfunctions (e.g. case consultation) should be undertaken are questions that require further investigation. Helping clinicians to provide eth- ically sound patient care should be a priority of public hospitals in NSW and elsewhere in Australia.

Competing interests

The authors declare no competing interests.

Acknowledgements

This study was funded by the NSW Ministry of Health. The authors acknow- ledge the support of the Clinical Ethics Capacity Building Project Reference Group:MrTerryClout,DrJoMitchell,DrPeterSaul,MsSarahThackwayand Professor William Walters.

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