Jennifer's here said to me, How did you get into this? I said, Well, I fell into that.
I had information I had never had. Of course, in bioweapons they didn't exist.
Can have it. And how did I get into the issue of nutrition fluid?
Jenny asked, and I said, Well, that was in the great American style. There was a court case and I.
Testifying that this morning afternoon did grand rounds of Radcliff and the physician who was introducing the question
had to do with removing artificial of nutritional fluid from a patient who wanted to starve himself to death.
And she said, We have never seen a case like this.
So I said, Well, I have bad news for you in discussing this issue since the 16th century, and we have a long history of it.
And there are, as you can imagine, long, long cases in the United States on this.
It began there and it hasn't ended. It did go on.
Pretty much that issue has been resolved legally, at least the United States.
The question is, how did this all happen?
Well, Americans, Alexis de Tocqueville writing in the 1930 1830s and democracy America came to the United States and observed it instead.
These Americans had a really strange way of behaving. He wasn't the first to observe that.
No, the last. But he said what they do is they make all of life's moral dilemmas transform into legal problems and run the courts.
They tell us what we should think, and the judges are not terribly desires, he says.
I tell you, when you talk to judges, the last thing in the world to get a medical case.
In fact, in one of the famous case we had in Boston, Brophy case about nutrition of fluid.
The judge in the probate court was so reluctant to hear it that after six weeks, he still hadn't responded by disappearing.
And I told the attorney to go to the appeals court and inform them,
and the appellate judge said, Why are you here three months after this emergency order?
Because I feel as though the judge in the appeals court picked up the phone call.
The trial judge said he was scheduled for Monday morning.
What do you think the trial judge is going to do?
He didn't want to hear it so much. The easiest way not to hear it. He went on vacation.
He was subsequently removed from the bench by the Supreme Court on the grounds that he absolutely refused to hear cases involving controversy.
It's sort of like being a firefighter. I'm not going to have smoke coming out of it.
This is not a fire. But that's what we have.
The first of these cases occurred in Calif, in the United States.
And part of it is in Pellegrino wrote a wonderful little article years ago in JAMA, said,
You can divide all of medical history into three parts from the apocalypse to 1960, from 1960 to 1990.
Whatever happened from 1990 on, from 1990 until just chaos prior.
But the first part, he said, from the properties to about 1960 was really kind of not 1950.
Nothing much changed. And there was very little that the physician could do.
And so they used very little. Everything you could do was that little black bag that marked off the position and you couldn't do much.
And most people died of overwhelming sepsis. Life expectancy, about 40 years old or so.
And this whole question about the use of artificial cushion fluid and making people's lives just like never occurred.
Why not? Because you couldn't. We didn't have any way to feed them.
In fact, if you used a simple IV, how long can that be useful?
As this thing to sustain was still fresh and hours, days, hours, not very long.
And then they had the simple little flexible, relatively cut down the nose of the patient.
Isaac Hale But we didn't really have permanent nutrition until your lifetime and
when it originally came and could only be done by surgeons in the hospital.
So we had one set of viewers masters who could do it, but it wasn't a common procedure.
And without those lipids and fats, you couldn't really sustain the individual for very long pretty for us.
So we knew we had patients, this technology. And Pellegrino rightly said the technology came in and it changed everything.
And now that we have this technology, the question is granted, it can be done, should it be done?
And the technology is such that the battery, which I suppose is second from those can concerned for life.
It should be a so-called declaration of euthanasia in 1980.
And Part four says we have to protect patients now from the potential abuse that occurs from this technology.
We have this technology and part of this great technology we can stave off.
That's what we can't restrain the function of the degraded existence. And then comes the question over here.
And the question is, do you want it?
Would you want it? And the big question, of course, was the current equivalent case.
And what happens if you were in persistent vegetative state?
Just imagine what that means. Yes. Yes. Can see she so that you are unconscious.
And if in permanent vegetative state you'll ever see regain awareness of yourself or your environment.
Yeah. And it takes three months if it's. To make that assessment.
Well in the UK in six months and six for the investigation.
Well I suppose you pay for the parts of the media.
So yes, if it's a well diagnosed. And then comes the question, how long can you maintain the individual in this form?
Well, the old record was 37 years, 111 days. It's now being surpassed by somebody in Florida.
And comes a question if, in fact, you were to suffer. And most of these have been.
Kevin in Cleveland was 20 years old. So they're not necessarily ancient, although most people slip into peace out of Alzheimer's.
If you could be in a well diagnosed persistent vegetative state and we know it could maintain you, and what do you feel?
If I was if I was in TV, I hope I feel now. But if it was PBS, I hope I feel nothing.
And now I feel about this place. That's what they don't. Rather just tell us if you can believe them.
Uh, but they say there's no. There's no sensation. You have no experience of anything.
It's been unconscious. And now the difference of PBS person unconsciousness in a coma.
It used to be called terminal coma as the old phrase.
And the term persistent vegetative state was devised by Fred Clement, NYU, in 1972.
And it's a pejorative sort of term. People don't like pickled vegetables, but he said they have no conscious activity.
That's what he was describing. Uh, and apparently they have no sensation.
They're not responsive to pain. And you can make hay this way for 30 seconds, but there's no suffering.
This is important because one witness said, well, you could stop if the patient is in pain of such terror because it would be inhumane to continue.
Well, if you're not afraid of any, you this great game continue living and there's no pain.
So when you want it made, you said.
I think a sanction might have dignity to my family, the NHS.
Look at all these people. How many of them would want to maintain this way and we could do it?
We have one. I should say them. You say 37 years.
But that's not the median. It's not the media. It's the. I said it was the longest recorded to date.
Yes. Yes. I just got an accurate amount of the same saying.
So when you say 5000 people. You don't say this off the front of us and say, oh, yes, definitely.
His name was Roger Bannister. Yeah. So but and so we don't ask how far you can rule on that because that's a matter of opinion difference.
Well, but he doesn't say it isn't to me, but the world doesn't care what's important to you.
No, but if we if we're talking about. Well, anyhow, what if you want to give a lecture, there's a lecture schedule, you can sign up, put it up.
But how many of you would want to be maintained in this when the average life expectancy is about a year?
But you could go for three years and we have no way of knowing when we start.
How long you like to watch? You also do that for medical technology.
We stand for seven years. No, we don't. But we make bad decisions when.
But seven years from now. No, we make the decision in the in the now.
Let's do that now. I live with this. And there's been.
If those directors and they can say, oh, what a foolish bet that was about the fact that I can take you.
Surely we have to make the decision before we go in this state.
We have to work out those decisions. Yes. Or or at least have articulated some views on that becomes a problem?
Well, not necessarily. Then we've got nice ways judges can find ways to do it going it old British law for it I about those
maybe but you can be kept this way and the question is should you would you want it to be done?
Now the first of these cases that actually came up was quite dramatic and occurred in California as a legal case.
Now, there were no legal cases before that because, in fact, you couldn't sustain these.
We didn't have the technology to do it. So what's the question now behind the technology?
The question was great. We had ordered to be used.
And then comes the question, whose position is it? And that's always to be quite the two big questions of career and bioethics.
One, whose decision is it and on what standard is that decision going to be made?
Well, the first of these cases occurred in California.
As many as two of her clients were. And he went to the hospital for a simple ileostomy closure.
It was uneventful. So 20 minutes.
And before he went in, he said to his family, his wife and his seven adult children, if anything goes wrong, I don't want to be another Karen.
And clearly, she proceeded the longest way.
And she's she's maintained with the feeding tube for almost a year.
When finally decision was made not by Alex, when she had a motive and she died.
He had the surgery. It was successful.
And when he was in the recovery room, the nurse moving somebody even from the ICU to another room and he suffers in unwitnessed cardiac arrest.
And the data for successful resuscitation with unwitnessed cardiac arrest in elderly patients is dismal.
And the doctors said, we've got his heart beating again, but he's unconscious and we don't anticipate that he ever will be conscious again.
Probably a little quick for that assessment, but that's what they said.
The wife of the seven children said he told us beforehand he wouldn't like being kept this way.
So sure, off the ventilator, in the hallway that was shot.
But guess what? They didn't do a CO2 test.
And he Reynoso now was decisive, but he said he didn't want to be somebody who is currently unconscious.
They maintain the captain, but with the Navy feeling, too.
And. One of the songs said to nurses police is the question is why stop everything?
She said, Oh, you've got to talk with Dr. Natal, the chief of surgery.
So Dr. Natal said that's acceptable and signed an order to remove the feet.
He had written signed the order for the removal of the ventilator. And here's where the problem came.
You moving to education? And you usually order a missing machine when move.
She puts a little vaporous vapour. To prevent a mucus plug from blocking.
Yeah. What's that?
They just switched machines. They just switched machine up. Great.
Somebody has got to stop reading. Huge device usually works, but when it doesn't.
Well, the upshot of it was that the nursing supervisor came the next morning and sees a young resident and.
Says, Where's the listening machine at standard nursing practice of standard protocol.
Now, you've been a resident, you could call registrars, etc.
And as the head nurse who was the supervisor on duty for the weekend, says to you, Young Dr. Wilkinson, why have you not used the standard protocol?
What would you tend to do? Do what they say. You do what they say.
And guess who comes in 20 minutes later? The chief of surgery, who says?
Dr. Wilkinson, have you pronounced Mr. Herman dead yet? And you say, No, no.
In fact, I put the mystery machine, this machine up.
Tell me what happens in British Hospital when the chief of surgery finds that the resident has done just the opposite?
What he told me. Yeah.
And the first thing you must file. Who is this? Who gave this order?
So there was a fight between the nurse. And so she decides she's going to get him.
And after they remove the feeding tube. He survived for seven days and his families in attendance.
And the nurse goes to this journey and she raises two questions.
One is in food and water and ordinary means. And two is every patient came to ordinary care.
And your answer would be. No patient is all right.
No, no patient is order. Well, they're just talking about the treatment itself.
I'm an administrator of ordinary extraordinary care.
What do those words mean in the idea? Because a terribly misused, confused and abused.
And in fact, we've argued in the president's commission that they should simply no longer be used and no longer useful in public discourse.
And they came out of 16th century moral theology.
And the question was this where we went into Dr. Wilkinson this morning, what are you obliged to do to keep.
Your right. Do you have any obligations to sustain your life?
Not if you have. Well, that's the modern secular back of the 16th century.
Go back to go back to 16th century medieval Oxford.
You owe it to God. It was theologically. It was to God.
And if you failed, in your view, to God, what was the theological understanding of what the consequences were till you went ahead?
Now, if, in fact, I told you that if you didn't utilise certain resources, certain procedures to sustain your life, you'd go to [INAUDIBLE].
The first question. Mm hmm.
What was the question?
If you understood that your failure to utilise those procedures to sustain your life that you required, what would be your first question?
What excuses? Yeah, yeah, yeah, yeah.
And so the theologians are on to well, what, what? Excuse me, what do you think would excuse.
Well, I mean, I think that it's sort of it's futile. Well, I suppose as your mother was writing this for me, never used that f word.
It doesn't solve it. Yes. It's just that this is sort of in the guise of the right direction.
I think it does. The first is, and I'll use this example of use this morning, supposing, in fact,
you had a rare disease that could be cured if you went into outer space.
Mm hmm. A is a physically possible thing to do that to go into outer space.
Mm. Yes, it is.
Yes. So you just have to know.
Right. Okay. Yeah. You have to go to the moon.
Yeah. Now, is there a way for you to get there other than being an astronaut?
No. Oh, yes, there is. Hey, hey, hey, hey.
Rush. Food will be required for us to meet in the Oval Office.
And you? A trip to the other space. And the place is.
$1,000,000. $5.5 million.
Are you going? I have the money. What's that?
If I had the money, I can do you over. That's the question. Do you have the ability to do this?
Well, yes. Yes, I think it's the right.
I have $5 million now. So you are not obliged to invite you can't be obliged to do your show?
Yes. And what else would make?
For example, now you didn't live through the American Civil War,
but you've seen the movies and it was great slaughter battlefields and the people gave their lives.
Shattered Ryan. Cannonball. What's the medical remedy for that?
You're not a philosophy student.
Well, I don't know if. Did I decapitated ex or something?
Well, they don't call it the Catholic League. With every takeaway he'd like that stricken from the right now.
Here comes the great question. What would you call surgeons in the UK?
Never met one. Well, I had other insurgents.
Who? What's their title?
Consultant Now Mr. Jackson, Dr. Wilkinson and Mr. Brown.
Mr. Brown is a surgeon and skill columnist.
Now, why did you go missing? Because you know for sure.
Yeah. Evidence for a decapitation attack.
Why aren't they followed in packages of great expectations?
Number one hypocrisy is talking about what's what's the role of the physician has to be lower position was threefold
to mediate such reverse disease processes where possible and not conformance to medical treatment on the Dalai Lama.
Because they're dying. Yeah, because a little man come back.
Because they. If they die, they're going to die.
And what happens if you treat them and they die? But it was actually Xavier.
Xavier. What are we going to say about Xavier? I think trade me.
No, you treat them. Then they all got off. I mean, that is just always.
Yeah. Resources all the way. So what about you?
I mean, this stupid.
You don't know what you're doing and what happens to your business. I go.
You go, bro. So he's. He's very careful. You tell him don't jeopardise your profession by doing things that don't work.
Now. And that's why physicians never went into surgery, because it wasn't going to be successful.
They weren't going to be able to now get the surgery.
To people with knowledge source. Yeah, I do.
Oh, you do? Do I? The butcher.
The butcher's who cuts the leg off for when and chops the butcher doesn't get the sword or have a bath when they used to have the barber of.
Sweetheart. That's ridiculous. So they were the that.
Now. They're going to amputate that legs.
What are they used for? An anaesthetic. I don't know anything.
It didn't have if it had not been devised. In fact, you know, in the Ethiopian mass hospital these days are still there.
They even happened not so long ago. So what happens when the budget comes along?
We just saw the impact this on. What are you going to do as the patient?
Yeah, I'll probably want to do it.
You go to die for them. You're going to die doing it. But if you don't do it, you're going to die with blood.
Lots of pain. Lots of pain. And the way to stop you from screaming and making the bother, which is very unhappy, is to actually bite the bullet.
You know what that means? Well, I know what it means, figuratively.
But what does it mean for you? You got to face up to it instead of.
I could take them and they're not going to use a modern bullet made up brass because the purpose in fighting it was put in and squeezed out of.
The purpose of it was bigger from screaming, which is what you can do is not.
And if we let you scream at your own fault, then it would bother you.
But you wouldn't achieve this. But you can scream as loudly now, you know, I, you know,
I would say bite the bullet to keep you from screaming in the ear of the person is trying to amputate your leg in maintenance or pain.
So were you required because it was so painful? No. Awesome, which was very burdensome.
If they told you to move to another country. Nobody.
My old age or something or. Even if it wasn't very painful, it wasn't right costume.
It wasn't very realistic if it didn't offer a substantial benefit to you as a person.
Why would you do? And that's where it all started, back with the apocalypse.
And then by the 16th century, living in the U.S. and said the same principles apply and they said we don't have to do what would excuse you from it.
It's too costly for one's customers or too burdensome or too painful or didn't offer substantial expectation of benefit to.
Then we come over to Jenny and she's now her PVS condition and she says this would happen
despite the fact you're going to find this hospital in the nation and we know where that is.
No, I think. Oh, I imagine you would.
Oh, so I come from Cardiff. I'm trained to say.
Oh, they. Right here we are. And.
But things could go wrong. And so you would say, if they all go wrong, I don't want this.
And now comes the question. Is it determined to withhold the feeding tube that we have here and we can place a smile without a great deal of pain?
We have anaesthesia. We don't have to give you a bullet to give you some anaesthesia.
We can easily insert this into your abdomen and or give you a side of the abdomen.
Because if you get pregnant, do all that and.
Now, the big question today at Netflix is here's a man who's 54 years old who said, I want to die and I want to die by not eating and I want pain.
Relief from pain. And the doctor said one question, can you with an advanced directive?
You can't. What would we have a duty to follow to say, I don't want food and water.
Or as we have now, artificial attrition fluids. And we know we know perfectly well how long you can live without food and water.
We learned all this from the Nazi experiments. How long can you go without food?
He's a part of the British spirit, which leads weeks and weeks, 54 days.
You live off the fact that the land is for. But how long without fluids?
Two or three weeks. Yeah, 77 days, you know, like 5 to 7 days.
So the question, when the Germans are putting supplies in the lifeboats, would you put food in their.
Not if you didn't think people would be collected and picked up in that time.
They were just. If we don't get it within 50 days, what can we do?
What can we do, sir? They could eat fish, but the meat that's been known to have used with aeroplanes crashing and stuff like that.
But you can look at this law and with Mr. Herbert, the question came.
He now has a feeding tube inserted and the family has to move.
And it is then the nurse who was appalled is when the district attorney said, this is murder.
What do you think? Murder. Where? The medical. Oh, she's now using the famous mother.
This is a random trip. And you were a baker with.
This is a well-known trick in medical schools can only help those who told us so, which is all we can do about it.
We be get. But that's the thing with telemedicine,
where you get to see who's coming around this big fight and it will make you and I told Resurfaces
there was an article in the Journal of the American Medical Association called The Fine Art of Poop.
Pooping is a technical term in medicine, meaning when you use that term,
you know, it means to to offer one's services, maybe for the prospect of money.
Well, that's somebody else's. That's another word we pay.
Yeah. Yeah. But for somebody else's services to be in medicine was when the consultant came along.
And you ask questions of the residents to see whether they know anything about this, you know?
And so you put them on the spot by asking these questions. And there were really clear rules about it.
You never, ever questioned the chief resident. You don't embarrass him in front of his.
Okay. And then came the question, how do you avoid getting caught?
And was.
But when the nurse went to the district attorney, the question is including a lot of ordinary means and is everybody kind of the ordinary kid?
The district said, yes, they are. Yet nobody is talking about an election first degree murder.
You had great theories. What do you think? The reason? The district. But what we saw was a double murder of the patient wife.
Well, private detention or. Well, that's how it is.
Why did you the most powerful. Menswear.
Well. They did that because in the absence of.
It costs money. They realised they had a shoot out and he's out of the system by mistake.
He could be here. How long? Ten years.
Ten years? Four years? Three years. And who's going to pay for all that?
The hospital. So bury the evidence.
Get rid of stuff. And the lawyers, and they had 11 lawyers on the case.
We knew they murdered them. We knew they killed them. We knew we'd get them off.
Fellows, we didn't have going to do it. How you feel?
Strongly. How do you defend what the doctors did? Killing the patient to save money?
Well, not to the doctors. But it was up to him and what he told his family.
Didn't like it now. You can. Do you have that in writing?
In practice in a court of law will recognise adequate pianists might take over the course of recognised.
I've seen books that have I've seen cool to have like notes to say oh it would have been so much nicer if they put it in writing.
But blame the patient. Yep. Blame the family.
Yep. How are we going to mount a defence as to what the doctor did?
How about the patient's wishes? Well, supposing the patient said to you, I want to go out in a burst of glory.
I don't want to go quietly slip into that. Good night.
I want to have you put your in test tests.
I want to have a test come with a magnitude 57 and blow my brains out against this white wall and let that let me down.
But this patient wasn't asking you to do something. He was asking you not to do something.
Not to use intrusive medicine on him to prolong your dying.
And then comes the big fight is food and water medicine.
If it's shoved into a tube in the stomach. Yes.
And certainly they're not having the usual sensory inputs and the pleasure that you're still burping and bringing up acid.
You may say it's painless to put it in. I've seen the pain it causes patients who have to put up with it who just can't.
So the argument was made. Did the first question, did Mr. Herbert have a moral obligation to undergo this intervention?
There's two separate questions because does the patient have an obligation to receive data but also to the docs?
I have an obligation to write those. But first, the first one is the patient.
And does the patient have an obligation to accept any medical treatment that you propose?
Only theological, non theological, non theological sin as God.
So how many of you wrote a wonderful book? Whatever happened to simplicity?
To live in this secular, pluralistic society of England?
This fellow sin is not a coming from it, but that sin is come from in terms of his.
But yeah. Thank you, Jesus. Yeah. So.
If you or Tom, if he has a what's one? Oh, he has a freedom to choose the freedom to determine the course of one's own life.
You have to have capacity for that. Well, by definition, these patients do have capacity.
Oh, you don't have to have capacity. Let's look forward to the big question that comes most of these patients.
What percent of you have a written advanced directive?
Two, three. Poor, poor. Appalling is right.
But England is different from America. I mean, you told me that they better have it in writing or they have no protection.
The audio relatives is they can represent your wishes and the cheapest the the medical practitioners listen.
But in the end, they end up making a medical decision because that is easy of the answer.
The only one message we call upon to make, well, they get nervous.
They ought to be charged with murder, do they? And they read about this case in California.
And there are just as many. Well, prosecutors in the UK is around United States.
So everyone goes with the least restrictive option, which by prolonging the dying process.
Sure, it's easier. It's easy to say expensive.
But it was protecting the world. But. It's not much more expensive.
The lawyers have about perhaps a third of the costs.
Some of them are always very costly to go to take these cases because these cases overall case of first impressions,
the lawyer says, I don't know, it's going to happen. A lot of research here.
What do you think a lawyer would tell you if you had a relative who's now in a persistent vegetative state in a feeding tube?
You like food, you say this would cost about one point.
In the US. I have no income in the UK.
In the UK it's the responsibility of the clinical commissioning group to take that bill and then have clear guidelines.
You're not meant to pay. It cost the health board in the fin whales a big reckoning with a lot of money,
a lot of but less actually than sustaining that person so that she's got saving, which is a bit of a problem.
The patient, though, came to one. What's his obligation to undergo this medical intervention?
But he had specifically said, if you want to know the answer, if he doesn't have one,
if he has some obligation to undergo what claimed as a physician had to impose it.
What do you need in order to touch a patient consent?
Consent. This is old, old, old English.
There goes back to 1767.
It is Slater versus Bateman Stapleton. And in this case it's a marvellous case.
Mr. Baker was a surgeon and Mr. Slater broke his leg and came and the treatment for a broken leg was compression and the small.
But Mr. Baker had a great idea that he had a better way of doing it called extension.
So he invented this little machine that he thought. But in order to test out his machine, what did he need?
Some weight victims with a broken leg. Now, if you sit around waiting at Rancho Hospital for a broken leg to come in, you might.
I'm sure you know what I mean. I mean, you know.
So it wasn't the best way of getting a broken leg. When you made the leg broken.
So they take me. I love this thing to bring an old age and they put the carry and the surgeon take the patient's knee and they give it a crack.
And I always use one of my students say, what would you say?
They say, We know what you would say, but don't use those words.
I told you. In fact, the patient reportedly says, Why now?
What nature have you come to? The British have a five way of speaking.
So he's been right and then he sues.
And the defence was he was at St Bartholomew's Hospital still there.
He was the first surgeon at St Bartholomew's. He had a great reputation.
He gave lectures all over the country, published lots of articles and how grateful to accuse him of not knowing what he was doing.
The court looked and said, we know what he was doing. What was he doing?
Patient wasn't treating the patient. Treating a patient.
He was testing an experimental procedure. But what do you need for that consent?
Now, interestingly, the word that you usually use when you talk about consent usually put an adjective in front of it, which is informed.
But the British didn't do that. They got consent.
You're a physician? Yeah. Yeah. It's kind of like, well, if you got negative, it's true or not.
Well, we just have a handful extreme cases, and now they put a little injection in and they come to do an anaesthetic because of the injection.
So what do you think will happen if you come along with this nice, big, bold needle and you stop with a little prick?
So what might the patient want to do? Something. No country, you know.
Full of impact. So you tell them what you're going to do so that he can not pull away, not far away, and you might have somebody else hold a hand out.
But you tell him and you say, look, this is going to hurt. So but the whole concern is to have the patient cooperate.
It's not to say that was the old English way.
Remember, it's like what he says. But what do you tell the patient?
The property says, tell the patient nothing on his or her present or future conditions.
Why not? They might mistake or attempts to think no one might get it home.
No problem. Without trauma, psychological trauma, they might say, oh, my God, I'm right.
I'm not I'm safe here. I won't be amputated, you know, decapitated or whatever, you know.
And he doesn't get the good thing that so you don't tell him lest he get all this so-called therapeutic exception later and runs away.
I'm not going to do it. So the company says you've come to the doctor.
And here's a different question. Why do you go to a doctor?
Now, Jenny, you don't take every problem that you have to the doctor.
You know, know if you ever get a little if you do you lots of people.
Are you paper burn? Yes. Yeah, yeah, yeah.
What do you do when you get a bit. I say actually ignore it, you know.
So you just bleed out usually in some fights.
So yeah, I could have put a Band-Aid on.
I can see that's probably the right answer. What the kids do, they suck.
They suck. What do you catch it? They like it. They really know what to do.
Cats and kids know that, you know, there's something in saliva that is magical for healing.
It is the best anticoagulant in your head is about.
And I'm just new to me. That's why we have some of our I now.
If you broke your leg, would you live it? No. No.
Would you actually go to San Diego? I absolutely would.
Why do you go with a broken leg now? We have a friend, a dummy.
Do we not? Yes. Yeah. And his speciality is paediatrics.
Media, neonatology. Yeah. Do you want a neonatologist to look at your broken?
No. Although if he was the only person in the room, I certainly use the same person room.
You use the internet. You're just trying to make a point.
Yeah. You say you go to him now. Why would you go to an orthopaedic surgeon?
I think they have the skills to help me make a pain anyway and restore me to function.
And you trust that when you meet up with him or her that the name is not chipped?
I probably do a little bit of Googling and a little bit of research, and I probably take a family member with me and I'm a bit suspicious.
So but yes, basically you go to the Ahab if you want to be viable.
Yep. I usually did it with my do.
And. Then comes the question, what can you.
If there's anything I want to say, I have no capacity.
That's so. You have to assume capacity in the UK until proven otherwise.
And so you've just got to assume I have to make my own decisions to refuse to refuse.
Let me give you a case that we recently had at Mass General Hospital.
You know, that is actually reckless of the United States. Yeah.
And the woman comes in, a 29 year old woman.
She's got a long history of asthma and she has as an attack.
She called her sister and the sister calls the mass general and purportedly says, we have no record in this.
We have my sister doesn't want the ventilator and can you possibly have a ventilator if you come and purportedly live here?
So she comes and she meets with the resident technical consultant who's 7:00 in the morning.
And you come to air in handy, Amy, because the E.R., let's say we watch the programs.
We know she's in communications and the consultant says you have a very severe asthmatic attack and we need to put you in middle age.
I don't want it. And she then runs to the doors.
There it is.
She needs a ventilator. Maybe you can bear asthmatic attack.
So how do you insert a ventilator in the patient?
And most of the way. She didn't look that sedately.
Well, easier. Cheaper.
You can't. Do you think she can refuse treatment?
She's refused it. And so he tackles.
Well, he's been well sorted out in a straitjacket.
And then put the feeding tube in. And 45 minutes later, she's fine and she leaves.
Well, you say thank you. Probably no good.
And it gets really complicated because to desperation is another attack.
And. If you just go to a hostile community, trust me, or we can go to the other pieces you trust,
you can pick things you believe that he or she knows something about, and you trust that they're going to act in your behalf.
We hope that as you recognise it, that.
Well, supposing, in fact, Jenny, you're so sophisticated and you said you have this broken leg and you say to the of the surgeon,
I would really like to be doctor. You know, that is, you know, distinctive.
That's quite funny. They told. What do you what did you say to him?
Face what you did with when you go in like this.
Oh. What do you want ancient pigeon to.
Yeah. And you say to the orthopaedic surgeon, I would like you to rotate my femur 14 degrees to the right.
I can't make them do anything they don't think is right.
I can refuse subjects like to me, but I can ask them to do something.
I can do what I can, and they can ignore which which I hope they would.
I mean, actually, given what happens with cosmetic surgery, there was a question mark over that.
Oh, yeah. So you have the question, what obligation does the patient have to undergo the nutrition of fluids?
No, none. And it became clear that he had stated that he didn't want this.
The wife and seven adult children all saying this is what he said.
The quote, believes this and. Mysterious.
He thinks it's murder. And then windows. Windows, presumably. And the argument before the court was very simple.
He had no obligation. He didn't want it. He had no obligation to undergo it if he declined it.
What requisite position have to impose it on? The answer is sanctity of life.
The only potential future of poverty.
He was willing to admit that he might be a new person. His only justifications that really have merit are.
What's that mean? Well, the emergency is occurring, the emergency situation.
That's what the doctor at the National Park. It's just an emergency situation.
And she would die if she didn't get it. So be prepared for punishment.
Just to be clear. Has is it in this case, the patient has.
Sex to somebody that he doesn't want to pay an edge but is not formally refused treatment.
So there's nothing to say. He said, No, if I have to get this alone, it's just that it's not something that he would like.
Because there's a difference, I think. You mean he didn't use words of contrition, but he wasn't he didn't have a specific case.
Might it just this is not the kind of thing you talk about.
That, in fact, is what the chief justice of United States Supreme Court at the time, Mr. Rehnquist,
argued in one of these cases, say the patient didn't say she didn't want the official fluids, she didn't want heroic means.
Who would think of food and water as heroic means? Exactly.
And so authorised. But that was in the present early on.
But in this case, it was clear that this was they had contemplated.
This is not something. Yes. And so the jury magistrate dismissed it.
And the appeals court, the same appeals court, the same three judges that you had in the Conroy just did have a chance to look at that.
That's really Strong said. He said. These judges said what the doctor did was monstrous.
How dare the doctor? Or they also attacked these judges.
Three appeals court judges attacked the lower court judges, saying the court has no authority,
the judge has no authority who makes the decisions over your body and on what basis?
And the basis is, of course, two to we have two arguments.
One is privacy, which is the right to be left alone, the right to be free of unwanted government or outside intervention in your life.
And the other is consent. You have a right to be free of unwanted touching your right to be free to be left alone and.
Very old case back in 1940.
Anybody who touches a patient without the consent of a patient commits an assault for which they shall be liable in damages.
So you have very, very clear articulated rationales as to why this would happen.
When this case went to the appeals court. Very strong compliance and patient has absolutely no obligation to undergo that.
The physician proposes you go to the physician. Why?
And interestingly, the board of trustees of the American Medical Association got into a big dispute over maternal foetal conflicts and saying,
what's the role of the physician? The obstetrician was really, really interested in saying, who is the patient, the obstetrician.
No Napster music. Yes, we have.
That's right. You've never seen lies? I've never seen it.
Subscription? That's correct. Professional delivering a baby.
Well, you know, confession. God. So right now I have not seen.
Yes, you might have seen. That's why we have correctly asked that.
If the obstetrician is dealing with a pregnant woman. The features of the obstetrician.
The I don't know why they said that. Obviously, I didn't want any.
And for you, you know, and supposing there's a conflict between.
So what do we do? Each time we go to court, usually, usually to go to court case for it.
Here was a case in the District of Columbia Russian High School.
A woman is in her 23rd week, pretty busy.
She has cancer and she said she would deliver the baby by C-section.
It's about 28 weeks, but in the 24th week, the assessment was she was going to die in the next 24 to 48 hours.
And they said, oh, we've got to do the C-section. So the obstetric consultant doesn't go to get the consent.
Whom do they send the message? The registrar, the staff.
And she says, I don't want it. Now. They've got an awful dilemma on their hands.
Here they are. They believe that this foetus from 3 to 4 weeks was potentially could survive.
Mom says she doesn't want the C-section. You can't deliver it vaginally.
What do you do? Nothing. It's been so long. Oh, Jack dominates this.
Well, I wouldn't go that. Court ordered caesarian.
And that's what that court orders said when she got to local justice.
I know you do all kinds of strange things. Sometimes they imagined that she suddenly lost capacity.
Yes. Yes. But not always.
Not always. And in this particular case, they went to court and they were ordered to do the C-section.
The baby died in 2 hours. Mom died the next day.
And another family in great American tradition, for instance, on the grounds that you had no right to do this.
What do you think the appeals court said? What's that?
James might write a big check. That's right.
And change your policy in the hospital. And then go home and.
Who became really concerned about issues in the American public years ago and got to college.
So they wrote a policy position that says the role of the physician is to be a counsellor and consultant to provide information to the patient.
And that is the extent of his or her obligations.
And having done that, the physician bears no responsibility for the decision that the well-informed woman makes.
What were they actually? What was their policy about protecting the physician from potential liability?
And if you say that she has a fiduciary duty to both the foetus and the mother, then what a miss.
That is what she needed to say. You know, whatever she says and what we've come down to very much.
Is that at least confident if you look at the non-competition to say competition, have a right to decline in all unwanted medical interventions.
And the question then becomes, is unofficial Trishna fluid a medical intervention or is it just ordinary food?
And the issue today was about ordinary food. And certainly every quarter file jurisdiction, including in the U.K.,
has said that artificial treatment fluids are many medical treatments to be assessed as any other medical treatment.
And what way do you assess whether or not to utilise an intervention?
The risks and the risks and benefits simply we do this with respirators.
And, in fact, the the the appellate court the three judge panel had a very interesting comment when they looked at and most of these judges would say,
I don't know anything about medicine. Why are you asking me?
I gave a talk recently on new forms of reproduction to a group of cheap judges of the United States state courts.
And chief justice of the court in California said, I don't even know what you're talking about.
We were talking about foetal ovary transplants is I don't even know what it means.
Does it mean we can have babies? What do you think I said to him, say what about it?
I said, Judge, I don't think you know,
the birds and the bees are what you go to these and you ask these questions and they will they will make decisions.
Some of them are terrible, you see. But in fact, George Anderson writes in the New England Journal of Medicine says,
Most trial judges haven't the slightest idea what they're talking about.
He totally and but they do have an idea.
If you talk to trial judges, superior court judges, they say, I'm going to have to face who in the courtroom, the crying mother.
The spouse, the family. And I know perfectly well that no matter what I will, the losing side will do well to appeal.
So let the judges upstairs handle it. They don't have to see the crying mug.
So the easy way out is to say, look, do you want to keep going?
Know, Trump is if you read the concurring opinion on the in the Bouvier case that this is cruel beyond imagining making
patients suffer for six more months just so that we can kick the can down the field of equal judges worse than doctors.
What we've done here is that they could leave expert judges and take these cases through them.
And of course, protection, which might be a more efficient system we do that is called a protection.
It shows that, yes, it's a lot better than this.
And they are the things I would say.
And yet there's a way they are. There have been lots of these cases.
And the real issue that comes up is how do you make decisions for the now incompetent who never, in fact, made any statements?
But in this town, including she's 20 years old, she, in fact, made some comments that the trial judge in the Supreme Court in New Jersey,
which is really even cooler, said those were casual comments of an 18 year old.
And we don't give much credibility. But later in the congregations, we made a mistake we should give credibility to.
But what do you do for the Net? A company that's so difficult?
They do this, you know, this a philosophy. So, yeah.
Yeah. Here we have this problem. We have no idea what she will do.
She's never said anything, you know? No.
Have you? As far as I suppose you use up a single incident.
Okay. Well, the school system in the state. Who would be testimony as to what you, in fact have said opposition.
But I've been combative that. So now about how I can assess that current.
Well, probably like next of kin person responsible. Yeah.
You have some you have some family life and you talk to them about these issues.
Um, yeah. So how we make decisions.
Okay. You just heard what the New Jersey Supreme Court is to say.
Look, we've done a survey, and of all this from this study, sometimes it depends on how many said he or she would like to have.
Very small percentage. What? So the court said if she reaches a state, we can presume.
But she would act as a vessel running. The majority of people would do it.
So coalition forces course it and so it me be that she's reasonable as we would with
James he's a reasonable individual and he would do with a reasonable person would do.
But then along comes the next case was Mr. Safe,
which was a patient who was in a states which was like an IQ of about ten and had never had a conscious, articulated thought in his life.
How do you rate your decision for him? You can't use the Russian person because he's never been Russian.
Well, I don't want to. I mean, he's never he's never actually been rational in himself.
But I mean, what I understand to be values. Well, that's the question that we face with this.
And they want these pictures that went to the British court, an old, old British case called exponent, white bread, a lunatic.
The British don't mince words.
And this was a very wealthy man in the UK and he gave $10,000 to the Norwegians, first order £10,000 to the second daughter.
Then he goes mad. That's the word they use here, isn't it?
And under your statutes, all of his assets now can be used only for what?
His purposes. Third dog comes along.
There's no alienation. Does she get $10,000?
£10,000. Hmm.
Help! Help! Help! Save his colleagues. Are you asking me questions?
No. We're not going to get into the publication of the court protection and argue that that would have been his intention.
And there was no nation. And you make a statutory well on that basis or something.
And what they did was they used the so-called standard.
And the nomenclature is terribly misleading because it says substitute judgement doesn't mean the court substituted his judgement.
It means and this is the exact words they used. I love these words and I use them to have a speak for justice.
But the role of the court is, to quote, Don, the mental mark of the incompetent.
I said something our courts do all the time.
That is, they see themselves, for one, which I know is if they were reasonable, conscious, see themselves as unconscious and never been reasonable.
What would they want? And this was whether or not to give this patient given chemotherapy.
Well, you know, the vast majority of people who were not compromised medically left the chemo.
Why do they like the chemo? They know it could be painful.
Why do they like it? You don't think it's worth going for? They have to come through the other side and they can manage the process.
They can manage within the limits of the body because they live in hope that they will get better.
What will the sick, which is never they fight it struggle, not understand what's happening to him.
It'll feel like torture. You will feel the pain. How would you if you could see yourself?
Agreed to suffer pain without any expectation of.
No, no. So that's what they came up with to substitute judgement.
Now, the New York Court of Appeal, this high school in New York, just in fact, is a fairy tale, total fabrication, judicial fantasy nonsense.
Now there is a good default position there. What's the default position that you would have if we don't know this walk?
We don't want to take risks. At least rational. What the rational person suggested.
Well. Clear and convincing evidence from patient incompetent.
The only rationale for withdrawing is if he had said this or wrote it down.
That is what happened. Then we have evidence of what he would have wanted.
But in the absence of that, it is a charade to attribute a physician to this non-responsive patient.
So you have. Three options which when you add in those three.
Yeah. So I would say rational process of conjecture or clear evidence.
Why try clear and convincing evidence first? Probably you would not.
Who not protected under that standard. You just have to think. Children, children.
All children are confident that they quote unquote in cold like nights.
It would be classified incompetent at the time that I had the statements.
Yeah. The other problem.
The Normandy. Those who don't know that have written for the slope for which people like you know that well and you haven't
done it you in good company 96% of people in England and Wales that to take advantage of this decision.
Right. Well that 30% rate and under Zambia's standard, they're all going to get treated with only one of them.
Yes. And that's just happening in the world. But I think our time has expired.
So autonomy is reaching its corners now.
There's been a distinct imbalance of power here.
All the questions have come from from China. So now is your chance to redress the balance and feel free.
So feel free to pose, Joe, the tricky questions.
And we we could we could do the revision of your your straw poll and who in this room would
choose it in in the setting of being permanently unconscious to have a feeding tube in,
to be kept alive,
perhaps in the hope that technology improves and you sign my name and so to speak, and perhaps people who would choose not to be kept alive,
we had people being fierce, people who would like to be kept alive with being kept in between.
Yeah, I know. You just know that. Yeah.
Okay. Well, I think they've done thoroughly.
Probably you're playing into the at least people's views that that ethics isn't necessarily just a question of what what people view that.
You've got a question for John. Yeah. It's it's related. So so there's one question about what you do yourself versus what you do for somebody else.
So if you said if you had a child with an accident and was in a coma and probably wouldn't survive, then you were holding on some jobs that they lose.
How many people would would withdrawal particularly to Peter?
Are you are you now the parent or the position of the parents?
SIMON So well, we could we could have that we could have had that poll.
So we could say so imagine you're a parent of a child who is unconscious, presumed long lasting, but there's some hope.
You hold onto some more small chances of recovery if you want that artificial nutrition to be continued for your child in that setting.
So to look at the same old same sequence out both for you wouldn't you wouldn't choose.
So you will choose a feeding tube for your child in that setting, and you would use that to your child.
So there's a couple of things. No, no. And let me let me show you how far we can go with this, to how much authority you want to give to pirates.
And this is a big, big question. We changed everything changed around 1990 and up until 1990.
All of the bioethics questions had to do with withdrawing ventilators, dialysis, oxygen, pressure, fluid.
But by 1990, we had two things happen, at least in the United States.
You had the Supreme Court saying that the competent patient has a right to decline any and all and wanted,
and the various states could set up whatever evidentiary standard they want.
And that's legitimate. And then you came to the question of how are you going to do it for the non-combatant patient?
And we have a huge variety of standards in the states.
New Jersey has rationing, of course. They then shifted later in the cholera cases saying, Oh, there are three ways.
One, if they make a clear statement, that's the best.
Two, if they have no values that we can learn from their family.
And three, if they were in intractable pain, that would be such as to be inhumane.
But that doesn't apply to anybody in PBS, does it? And in fact, it reduces the patient only to be a pain avoider.
But Jenny had other reasons why she didn't want to be maintained this way.
Effect on my family. Yes. I don't think I'm an island.
I think my moral judgements are part of the network and my personhood.
No man is an island unto itself. You know, there she is. She had a little cloud of your phone.
And see, I have a list for. John Dutton's American division decision that in 1954, as a freshman in college, he ever never forgot.
And do you have any person say to you. Okay, so coming from it, I obviously had no medical background.
I the main question I have, one of the scenarios it's drawn out is what on earth is meant by the idea of a vegetative state and like,
are there different grades of degrees of consciousness?
And why on earth is there a reference like vegetative? Like where did that come from?
The term came from Fred Plumb, who was a neurologist at NYU.
And what you observed was producing coma and his condition.
And he noticed said after about two weeks, the people who were in coma have a different behavioural pattern.
They have wake sleep cycle he would call those don't get waves in cycles.
I know but they don't track condition when that was the whole big thing about shadow performance.
Oh she's responding for some clicking crying but.
That was a two hour, 24 hour period. And so persistent vegetative state be defined as the state of.
And it takes six months signifying this.
And it depends on whether it was a. Ischaemic episode or forms of trauma.
Trauma takes longer to designate, but the expectation is certainly after a period of time, there's going to be no there's no respect for a patient.
Now, sometimes it is diagnosed. You have what's called a locked in syndrome, which the patient.
They really see cancer patients eyes track, but they can't speak to Pakistan and they communicate through a signboard, an alphabet.
I saw one of these, David Mack in Minneapolis and we in conversation.
What do you think he said? HD and HD.
Help me. What's the next? Yeah.
I know what you want to do.
So he's. Yeah. Okay. Well, that complicates things. Yeah, he's conscious.
Mm hmm. Got to take it back.
Your boss and Rush, you had a question such as what's interesting about substitution thing is that it's not the patient making the decision.
It's we're making decision about the patient. And it's the doctors who have to execute that decision.
And I. I struggle with that. Who's.
Judgement of a substitute teacher. And do you see what I'm saying?
Yes, but we kept the language terribly confusing. Great.
And really is. Is there any way of discerning what is in the case they had?
Was this man who has. You can't win.
And he's never been. How. Would he want the chemotherapy if he could speak?
And we know he's never been and he never will be. Exactly.
Because it strikes me that you're making a decision about his care and you're creating a fiction to justify your action.
That's exactly what they did. I mean, they said it is a fiction, but what's the only alternative is to take you say here and say to him,
we're going to put this feeding tube into you and keep you here and it and you're going to resist it.
Well, we're going to give you cheap therapy. You're going to resist that.
And they said the only way we're going to be able to provide you with the chemotherapy is to do what?
Every time he comes near, you strike out to him. So you put him in.
Tie your hands now. So we need to restrain Russia, but we want to do it.
Well, I don't know, because I think you could use a different tone.
Well, we use a standard of you. Would you really want to be tied down and subjected to what's causing you suffering when
you have no understanding and no capacity to understand what the purpose of it is?
If I was having chemo and there was a potentially cruel leukaemia.
Yeah, the treatment was probably yeah. He had at least the haematologist had he had a 30% chance of remission from 3 to 8 months.
So it's, I don't know if it was a complete cure back to normal life, but I would say, okay,
if it's a little bit of benefit, the price of being held down like that doesn't say what.
And it's a risk benefit thing, but it's not. If you can tell me what you're actually doing is weighing the benefits and risks,
but reasonable person, stop trying to do that for this patient who's not.
That's exactly what they were doing. I know. But the point is.
Well, the alternative is saviours. And I'll give you the the companion case was story in New York.
He was another profoundly compromised individual I.Q. of an eight month old.
His mother visited him every single day since 1942.
This is in the 1980s. And he got cancer of the kidneys.
And was losing blood and he was losing one unit of blood every eight days or so.
And the mother and he resisted the blood transfusions because how do you transfuse blood?
You completely put neatly. And he didn't like the needle.
So his mother said, what are you giving him blood transfusions for?
Stop. No blood transfusions.
Ordinary. Extraordinary. And now you know why those words no longer, sir.
But what's the proportional benefit burden that accrues to this patient trust? That's the actual arithmetic that's going on.
And it seems. And the New York Court of Appeals, the highest court following it, said,
we're not going to go with that fantasy out of Massachusetts about substantive
judgement unless we have clear evidence from this man when he was competent.
Now, when was this man ever competent?
So our rule in New York was everybody who has not made a public statement or will get everything possible to stay life as long as possible.
Now, that's a different statement. That's what they came up with.
So what they do here is they use a best interest. Just doesn't mean you have to do everything you have to.
It's a different but it's been more flexible in that sense.
It really depends on who the judge is. Exactly. And do you really want to have Russian roulette with.
Jenny, you've got a question and we're almost out of time.
I just wanted to ask if you could comment on on the role of religion here and are we individuals
who should be making autonomous choices and other bigger issues here and what the Catholic Church?
Well, first of all, I wrote an article one time against Bob, which called Autonomy Run Amok.
I think that the notion that we are autonomous entities in the mills, in a sense is a fantasy, total fiction.
I used an example today with talking to Dominic. I said yes.
In fact, over his mind and his body. Every human is sovereign.
I asked Dominic what would be different about Dominic?
I said, I can just use myself. I wouldn't be five foot six, I wouldn't be bottle and I wouldn't need glasses.
Can I change any rules? So we don't have that to be solved in this economy that we have.
And then the other fallacy is that we're all absolutely independent.
We're sort of like zig zag. And we're sort of like like blitzing free floating monads.
You know what those are? Yes, I know it is.
Are you one of them? Oh, well, no, no, no.
And so and the great theory about the monads is that they never interact.
They never touch the never. But your life is totally involved in physical.
And so you say that in an adequate assessment when purely economy and part of of where we've gone when we adopted
this idea that we will just use the economy is that everyone thinks that he or she is absolutely sovereign.
And not only we have we have very clear directions in the evolution of this absolute right to decline unwanted medical interventions.
Everybody understands that. But that quickly morphed over about 1990 when we solved the problem of.
You don't have to have dialysis to. If I am sovereign, what does that mean?
I can demand. I can demand anything I want. And you must.
And I'll give you the furthest, most example that it's an ongoing case right now in the United States called Jahi McMath.
She's bringing it and meets all of the criteria.
And the judge in the superior court in California declared that she's legally dead and the coroner issued a death certificate.
The parents say, we don't believe she's dead and we don't believe that judges or doctors should determine who's dead.
Only parents can decide whether the children are alive or dead. Try that.
In the UK population, you know, that's 6.6 million.
You want to have 6 million people deciding whether on Jenny is alive or dead in the attic.
Think of the public health problems we've had from that.
Yeah. And in fact, one of the great constraints upon the right to demand is you can do whatever you want,
provided that your actions don't present an immediate, clear and present danger to the public health, safety, welfare.
For example, if you had contagious tuberculosis and you free to just do what you want, get on an aeroplane.
You can be. Yeah. So you don't have absolute freedom.
So that idea that we have, that we're totally autonomous entities is just a fantasy.
But what about the other question that Jenny asked about the role of religious traditions
or the views of religious traditions on this question of whether individuals.
So should a good Catholic just accept the feeding tube?
Would would a good Catholic be allowed to refuse the feeding tube?
Well, I've spent my whole life dedicated to being a Catholic,
and my events director says if I'm ever in an institution that believes that you must have a feeding tube inserted,
please transfer me immediately to a hospital.
And you had for 500 years a consistent moral tradition in the Catholic Church that feeding and in fact this historically you go back to.
To the solo dignitary Victoria.
And then we're talking about in the relaxing, which is the holiday I suppose in fact some opinions and packages.
And you could live another 20 years if you ate Partridge.
But what do we know about packages? Live in palm trees they live in.
They're expensive. But I'll give you the prime example. Another good example, supposing, in fact, we're now living in a society which doesn't have.
A big social welfare net. And you run a farm and you show Exxon's how you pay for it and.
One of the members of the family gets sick and the solution is Jewish penicillin.
And if a Jewish consumer, what you need. Chicken.
Chicken. Chickens. And so we did.
So the chicken today, you get the chicken soup and the industry is what happens to our.
It's not my life. I'm a vegetarian. You're asking me bidets, don't you?
I do. And where do we get the eggs? Chicken.
And if we use them all for chicken soup, we don't get any eggs.
And then we all stop. So are you morally obliged to do that?
No. No. So if.
If in the 15th century, they talk about chickens and eggs.
How much more so? Speaking as grass roots and vegetables. Well, we then we've ended that talk on the question of the chicken and the egg,
which which is perhaps a fitting and challenging into to a great discussion,
an exploration of both the profound and and absurd and absurd and simpler ethical questions around nutrition, hydration, obligations.
I'm chicken. I'd like you to join me in thanking Professor John Paris for a fascinating evening.
Thank you very.