This paper is based on the second Jack Pritchard Memorial Lecture given at the Queen's University of Belfast (1). The author describes his own personal response to having multiple sclerosis (MS), and then examines the psycho-social aspects of the disease in a wider context. The distress caused by the emotional difficulties associated with MS is emphasised, and in particular the strain placed on the doctor-patient relationship at the time of diagnosis. The physician's ability to cope with the needs (...) of MS families is explored, together with the importance of offering counselling. Also discussed is the ethical question of whether or not the patient should be told the complete truth. Patients with MS are seen as having a potential not only for helping each other, but also for being able to share in the management of their own health care. (shrink)

Although working memory and information processing speed impairments in multiple sclerosis have been widely investigated, several questions, regarding the nature of these impairments and their relationship, remain unclear. The aim of this short communication article is to present an overview of our recent research findings regarding the characteristics of WM impairment in MS patients and, more precisely, the degree of impairment observed in each WM’s component, i.e., phonological loop, visuospatial sketchpad, central executive, and episodic buffer and the relationship (...) between IPS and each of the four WM components, in an attempt to expand the existing rather narrow understanding of the interconnection between reduced IPS and WM impairment. Two studies of our research team are presented here and their findings are briefly discussed, highlighting the importance of further research on a specific component, namely the episodic buffer component among MS patients. (shrink)

The Neurological Disease Ontology (ND) is being developed to provide a comprehensive framework for the representation of neurological diseases (Diehl et al., 2013). ND utilizes the model established by the Ontology for General Medical Science (OGMS) for the representation of entities in medicine and disease (Scheuermann et al., 2009). The goal of ND is to include information for each disease concerning its molecular, genetic, and environmental origins, the processes involved in its etiology and realization, as well as its clinical presentation (...) including signs and symptoms. (shrink)

Multiple Sclerosis is a debilitating chronic autoimmune disease of the central nervous system that results in lower quality of life. Medication adherence is important for reducing relapse, disease progression, and MS-related symptoms, particularly during the early stages of MS. However, adherence may be impacted by negative emotional states. Therefore, it is important to identify protective factors. Past research suggests that the ability to discriminate between negative emotional states, also known as negative emotion differentiation, may be protective against enactment (...) of maladaptive risk-related behaviors. However, less is known as to how NED may promote adaptive health behaviors such as medication adherence. Utilizing weekly diaries, we investigated whether NED moderates the association between negative affect and medication adherence rates across 58 weeks among patients newly diagnosed with MS. Results revealed that NED significantly moderated the relationship between negative affect and medication adherence. Specifically, greater negative affect was associated with lower adherence only for individuals reporting low NED. However, this link disappeared for those reporting moderate to high NED. Building upon past research, our findings suggest that NED may promote adaptive health behaviors and have important clinical implications for the treatment and management of chronic illness. (shrink)

Tackling impaired bioenergetics in multiple sclerosis has been recently recognized as an innovative approach with therapeutic potential. Guanidinoacetic acid is an experimental nutrient that plays a significant role in high-energy phosphate metabolism. The preliminary trials suggest beneficial effects of supplemental GAA in MS, with GAA augments biomarkers of brain energy metabolism and improves patient-reported features of the disease. GAA can also impact other metabolic footprints of MS, including demyelination, oxidative stress, and GABA-glutamate imbalance. In this mini-review article, we (...) summarize studies evaluating GAA effectiveness in MS, explore mechanisms of GAA action, and discuss the challenges of using dietary GAA as an element of MS therapy. (shrink)

Tremor of the upper extremity is a significant cause of disability in some patients with multiple sclerosis. The MS tremor is complex because it contains an ataxic intentional tremor component due to the involvement of the cerebellum and cerebellar outflow pathways by MS plaques, which makes the MS tremor, in general, less responsive to medications or deep brain stimulation than those associated with essential tremor or Parkinson's disease. The cerebellar component has been thought to be the main reason (...) for making DBS less effective, although it is not clear whether it is due to the lack of suppression of the ataxic tremor by DBS or else. The goal of this study was to clarify the effect of DBS on cerebellar tremor compared to non-cerebellar tremor in a patient with MS. By wearing an accelerometer on the index finger of each hand, we were able to quantitatively characterize kinetic tremor by frequency and amplitude, with cerebellar ataxia component on one hand and that without cerebellar component on the other hand, at the beginning and end of the hand movement approaching a target at DBS Off and On status. We found that cerebellar tremor surprisingly had as good a response to DBS as the tremor without a cerebellar component, but the function control on cerebellar tremor was not as good due to its distal oscillation, which made the amplitude of tremor increasingly greater as it approached the target. This explains why cerebellar tremor or MS tremor with cerebellar component has a poor functional transformation even with a good percentage of tremor control. This case study provides a better understanding of the effect of DBS on cerebellar tremor and MS tremor by using a wearable device, which could help future studies improve patient selection and outcome prediction for DBS treatment of this disabling tremor. (shrink)

Melatonin is a hormone with complex roles in the pathogenesis of autoimmune disorders. Over the years, it has become clear that melatonin may exacerbate some autoimmune conditions, whereas it alleviates others such as multiple sclerosis. Multiple sclerosis is an autoimmune disorder characterized by a dysregulated immune response directed against the central nervous system. Indeed, the balance between pathogenic CD4+ T cells secreting IFN‐γ (TH1) or IL‐17 (TH17); and FoxP3+ regulatory T cells and IL‐10+ type 1 regulatory (...) T cells (Tr1 cells) is thought to play an important role in disease activity. Recent evidence suggests that melatonin ameliorates multiple sclerosis by controlling the balance between effector and regulatory cells, suggesting that melatonin‐triggered signaling pathways are potential targets for therapeutic intervention. Here, we review the available data on the effects of melatonin on immune processes relevant for MS and discuss its therapeutic potential. (shrink)

Abstractabstract:This article examines the complexity of narratives of space and time which support the diagnosis of multiple sclerosis, and the consequences for patients disadvantaged by deficits in social cognition or socioeconomic status in areas relating to literacy. In the context of demonstrating the significance of narratives of space and time in the diagnostic process for multiple sclerosis, the article discusses new strategies for treatment that engage the arts and humanities and presents a brief history of the (...) disease and current diagnostic criteria, before discussing the MS Society of Great Britain and Ireland's awareness and fundraising campaign from the 1980s, and Tom Kempinski's play Duet for One, inspired by the life of cellist Jacqueline du Pré. The conclusion addresses the urgency of heightening patient and clinician awareness of how the presentation, interpretation, and sharing of narrative accounts of disease influence health outcomes and makes suggestions about how to adjust for these biases. (shrink)

Objective: To determine the views of people with multiple sclerosis (MS) and professionals in relation to confidentiality, consent and access to data within a proposed MS register in the UK. Design: Qualitative study using focus groups (10) and interviews (13). Setting: England and Northern Ireland. Participants: 68 people with MS, neurologists, MS nurses, health services management professionals, researchers, representatives from pharmaceutical companies and social care professionals. Results: People with MS expressed open and altruistic views towards the use of (...) their personal information to facilitate service provision and research, placing trust in responsible guardianship and legitimate use of their information. Participant’s proposed that people with MS should be able to select their individual level of involvement in a register using levels of consent. It was agreed that access to the register should be governed by a guardianship committee composed of a range of stakeholders. People with MS did not wish their details to be used by marketing agencies and did not consider this a legitimate use of their data. Whilst participants were positive of the role a register could play in promoting research, participants felt that access to data by pharmaceutical industries should be administered by the guardianship committee. People with MS are concerned should their employers be able to access their personal information. Professionals were more cautious than people with MS in their approach to the use of patient personal data within a register. Conclusions: Whilst all stakeholders were positive of the benefits of an MS register, development of such a resource must incorporate robust data security and guardianship measures in order to ensure that, whilst opportunities are maximised, risks to the privacy of individuals and legal challenges to professionals are avoided. (shrink)

For patients with multiple sclerosis, deficits in gait significantly reduce the quality of life. Using the concept of muscle synergies, this study investigated the modular organization of motor control during level and inclined walking in MS patients compared with healthy participants to identify the potential demand-specific adjustments in motor control in MSP. We hypothesized a widening of the time-dependent activation patterns in MSP to increase the overlap of temporally-adjacent muscle synergies, especially during inclined walking, as a strategy to (...) increase the robustness of motor control, thus compensating pathology-related deficits. We analyzed temporal gait parameters and muscle synergies from myoelectric signals of 13 ipsilateral leg muscles using non-negative matrix factorization. Compared with HP, MSP demonstrated a widening in the time-dependent coefficients, as well as altered relative muscle contribution, in certain synergies during level and inclined walking. Moreover, inclined walking revealed a demand-specific adjustment in the modular organization in MSP, resulting in an extra synergy compared with HP. This further increased the overlap of temporally-adjacent muscle synergies to provide sufficient robustness in motor control to accomplish the more demanding motor task while coping with pathology-related motor deficits during walking. (shrink)

Common symptoms of multiple sclerosis include motor impairments of the lower extremities, particularly gait disturbances. Loss of balance and muscle weakness, representing some peripheral effects, have been shown to influence these symptoms, however, the individual role of cortical and subcortical structures in the central nervous system is still to be understood. Assessing [18F]fluorodeoxyglucose uptake in the CNS can assess brain activity and is directly associated with regional neuronal activity. One potential modality to increase cortical excitability and improve motor (...) function in patients with MS is transcranial direct current stimulation. However, tDCS group outcomes may not mirror individual subject responses, which impedes our knowledge of the pathophysiology and management of diseases like MS. Three PwMS randomly received both 3 mA tDCS and SHAM targeting the motor cortex that controls the more-affected leg for 20 min on separate days before walking on a treadmill. The radiotracer, FDG, was injected at minute two of the 20 min walk and the subjects underwent a Positron emission tomography scan immediately after the task. Differences in relative regional metabolism of areas under the tDCS anode and the basal ganglia were calculated and investigated. The results indicated diverse and individualized responses in regions under the anode and consistent increases in some basal ganglia areas. Thus, anodal tDCS targeting the M1 that controls the more-affected leg of PwMS might be capable of affecting remote subcortical regions and modulating the activity of the circuitry connected to these regions. (shrink)

In Dutch healthcare policy patients are seen as informed, autonomous experts and active decision makers with control over their illness and care. Healthcare professionals are expected to operate as providers of information. The purpose of this article is to argue that the consumerist approach of the patient–professional relationship is not a productive way to envision the patient–professional relationship. We argue that an interpretive/deliberative model is a more productive way to envision this relationship, especially in the care for people with a (...) chronic illness. This is illustrated with a case study. It concerns a study of the experiences of a Multiple Sclerosis (MS) patient and healthcare professionals involved in her care. The presented stories show that the participants did not act in line with the roles and responsibilities embodied in the consumerism rhetoric in Dutch healthcare policy. Expectations of patients and healthcare professionals are better met when care is redefined as mutual endeavour in which the caring abilities of healthcare professionals and the vulnerability of chronically ill patients are taken into account. (shrink)

BackgroundMultiple sclerosis, the most common neurological disease that causes disability in youth, does not only affect physical functions but is also associated with cognitive impairment, fatigue, depression, and anxiety and can significantly impact health-related quality of life. Since MS is generally diagnosed at a young age—a period of great significance for personal, relational, and professional development—adaptation can become highly challenging. Therefore, enhancing the competence of young people to adaptively cope with these potential challenges is of utmost importance in order (...) to promote their potentialities and talents. It has been shown that psychological interventions targeting MS patients can enhance resilience and HRQoL and that regular physical activity and social engagement can improve psychological well-being. However, literature on the development of global interventions based on the bio-psycho-social model of the disease is missing. Even less attention has been paid to interventions dedicated to young adults with MS and to the involvement of patients in the development of such programs.AimsIn collaboration with MS patients, this study aims to develop a bio-psycho-social intervention for YawMS, aiming to improve their HRQoL and to explore its feasibility, acceptability, and effects.MethodsTo tailor the intervention to the specific needs of YawMS, “patient engagement principles” will be adopted in the co-creation phase, performing a web survey and focus groups with patients and healthcare professionals. In the intervention phase, a pilot sample of 60 young adults with MS will be enrolled. The co-created intervention, composed of group sessions over a 12-week period, will cover psycho-social strategies and include physical activities. Adopting a longitudinal, pre–post evaluation design, self-report questionnaires measuring HRQoL and other bio-psycho-social features will be administered, the quantity and quality of PA will be measured, and a questionnaire developed by the authors will be used to evaluate the feasibility and acceptability of the ESPRIMO intervention. (shrink)

BackgroundEvidence suggests that organizational models that provide care interventions including patient support programs may increase patient adherence to multiple sclerosis therapies by providing tailored symptom management, informational support, psychological and/or social support, lifestyle changes, emotional adjustment, health education, and tailored coaching, thus improving patients' overall quality of life across the disease course.ObjectiveThe main objective of this study was to describe MS patients' self-reported experience of a nurse-led, telephone-based PSP and to explore its potential role in improving disease and (...) therapy management skills.MethodsSurvey data were analyzed from a subset of patients relapsing–remitting MS using interferon beta-1a already registered in the adveva® PSP from three Italian multiple sclerosis centers with a consolidated experience in RRMS disease, treatment management, and PSP programs.ResultsIn total, 244 patient data at baseline were analyzed, of which 115 had a follow-up of at least 6 months. Results from this study provide an early view into the role of this PSP in improving the patients reported overall experience regarding disease management and injectable therapy, thus potentially ameliorating treatment adherence and decreasing health care cost. Moreover, study findings confirm the role of providing a patient-focused support by addressing non-medication-related topics in the PSP consultations. Indeed, patients involved in the adveva® PSP program reported a better psychological status in the follow up as demonstrated by an increased optimism regarding their future, tolerance of disease uncertainty, and their perceived ability to benefit from external help and social support.ConclusionsAs such, it is reasonable to conclude that the involvement in the adveva® PSP and the PSP's assistance in guiding patients on proper treatment self-management techniques is of great value to patients as it might contribute to improving engagement in their health care journey in terms of perceived self-care skills, emotional coping toward the future and the unpredictability of the disease course and their general attitudes toward the injection itself, involving pain tolerance. (shrink)

BackgroundIn 2009, Dr. Paolo Zamboni proposed chronic cerebrospinal venous insufficiency (CCSVI) as a possible cause of multiple sclerosis (MS). Although his theory and the associated treatment (“liberation therapy”) received little more than passing interest in the international scientific and medical communities, his ideas became the source of tremendous public and political tension in Canada. The story moved rapidly from mainstream media to social networking sites. CCSVI and liberation therapy swiftly garnered support among patients and triggered remarkable and relentless (...) advocacy efforts. Policy makers have responded in a variety of ways to the public’s call for action.DiscussionWe present three different perspectives on this evolving story, that of a health journalist who played a key role in the media coverage of this issue, that of a health law and policy scholar who has closely observed the unfolding public policy developments across the country, and that of a medical ethicist who sits on an expert panel convened by the MS Society of Canada and the Canadian Institutes of Health Research to assess the evidence as it emerges.SummaryThis story raises important questions about resource allocation and priority setting in scientific research and science policy. The growing power of social media represents a new level of citizen engagement and advocacy, and emphasizes the importance of open debate about the basis on which such policy choices are made. It also highlights the different ways evidence may be understood, valued and utilized by various stakeholders and further emphasizes calls to improve science communication so as to support balanced and informed decision-making. (shrink)

Increasing pharmaceutical industry presence in health care research and practice has evoked critical social, political, economic, and ethical questions and concern among health care providers, ethicists, economists, and the general citizenry. The case example presented of the ‘marketization’ of nursing practice not only reveals the magnitude of the purview of the pharmaceutical industry, it demonstrates how that industry imparts effect upon the organization of nursing work, an area of health care professional practice where the ethical polemic of pharmaceutical industry involvement (...) and influence has been largely ignored, and the profession of nursing conspicuously silent. Drawing on a Foucauldian dispositive analysis that troubled the complex apparatus responsible for the production of knowledge and action in the neurology subspecialty of multiple sclerosis (MS), the case discloses how the pharmaceutical industry has created compliance and adherence as clinical imperatives in the practice of MS nursing. The case makes explicit the conscious transformative self‐action undertaken by MS nurses as a result of their subjectivation (marketization) and demonstrates how MS nurses have become pawns in pharmaceutical industry strategic games of power, truth, identity, and wealth creation by turning their clinical practice settings into heterodiscursive spaces of surveillance and persuasion. MS nurses have become instruments of the pharmaceutical industry, and their clinical practices ordered, organized, limited, constrained, and marketized as a result. (shrink)

Geron recently announced that it had begun enrolling patients in the world's first-in-human clinical trial involving cells derived from human embryonic stem cells (hESCs). This trial raises important questions regarding the future of hESC-based therapies, especially in spinal cord injury (SCI) patients. We address some safety and efficacy concerns with this research, as well as the ethics of fair subject selection. We consider other populations that might be better for this research: chronic complete SCI patients for a safety trial, subacute (...) incomplete SCI patients for an efficacy trial, and perhaps primary progressive multiple sclerosis (MS) patients for a combined safety and efficacy trial. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Finding PartnershipThe Benefit of Sharing and the Capacity for ComplexityMichaela Amering (bio)Keywordsrecovery, empowerment, trialog, user involvement, schizophreniaIs There Ignorance and Arrogance? In Psychiatry? In Medicine?Adding insight to injury' is the paraphrase psychiatrist Pat McGorry (1992) coined for his reproach of 'pushing for "insight" or "acceptance of diagnosis"' without carefully taking into account the complexities of the individual situation, context, and needs. That must be about the kind of behavior (...) Marga Reimer has in mind in her paper on treatment adherence in the absence of insight, which depicts mental health professionals characterized by arrogance against the common sense of motivating compliance by perceived or anticipated benefits on different everyday life levels, but instead trying to get people to believe in a mental illness such as schizophrenia and wishing them to want treatment for that in the form of medication.In addition, Reimer presents examples from general medicine to make her point that adherence follows perceived or anticipated benefits instead of being a result of insight into a medical model of illness and McGorry (1992) also suggests that disregard for the active role that patients may play as reflected in psychiatry in terms such as 'case management' and 'compliance' "is a failing which extends to mainstream medicine and probably to most systems of human service delivery." On the other hand, Bill Anthony (2006), one of the most eminent experts on psychiatric rehabilitation and recovery in a personal report on his own medical illness, multiple sclerosis—MS, and the assistance he has been receiving in connection with it, describes the 'MS-Community' as exemplary with respect to instilling courage and hope, continually providing information and opportunities for exchange, and for never questioning a person's ultimate freedom of choice. In contrary, in mental health care he does not experience the medical profession as acting with full respect and support for its patients and suggests a great deal more work and transformation—especially concerning coercive treatments—ahead to follow this example. Similarly, it has been suggested that psychiatry should be better integrated into medicine to overcome stigma and discrimination of psychiatric health problems and interventions. A pertinent example of an initiative in this direction is the proposal of a fusion of mental health and incapacity legislation to arrive at ethically consistent legal situations with regard to involuntary [End Page 77] treatment across medicine (Dawson and Szmukler 2006).Is There Something Called Schizophrenia? and How Much Longer?Reimer's main example—schizophrenia—is the diagnosis that poses some of the greatest problems to the field and to the recognition of psychiatry as a scientific medical discipline. The current concept as well as the term 'schizophrenia' will probably not be around much longer; 'a century of schizophrenia is enough' (Kelly and Murray 2002). Suggested solutions for the problems of the diagnosis of schizophrenia concern the urgent complement of the categorical with a dimensional approach (Allardyce et al. 2007), a change also put forward as one of the essential remedies to undermine the stigma of mental illness that is often exacerbated by clinical diagnosis (Corrigan 2007). Such a move would also clearly help against the still prevalent experiences of users of services and their families and friends, whose hopes and dreams have been crushed and whose resilience has been undermined by clinical situations, which in times of psychotic crises, not only forced diagnoses but also prognoses—often scientifically unfounded—on them (Amering and Schmolke 2009).Is There a Solution? Can We Use Our Talents? And Those of People With a Lived Experience of Mental Health Problems and Care?Clinicians as well as scientists know that health, illness, and recovery occur in complex ways and contexts. People faced with mental health problems clearly realize the complexities of their situation and are especially motivated to appreciate the variety of factors and interactions that need to be integrated to arrive at a valid assessment. Ideally, the therapeutic relationship—essentially a partnership—holds a formidable chance of sharing efforts and creating the wisdom for finding and facing the truths necessary to develop solutions that can uphold and work in line with the complexities of human life.I would argue that psychiatric professionals are certainly part... (shrink)

About a week after Maran Wolston was prescribed Copaxone, a drug for multiple sclerosis, she got a phone call from a nurse at an organization called Shared Solutions. The organization was familiar to Wolston; when her neurologist had asked permission to share her health information with Shared Solutions, Wolston had agreed, assuming it was connected to her health insurance.The nurse who called Wolston was checking in to see how the treatment was going. It was not going well. While (...) Copaxone is not typically associated with some of the unpleasant side effects of other MS drugs, it does have at least one serious drawback: the drug must be injected every day. The injections can be brutally painful. “No matter where I injected the drug each day, the injection site swelled up into a huge welt and felt like a gigantic bee sting,” Wolston writes. (shrink)

The development of ethical and practice guidelines related to mental health service on the Internet has lagged behind the movement of practitioners into this area. Even for clinicians who are not offering services on the Web, the Internet has led to confusion and concern about proper roles and responsibilities. This article discusses an actual experience we had with a self-described rationally suicidal man with multiple sclerosis. After presenting some background on MS, we report initial interactions with the man (...) verbatim and summarize subsequent correspondence in an analysis of the man's claim that his decision to die was well reasoned and that he should be allowed a physician's assistance. (shrink)

Central nervous system (CNS)Abbreviations: CNS=central nervous system; PNS=peripheral nervous system; MS=multiple sclerosis; MBP=myelin basic protein; MHC=major histocompatibility complex; EAE=experimental allergic encephalomyelitis; O‐2A=oligodendrocyte‐type 2 astrocyte; GC=galactocerebroside; GFAP=glial fibrillary acidic protein; FGF=fibroblast growth factor; IGF1=insulin‐like growth factor. regeneration is a subject of great interest, particularly in diseases causing a dramatic loss of neurons. However, some CNS diseases do not affect neurons but damage other cells, such as the myelin‐forming cells — called oligodendrocytes — which are also crucial to the harmonious (...) function of the nervous system. Diseases in which oligodendrocytes and myelin are attacked can cause devastating neurological dysfunction which is sometimes followed by recovery and myelin repair or remyelination. The question of the regeneration potential of oligodendrocytes in experimental and human demyelinating diseases such as multiple sclerosis has been debated for a long time. Present evidence suggests that oligodendrocyte precursor cells persist in the adult CNS and that oligodendrocyte regeneration can occur but may be limited by ongoing disease processes. Here we will briefly review recent advances which have broadened our understanding of the cellular and molecular events of CNS remyelination. (shrink)

The California Verbal Learning Test-Second Edition, is a commonly used tool to assess episodic memory. This study analyzed learning and memory characteristics in a cognitively healthy Chinese population, as well as the effects of age, sex and education on CVLT-II factors. In total, 246 healthy people aged 20–80 years and 29 persons with multiple sclerosis were included in this study and completed the CVLT-II. Factors including total learning, learning strategy, serial position effects, short-delay free and cued recall, long-delay (...) free and cued recall, repetitions and intrusions during recall, hits and false positives of recognition, and total recognition discriminability were calculated. The effects of age, sex and education on these factors were analyzed using ANCOVA or independent two-sample t-tests and further confirmed by multiple regression analysis. The regression-based normative data were then computed by the equivalent scores method. Moreover, differences in learning and memory were compared between persons with MS and age-, sex- and education-matched healthy individuals. Most CVLT-II factors significantly differed between different age and education groups; in particular, better performance in total learning, recall, semantic clustering and recognition was observed in the younger and more educated groups than in the older and less educated groups. Male participants showed higher recency effect scores, more repetitions and fewer hits than female participants. Compared with healthy individuals, persons with MS showed extensive impairments in memory processes, such as learning, recall, learning strategy and recognition. These findings indicated that verbal learning and memory were highly dependent on age and educational level but not strongly affected by sex. The CVLT-II effectively assesses episodic memory impairment in the Chinese-speaking population. (shrink)

House of Lords ruling on assisted dyingIn July 2009, the House of Lords ruled that the Director of Public Prosecutions must produce clear guidelines on the prosecution of those who help friends or relatives travel abroad for assisted suicide. 1 As previously reported here, both the High Court and Court of Appeal had rejected Debbie Purdy’s case before it reached the Lords.2 As a person with primary progressive multiple sclerosis, she had asked the court to rule that her (...) husband would not face prosecution if he accompanied her to Switzerland if she decides to end her life. 3By requiring the DPP to publish offence-specific guidelines about the circumstances in which a prosecution would be brought, the law lords did not go so far as to assert a right to assistance in dying by legalising assisted suicide. It was reiterated that any change to the criminal law against aiding and abetting suicide remained a political matter for Parliament. The Lords did, however, acknowledge that the right to privacy, and the associated right to autonomy, was potentially infringed by the absence of a transparent policy about those who are competent and terminally ill, or severely and incurably disabled, and who need help to travel abroad for assisted dying. The five law lords unanimously agreed that Ms Purdy’s right to a private life, as protected by article 8 of the European Convention on Human Rights, included the right to clarity regarding the exercise of the DPP’s discretion as to whether or not to prosecute.Following the Lords’ ruling, the DPP, Keir Starmer, confirmed that the new guidance would apply to all acts of assisted suicide, those taking place within and outside of the jurisdiction.4 He then published an interim policy for wide consultation in September 2009, and is expected to produce the final policy in …. (shrink)