An experienced consultant neurologist and ordained Catholic priest has been vindicated by the General Medical Council (GMC) after being investigated for three years for giving a ‘pro-life’ medical opinion in an end-of-life court case.
Rev. Dr Patrick Pullicino, 74, based in London, faced an investigation by General Medical Council (GMC) which could have seen him barred from the profession after he was targeted by a ‘Right to Die’ campaigner, Celia Kitzinger.
In a career spanning 50 years, he had never faced a fitness to practise investigation.
Dr Pullicino, who has been supported throughout the case by the Christian Legal Centre, is best known as one of the few doctors who first raised the alarm in 2012 over the abuses carried out under the Liverpool Care Pathway, an end-of-life protocol abolished two years later.
His case highlights the growing pressure on medical professionals not to break ranks with their colleagues who had taken a controversial decision which would end a patient’s life. In sensitive end-of-life cases, dissenting medical experts risk severe criticism by courts and activists, leading to protracted and stressful investigations by professional regulators.
Evidence in case of ‘RS’
The GMC investigation concerned Dr Pullicino’s role in a case which gained international attention in December 2020.
The case involved the Court of Protection authorising the removal of nutrition and fluids from a middle-aged Polish man, anonymised as ‘RS’, who had suffered brain damage after a heart attack.
The clinical team at a Plymouth Hospital had predicted that ‘RS’ had no prospects of recovering beyond spending the rest of his life in a ‘minimally conscious state’ (MCS).
The Court of Protection ignored the official requests by the Polish government to the UK to permit the man’s repatriation to Poland and ruled that prolonging his life was not in his “best interests.”
RS’s mother and two sisters sought to instruct Dr Pullicino as their medical expert, but the High Court Judge, Mr Justice Cohen, strongly criticised Dr Pullicino’s opinion that further observations and tests were necessary for a confident prognosis. The Court likewise rejected an opinion of a Polish neurosurgeon (who cannot be named for legal reasons), who agreed with Dr Pullicino.
RS died from dehydration after all nutrition and fluids were withdrawn in January 2021.
Accused of trying to save a patient’s life
Ms Kitzinger, who had been following the case and court proceedings, accused Dr Pullicino of bias for ‘trying to save a patient’s life’ and speculated that he “may have deliberately misdiagnosed the patient in the hope of saving his life” after he had given urgent assistance on Christmas Day, during lockdown, to a family facing tragedy.
In a written complaint to the GMC, Kitzinger accused Dr Pullicino of bias because he was a Catholic and had expressed “pro-life values” in the courtroom.
In May 2021 the GMC notified Dr Pullicino that it had commenced an investigation into his fitness to practice based solely on Ms Kitzinger’s complaint.
After having his regular revalidation by the GMC put on hold during the investigation, the GMC has now, however, concluded the case stating:
“Dr Pullicino is an experienced Consultant Neurologist, with specialist registration and a licence to practise, and we have no evidence to suggest that he lacks competence to assess a patient’s level of consciousness.”
They added that: “We do not have evidence to support an allegation that [his medical opinion] was inaccurate.
“We conclude that there is no realistic prospect of proving these allegations and they are concluded with no action.”
In regards to Dr Pullicino’s beliefs they ruled: “No evidence was adduced to support the allegation that Dr Pullicino’s religious faith or personal beliefs affected his opinion on Patient RS.”
Improved awareness at ‘farewell visit’
After RS was taken to hospital following a heart attack in early November 2020, the doctors at University Hospital Plymouth NHS Trust concluded within a few days that it was in his best interests to withdraw all life-sustaining treatment.
By the end of November, an application was made to the Court of Protection to resolve the dispute with RS’s mother and other members of his family, who insisted on preserving his life.
Following an online court hearing earlier in mid-December 2020, Mr Justice Cohen agreed with the NHS doctors that, with appropriate treatment and care, RS could survive “for up to five years or more”.
Since the heart attack RS had been recovering, but the judge found that he would never recover beyond “a minimally conscious state” where he could barely “acknowledge a presence of another human being”.
The judge concluded that it was not in RS’s “best interests” to be provided with nutrition and fluids to sustain his life.
On Christmas Eve 2020 the Hospital informed the family that nutrition and fluids had been withdrawn. Messages begging doctors to continue hydration until RS’s mother arrived from Poland were left unanswered.
On Christmas Day 2020, RS’s sister and niece were allowed a 30-minutes farewell visit to see RS in Hospital. They said they were astonished to see how much his awareness had improved over three weeks since they last saw him. When he saw his sister and niece, he appeared to recognise them and began to cry.
It was for that visit that the family urgently sought independent medical advice from Dr Pullicino.
Faster recovery than expected
The family relied on Dr Pullicino’s opinion, set out in a letter to the family, to make an emergency application to the Court of Protection to restore RS’s nutrition and hydration and permit them to instruct Dr Pullicino as a medical expert to carry out an urgent remote independent video examination of RS.
Dr Pullicino told the family in a letter that RS’s presentation suggested he was making a faster recovery than had been expected, and further tests and observations were needed for a confident prognosis.
When cross-examined in Court, Dr Pullicino pointed out medical research publications which suggested that patients making a similar recovery so soon after suffering a hypoxic brain injury had a 50% chance of recovering to the point of achieving independence within their home.
At an urgent hearing on 28 December, Mr Justice Holman suspended the permission to withhold nutrition and fluids from RS until this new evidence could be considered by Mr Justice Cohen.
By that time, RS had already spent five days without being given any fluids, and the Hospital had written to the family to confirm he was “at the end of his life” and was expected to die within 24 to 48 hours.
However, at a further hearing on Thursday 30 December, doctors working for the Hospital told the Court that RS’s condition had not changed.
Mr Justice Cohen agreed with the treating doctor’s opinion, and strongly criticised the contrary opinion of Dr Pullicino and refused permission to instruct him as an expert.
In further proceedings in January 2021, the Polish authorities took extraordinary steps to arrange for a full examination of RS by an independent expert, despite the resistance of the Plymouth Hospital.
The government of Poland went as far as to give RS a diplomatic status, ensuring that then Polish embassy in London could gain access to him pursuant to the Vienna Convention on consular relations, and arrange for a further examination.
In a separate development, a court in Poland had appointed RS’s Polish-based sister as his guardian and ordered RS’s repatriation to Poland for a medical examination and treatment.
However, on an urgent application from the Plymouth hospital, the Court of Protection authorised it to ban any visits from the Polish authorities.
On 26 January 2021, RS died of dehydration and starvation.
Right to Die campaigner complains
The complaint from Celia Kitzinger followed.
Kitzinger, a former Professor of gender and sexuality at the University of York, describes herself as “a scholar-activist with a background in academic psychology” and is best known for a legal challenge against the UK law’s failure to recognise her Canadian-registered same-sex marriage.
More recently, as a co-director of Open Justice Court of Protection Project, she commented extensively on end-of-life cases, and advocated further strengthening patients’ and families’ right to refuse life-sustaining treatment.
In her complaint, Kitzinger speculated that Dr Pullicino was “biased” because of his “pro-life values”, or “may have deliberately misdiagnosed the patient in the hope of saving his life”.
She drew the GMC’s attention to Dr Pullicino’s 2019 public lecture, where he suggested that “discontinuation of food and water is a form of euthanasia”.
She also complained that by considering the videos taken by RS’s sister and niece, Dr Pullicino “examined the patient” without his own consent, or that of his wife or treating clinicians.
Ms Kitzinger suggested that “Dr Pullicino allowed himself to be used as a tool of a religious campaigning group”, Christian Legal Centre, who supported the family’s efforts to save RS’s life and paid for legal representation.
She concluded that the doctor: “found himself colluding with ‘pro-life’ activists to produce an outcome-driven re-diagnosis of a patient in an attempt to reverse the decision of the court to withdraw treatment”.
The GMC subsequently rejected all of her allegations and refused to take action against Dr Pullicino.
‘Impossible to see how such actions may amount to misconduct’
Summoned to a behind-closed-door Tribunal hearing to decide whether his medical practice should be suspended, in Dr Pullicino’s defence his lawyers said:
‘Dr Pullicino received an extremely urgent request to advise in an examination of an incapacitated adult patient in a life-threatening emergency. He had to make an instant decision. He took the reasonable and legally correct view that he did not need to obtain consent from anybody and instead had to act in the patient’s best interests. He made a reasonable assessment of the patient’s best interests and acted on it.
“The aim of his assessment was to verify the relatives’ impression that the patient’s level of awareness was improving so as to bring that to the attention of the Court and the treating clinicians and thus ensure patient was not deprived of life-saving treatment as a result of a mistake.
“There is no suggestion that anything he said in his evidence was untrue or dishonest. He was complying with an express order of the Court, and with the guidance given by an experienced solicitor who had instructed him to comply. It is impossible to see how such actions may amount to misconduct.’
Dr Pullicino’s actions were backed by an expert consultant neurologist who said that: ‘a doctor faced with an urgent request to halt the withdrawal of life-preserving treatment would regard his possible intervention as essential as soon as possible’. In these circumstances, Dr CG said, ‘it was appropriate for Dr Pullicino to assess the patient by electronic means in order to respond as best he could to the niece’s request for some guidance’.
Another expert, an academic who has worked in the field of medical ethics for more than 20 years provided evidence to the GMC stating: ‘doctors have a duty to collaborate and communicate with one another but this is often after the fact and is secondary to their duty to consider the overall benefit of the patient’. Professor DJ also advised that Dr Pullicino was not required to obtain consent from the Court of Protection.
He added that: ‘Doctors have a duty to respect the Court and abide by decisions but not to ask permission in advance of every treatment or assessment decision on behalf of someone who cannot consent’.
Responding to the GMC throwing out the case, Dr Pullicino said: “I am relieved and pleased that the GMC has refused to take any further action against me.
“In an emergency situation, I was ambushed in the courtroom and then targeted by a militant ‘Right to Die’ campaigner with an agenda to attack, discredit and caricature my medical opinion.
“From the beginning it was a clear discriminatory attack on the medical opinion I gave because I am a Catholic Priest and believe medical professionals should do everything possible to save another human’s life.
“The GMC should never have allowed an investigation to proceed against me, which was so clearly targeted against and based on my religious beliefs.
“I am concerned that it has taken so long for me to be vindicated and cleared.”
Andrea Williams, chief executive of the Christian Legal Centre, said: “The irony should not escape us that this is a doctor under investigation for actually trying to save a life.
“In a world where truth is becoming stranger than fiction, we are now seeing doctors who work to save lives becoming the ones investigated by the GMC. This tells us something about the culture of the GMC.
“We are delighted that Dr Pullicino has been cleared, but it is deeply disturbing that this case got this far.
“The case highlights the growing pressure on medical professionals not to break ranks with their colleagues who had taken a controversial decision to end a patient’s life. In sensitive end-of-life cases, dissenting medical experts risk severe criticism by courts and activists, leading to protracted and stressful investigations by professional regulators.
“The investigation saw a distinguished Professor of Neurosciences, with an unblemished record, being dragged through the mud because a Professor of Gender and Sexuality took umbrage that his medical opinion was ‘pro-life’.
“This is not the first time the GMC has allowed a case to proceed against a Christian medical professional because of a lone secular driven complaint laced in religious discrimination.
“This was a targeted attack by Kitzinger which the GMC allowed to proceed when the complaint should have been thrown out at the first hurdle.
“Instead, a respected professional has had the stress and cloud of an investigation hanging over him for three years.
“We need more doctors and experts who are prepared to be fearless in defending the patient’s right to life.”