Debate: The Fiction of an Interest in Death? Justice for Charlie Gard

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Julian Savulescu

Dominic Wilkinson’s Response

A judge ruled last week that baby Charlie Gard will have his treatment withdrawn, against the wishes of his parents. His doctors argued that the rare mitochondrial disease (MDDS) he was born with was causing him unbearable suffering.

His parents had raised funds to take him to the US for experimental treatment and they wanted the chance to try the treatment. His doctors argued that such treatment could only prolong his suffering. It was their belief that it was in his best interests for treatment to be withdrawn, and for his life to end, a belief which the trial judge endorsed.

“It is with the heaviest of hearts, but with complete conviction for Charlie’s best interests, that I find it is in Charlie’s best interests that I accede to these applications and rule that GOSH may lawfully withdraw all treatment save for palliative care to permit Charlie to die with dignity.”

This is a profoundly difficult decision, and one in which all parties are acting out of care and compassion for the child. My comments are of course limited as I do not have access to all the relevant facts. However, it does raise an important question about the current basis of such decisions.

Ethics of Limitation of Life Prolonging Medical Treatment

In general, medicine has a presumption in favour of saving life, or prolonging life. There are three justifications for departing from this default. That is, there are 3 justifications for withholding or withdrawing life prolonging medical treatment:

  1. the patient autonomously refuses it. (autonomy)
  2. continued life is no longer in the patient’s interests (best interests)
  3. the probability of the treatment prolonging life, or the quality of life, or the length of time the patient can surVive are too low to justify the cost of the attempt (distributive justice)

Sometimes treatment is withheld or withdrawn because it is “futile.” Dominic Wilkinson and I have argued that although futility is often said to refer to “best interests”, it is more appropriately interpreted as a justice justification for limitation, that is, criterion 3. The reason we have argued this is that the best interests justification (2), requires that doctors establish that life is no longer worth living. That is, that the person would be better off dead. This is a very difficult standard to establish, even if the concept of a life not worth living is coherent. Justice does not require that we establish where the line of of a life worth living is. It only requires a comparative judgement – that compared to other uses of a limited medical resource, this use is not justified. The NHS has thresholds for cost-effectiveness that it routinely employs. A justice justification for limiting life prolonging medical treatment only requires an extension of this every day approach. For example, a treatment which has a 1/10,000 of prolonging a person’s life is a lower priority than a treatment which has a 50% chance of extending life. We need not say that the first treatment is “futile” or confers no benefit to the patient. We need only say that it is very poor value for money.

Decisions about Children and Other Incompetent Patients

In cases involving children, babies (such as Charlie Gard), or others without capacity, the first justification is not available – that is, the patient lacks capacity to autonomously refuse further treatment. In such cases, the court is asked to make a decision about what is in the best interests of the patient. This is a different decision than a substituted judgement for what the patient would want if they had capacity, although of course when adult patients lose capacity, their prior known wishes are an important factor. Explaining the basis on which he could override the parents, the judge said:

“although the parents have parental responsibility, overriding control is vested in the court exercising its independent and objective judgment in the child’s best interests.”

Best interests apply across a number of decisions around children, for example in family law cases, when two parents might reasonably disagree about decisions affecting a child the court is asked to choose which option is in the child’s best interests: which on the balance of probabilities will lead to the best outcomes. However, in a case involving limitation of life prolonging treatment, one option ends the life of the child.

The judge relied on best interests as laid out in a previous judgement (Wyatt v Portsmouth NHS Trust):

“In our judgment, the intellectual milestones for the judge in a case such as the present are, therefore, simple, although the ultimate decision will frequently be extremely difficult. The judge must decide what is in the child’s best interests. In making that decision, the welfare of the child is paramount, and the judge must look at the question from the assumed point of view of the child. There is a strong presumption in favour of a course of action which will prolong life, but that presumption is not irrebuttable. The term “best interests” encompasses medical, emotional, and all other welfare issues.”

The critical issue is in this case is how to define “best interests.” For example, here is a UN definition of best interests:

According to the UN Convention on the Rights of the Child, assessing the best interests of a child means to evaluate and balance “all the elements necessary to make a decision in a specific situation for a specific individual child or group of children”.[1] Due to the diversity of factors to consider, usually more than one profession or institution is involved in the assessment process, bringing together various perspectives and areas of expertise from the country of origin and destination and, in particular, the perspective of the child.

The following aspects are relevant for the best interests of the child:

  • The child’s views and aspirations;

  • The identity of the child, including age and gender, personal history and background;

  • The care, protection and safety of the child;

  • The child’s well-being;

  • The family environment, family relations and contact;

  • Social contacts of the child with peers and adults;

  • Situations of vulnerability, i.e. the risks that the child is facing and the sources of protection, resiliency and empowerment;

  • The child’s skills and evolving capacities;

  • The rights and needs with regard to health and education;

  • The development of the child and her or his gradual transition into adulthood and an independent life;

  • Any other specific needs of the child.[2]

 

None of these criteria clearly direct us to answering the question of when a child would be better off dead.

When Is Death in a Patient’s Best Interests?

In Charlie Gard’s case the possibility of experiencing pain from ventilation, suctioning, and other medical reasons was cited as a negative aspect of his well-being. But there are highly effective forms of analgesia, sedation and anaesthesia for these routine medical procedures. No one suggests that the discomfort associated with such procedures is a reason not to offer them.

Perhaps there is some other negative aspect to Charlie’s life such that it makes it the case he would be better off dead. Epileptic fits, perhaps. But again, these can be controlled with deep sedation.

Perhaps the argument is that in other cases of severe illness, the positive aspects of medical treatment outweigh these negative aspects, but in Charlie’s case there would be no positive aspects because of his profound cognitive impairment.

There are some conditions which I would regard as a life not worth living. One such condition is severe dystrophic Epidermolysis Bullosa. This is one of the candidate conditions for neonatal euthanasia in the Netherlands. In this congenital condition, the skin relentlessly peels off, causing extreme pain and infection. In the most severe forms, the child often dies of infection in the first year of life, even with maximal medical therapy. It seems wrong to live a very brief life of severe suffering (even if it can be almost entirely relieved) for no benefit.

Yet Charlie Gard’s case is different. He would not necessarily die in the first year and we don’t know for certain what level of cognitive function he might finally gain. It is true doctors are confident but it is important to remember that at one stage, according to the summary of the judgement,  “Great Ormond Street Hospital, where Charlie was being treated, got as far as deciding to apply for ethical permission to attempt nucleoside therapy, a treatment that has never been used on patients with this form of MDDS. But by the time that decision had been made, Charlie’s condition had greatly worsened and the view of all there was that his epileptic encephalopathy was such that his brain damage was severe and irreversible, that treatment was potentially painful but incapable of achieving anything positive for him.” This delay, if caused by the ethics process, would be another example of “lethal ethics”.

But can we be certain it is too late for anything positive to come about from treatment. To be sure, the odds are vanishingly small. But if they are not zero, why not have a trial of treatment for several months, or a year, under strict pain control (which we are told is so effective in palliative care)? The parents seemed to accept that Charlie’s current state was not one which was worth prolonging and if no progress was made, one could stipulate that treatment must be withdrawn. (There are clearly problems with jurisdiction in the US but the resources anyway would be finite as Charlie presumably does not have US health insurance.)

Is a month or year of experimental treatment that offers a slim chance of improvement clearly against his interests? This seems a different kind of case to the case of severe Epidemolysis Bullosa, where death and suffering are inevitable.

It is important to remember that this is no longer a choice between two futures. After death, there is no future that the decision can enhance. There is no patient and they no longer have any interests. There is only one pathway that the patient can be placed on.

If the treatment might be successful but will lead to a very severely impaired future, perhaps with multiple disabilities, it would still be in the patient’s best interests to proceed. There is no other future available to the patient. In order for treatment to be withdrawn on this ground, it would have to be shown that the individual is not merely severely disabled but living a life which is worse than death. This is both conceptually and empirically very difficult to prove.

The judgement thus seems to assume that a life with severe cognitive impairment is a life which is not worth living. This is highly controversial and difficult to defend in any precise way. I have spent over 20 years studying these issues and although I believe there are some lives which are not worth living, such as epidermolysis bullosa, I can’t say how cases like this can be said to be not worth living.

The basis on which many adult patients are allowed to choose to die is different. Adult patients may choose to have treatment withdrawn, even if that means their death, and it is not unusual for patients to make this choice. I have argued that voluntary euthanasia should be legalised in addition, so that patients whose suffering is unbearable for them, but whose disease is not immediately fatal without treatment may choose to die. The argument for both of these is based on the autonomous choice of the patient. Whilst euthanasia- where patients could make an autonomous choice to die –  is still controversial, it is a basic tenet of medical ethics that patients should have the ability to autonomously consent to – or refuse- treatment, and more broadly dictate how their life goes, and ends.

If we reject best interests as a basis for withdrawal of treatment, it would not mean that the decision to withdraw treatment could never be justified. If treatment is “futile”,-that is there is a vanishingly slim chance of meaningful improvement-, then treatment might be withdrawn on reasons of justice, so that the resources can be used for others with a better chance of survival, or a longer life, or a much better quality of life. That is, it is not worth spending hundreds of thousands of pounds trying to achieve a tiny improvement.

But now we arrive at the problematic aspect of the case of Charlie Gard. The most appropriate justification for limiting his life prolonging medical treatment would be on grounds of distributive justice. However, if an individual, or his parents, are willing to fund that treatment themselves, then arguments for limitation of medical treatment on distributive justice grounds would not apply. This was precisely what Charlie Gard’s parents were proposing. It would have been a very plausible argument that there much better uses of severely constrained NHS resources than providing continued artificial ventilation and expensive intensive care, together with experimental treatment to Charlie Gard. But that was not the argument of Great Ormond St, the doctors or the judge. Instead, they relied on the concept of death being in Charlie’s interests. While I believe that is a possibly sound argument, I have to admit I am not convinced it applies in the case of Charlie Gard.

Here is a thought experiment to put pressure on that argument. If life is really not worth living, it is cruel to allow an individual to continue to live. It is better for that individual to die. Now imagine euthanasia was legal in the UK, as it is the Netherlands. And imagine Charlie does not need medical treatment to keep him alive, though his cognitive impairment is the same. His parents are willing to feed him and keep him alive. If his life were really not worth living, the Court ought to order  euthanasia in his interests. But that would be wrong.

Of course, one might respond in this fictional version, there are no burdens of medical treatment to cause Charlie to suffer. But are the burdens of medical treatment, with modern pain relief, sedation really that great? I find it hard to believe, especially when we see people who spend their lives on artificial ventilators saying their lives are worth living.

Here is another thought experiment. Imagine that we discovered a baby like Charlie Gard in the US with an identical condition. However, he was already being treated with experimental treatment. Would we think it cruel and unusual, a kind of torture, such that treatment should immediately be stopped so that he could “die with dignity”? I doubt it. Such experimental treatment, under sedation and analgesia, would continue for a period of weeks or months until it was clear whether it was providing a benefit.

Taking best interests alone, the slim chance of life is almost always more in the patient’s interests than a definite death. Where an experimental treatment exists, steps ought to be taken to minimise the suffering and side effects of the treatment. However, when the alternative is death, the most appropriate justification for denying treatment is justice, not that it is in the best interests of the person to die. And when an individual, or others on their behalf, is willing to fund the full costs of the treatment, the argument from justice does not apply.

Of course, in the case of Charlie Gard, it is possible that the treatment might have some effect or that he could continue to live for a long time in a severely brain damaged state with the support of mechanical ventilation. If long term mechanical ventilation does not provide sufficient benefit to warrant its high cost, that would be a reason to deny life prolonging medical treatment. But it is not a reason to prevent his parents taking him to the US to take the one chance of a better life, even if that chance is very small.

April 26, 2017 at 07:41AM

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Debate Reponse: Charlie Gard, Interests and Justice – an alternative view

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Dominic Wilkinson

Responding to Julian Savulescu

The sad and difficult case of Charlie Gard, which featured in the media last week, is the latest in a series of High Court and Family court cases when parents and doctors have disagreed about medical treatment for a child. Doctors regard the treatment as “futile” or “potentially inappropriate”. Parents, in contrast, want treatment to continue, perhaps in the hope that the child’s condition will improve. In the Charlie Gard case, the judge, Justice Francis, rejected Charlie’s parents’ request for him to travel to the US for an experimental medical treatment. He ruled that life-sustaining treatment could be withdrawn, and Charlie allowed to die.

Two reasons

As Julian Savulescu argues,there are two different ethical reasons for health professionals to refuse to provide requested medical treatment for a child. The first of these is based on concern for the best interests of the patient. Treatment should not be provided if it would harm the child. The second reason is on the basis of distributive justice. In a public health system with limited resources, providing expensive or scarce treatment would potentially harm other patients since it would mean that those other patients would be denied access to treatment.

The importance of resources

When doctors and the courts consider cases of ostensibly “futile” treatment, they often focus exclusively on best interests. That is understandable, since the prevailing ethical and legal frameworks largely ignore the question of limited resources. The courts have no mechanism, statute or precedent, to allow them to assess whether or not a treatment would be too expensive or of too little benefit to provide it. Professional guidelines tell doctors that they should base decisions on the interests of the child.

In many cases, however, it is uncertain whether or not treatment would be in the interests of the patient. There may be much stronger and clearer arguments to limit treatment on the basis of finite and scarce medical resources.

Take, for example, infants with a severe congenital condition causing paralysis, spinal muscular atrophy. Infants with the most severe forms of condition are unable to breathe without the help of an artificial ventilator. They will be dependent on machines to breathe for the rest of their lives. They are unable to move, to speak. They may not even be able to open their eyes. In such cases, courts in the UK have decided that continued medical treatment would not be in the best interests of the child (see for example, this decision last year). Yet, in other countries long term artificial ventilation is provided for children with spinal muscular atrophy. Such children, though profoundly disabled, appear to value their lives, and judge it a life worth living. Life-sustaining treatment appears at least potentially in the best interests of a child with spinal muscular atrophy.

However, life-long artificial ventilation is extremely expensive. It is estimated to cost around £240,000 per year to provide home ventilation. This figure is almost ten times higher than the usual maximum cost of affordable treatment in the National Health Service.

To take an even clearer hypothetical example: a child with a relapsed form of cancer develops organ failure. Without a liver transplant he will die within a matter of weeks. With a transplant, he will potentially recover in the short term; however, given his cancer, he will nevertheless die within the next six months. Would it be in the child’s best interests to receive the liver transplant? Potentially. However, if the liver would match another patient, it would be unreasonable to give him the organ, it could harm someone else who misses out. There is a severe shortage of livers for transplantation. About 10% of patients on liver transplant waiting lists die before a liver is found. Ninety per cent of children who receive a liver transplant (in the absence of cancer) survive for at least 5 years.

Overlapping and diverging reasons

The different ethical reasons that might justify a decision not to provide treatment might come together, or they might come apart. The figure below shows the relationship between the two.

If treatment would be both affordable and in the child’s interests (region A in the figure), it should unquestionably be provided. If treatment would be neither affordable, nor in the child’s interests (region D), treatment should not be started or should be stopped. But sometimes the picture is more mixed. Perhaps long-term ventilation in spinal muscular atrophy is in region B, possibly in the interests of the patient, but unaffordable? In the Charlie Gard case, parents had crowdsourced funding to enable him to be taken to the US for treatment. That would potentially mean that the resource issue is not relevant. Perhaps then treatment would be in region C, affordable, but contrary to interests?

Best interests and life-sustaining treatment

Julian Savulescu argues that “taking best interests alone, the slim chance of life is almost always more in the patient’s interests than a definite death.” On that view, if resources aren’t an issue, there is virtually no situation when treatment would be contrary to the best interests of the patient. Is that right?

One way of thinking about what would be in someone’s best interests is to imagine a set of scales. On right side of the scales are the reasons in favour of a course of action – the benefits. On the left side of the scales are the reasons against. Which side is heavier? Which way will the scales tip?

Julian’s view that a slim chance of life is always better than no chance, would be correct if there were no down side to providing treatment. If it were a question of weighing a small chance of a positive outcome, against an empty scale on the other side, the balance would be tipped in favour of treatment, even if the chance (or magnitude) of benefit were tiny.

But there are often significant negatives in the balance. Those negatives can arise from the child’s illness, or from the medical treatment.

Being kept alive in intensive care is not pleasant. Although we do our best to provide pain relief, sedation, care and comfort to gravely ill children and babies, that ability is finite and imperfect. Children on long-term ventilation often appear uncomfortable at least part of the time. They have frequent needles and invasive procedures. They may be distressed and unable to communicate the source of their distress.

As Julian points out, we could remove all possibility of suffering from procedures or from a child’s illness by providing continuous deep sedation – perhaps akin to general anaesthesia. However, in taking such steps to remove the weight from the left side of the scale, we would also, in many cases, remove the positive reasons in favour of treatment, (the right side of the scale). If we are providing experimental treatment to a brain injured child, how would we know if it is working if the child is kept permanently unconscious? If, on the other hand, the reason to continue treatment is because it is judged that the limited conscious experiences available to a severely impaired child are judged to still give them a life worth living, anaesthesia would remove even these benefits.

Experimental treatment, best interests and children

The reason why these decisions come to the court at all is because we do not think as a society that parents’ have an absolute right to make medical decisions for their children. We do allow parents to make many decisions. Parents are given broad discretion about how to raise their children, how to feed them, how to educate them, whether or not to immunise them. Parents will not always make the best choices, but for the most part the state will not interfere or intervene. However, where parents’ decisions run a significant risk of causing substantial harm, their decisions must be challenged, if necessary in a court. For example, that is the reason why Jehovah’s Witness parents are not permitted to refuse a blood transfusion for their child.

When it comes to experimental treatment, there may be different views among health professionals about how to weigh up the chance of benefit against the burdens of the treatment. Some think that the chance is worth taking. Others may feel that standard treatment or no treatment is the better bet. In the face of such disagreement, the decision properly belongs to the parents. Assuming the treatment is affordable, (and the parents want it), it should be provided.

However, where no professionals think that the experimental treatment is worth pursuing and where parents’ request for treatment is unreasonable, they should be overruled.

Experimental treatment, best interests and adults

In treatment decisions for young children, the court focuses on best interests, because the wishes of the child are unknown. They can’t tell us their views, and we feel that it is important to protect the child from harm. The situation is different for adults, since they may be able to tell us their own views.

We might imagine, for examine, an adult equivalent of the Charlie Gard case, where a young adult had a progressive brain disorder and was now unconscious and dependent on life support in intensive care. In such a case, we would likely focus primarily on what we know about his views on treatment. An adult’s wishes might conflict with what would be in his best interests. He might have had idiosyncratic or unreasonable views. He might have made an unwise choice. But, as long as he had the capacity to make decisions, (and as long as the treatment option was affordable), we should try to respect those wishes. So, in this imagined version, if there is good evidence that the adult Charlie had wanted to be kept alive on a ventilator, if he would have wanted to pursue experimental treatment in the US, despite the apparently slim chance of benefit – treatment should be provided or continued.

These decisions about life-sustaining treatment for critically ill children are fraught and difficult for all involved. Parents are, rightly, at the heart of the decisions that are made daily in intensive care units up and down the country. Their views about treatment are important, and their wishes are usually followed.

However, there are limits.

Sadly, reluctantly, doctors and judges do sometimes conclude and are justified in concluding that slim chances of life are not always better than dying. Providing comfort, avoiding painful and unhelpful medical treatments, supporting the child and family for their remaining time. Sometimes that is the best that we can do, and the only ethical course.

April 26, 2017 at 07:41AM

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Damages and communitarianism

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By Charles Foster

The Lord Chancellor recently announced that the discount rate under the Damages Act 1996 would be decreased from 2.5% to minus 0.75%. This sounds dull. In fact it is financially tectonic, and raises some important ethical questions.

In the law of tort, damages are intended to put a claimant in the position that she would have been in had the tort not occurred. A claimant who, as result of negligence on the part of a defendant, suffers personal injury, will be entitled to, inter alia, damages representing future loss of earnings, the future cost of care and, often, private medical and other treatment.

Where damages are awarded as a lump sum, there is a risk of over-compensating a claimant. Suppose that the claimant is 10 years old at the time of the award, and will live for 70 years, and the future care costs are £1000 a year for life. Should the sum awarded be £1000 x 70 years = £70,000? (70, here, is what lawyers call the ‘multiplier’). It depends on the assumption one makes about what the claimant will do with the lump sum. If she invests it in equities that give her (say) an annual 5% return, £70,000 would over-compensate her.

In the case of Wells v Wells1, the House of Lords decided that, to avoid the risk of under-compensation, claimants should be treated as risk-averse investors. It should be assumed, said the House, that the discount rate should be fixed by reference to the return on index-linked gilts – Government securities. The rate was 2.5% from 2001 until February of this year. The reasons for the change to minus 0.75% are here

The multiplier for pecuniary loss for life for a 10 year old male claimant with a normal life expectancy has risen from 34.08 to 108.32. A leading firm of solicitors has estimated that in cases where there is continuing loss of a sort typical in major personal injury/clinical negligence cases, the value of a claim for claimants aged 10-20 years with a normal life expectancy will increase by 100-200%: a claim previously valued at £5 million will be £10-15 million.

Insurers are predictably distraught, and have said that we are all victims of the change, since premiums will have to rise in order to pay for the larger awards of damages.

Of greater ethical interest is the situation of claimants who sue an NHS body. NHS bodies are effectively self-insuring. The £20 million settlement in favour of a child whose cerebral palsy was caused by obstetric negligence comes out of the pot used to pay doctors and to buy drugs.

Once a court awards a lump sum of damages to a claimant, the claimant can do what she likes with the money. She does not have to spend it on the care (for example) for which it was given. There is nothing to stop her investing it in riskier but potentially higher-yielding equities. If her investment strategy pays off, giving her more than the index-linked gilts that the court assumed she would buy would have given, she does not have to account to the defendant for the difference: it is a windfall. This means that in an NHS case the NHS has overcompensated the claimant. The NHS may in fact be hit twice: it may have given the claimant £x for private medical treatment, but the claimant may get the treatment on the NHS – keeping the money. That is plainly wrong. But other ethical questions are rather harder.

The governing philosophy of Wells v Wells is that claimants have already been unlucky in being injured. They should therefore not be required to take any more chances – and in particular they should not be required to take their chances on the open investment market.

Is this right? Why should one bout of bad luck entitle claimants to value a claim on the basis of an investment policy that would not be endorsed by the overwhelming majority of financial advisers – at least in relation to funds that are not tied to medical or care needs? Is the principle of full compensation so important that it should require the courts and society to turn a blind eye to over-compensation? If it should require that blind eye in some cases, is it not importantly different in NHS cases? There there is the certainty that over-compensation of a claimant will result in compromises in the care of other patients. Are those compromises not a high price to pay for the principle? In an age of brutal health rationing, shouldn’t claimants pay the price of a slim chance of under-compensation in order to discharge their communitarian obligations to the patients whose care is affected by big damages payments? And in any event, shouldn’t there be more rigorous policing of the use that claimants make of their damages? If they’re paid an index-linked gilts-based sum, shouldn’t they be required to put the money into gilts – so at least giving society (and hence, indirectly, the NHS) the benefit of the use of that money?

The Lord Chancellor has promised a review of the system of compensation. These essentially ethical questions should be at the heart of the review.

References

  1. [1999] 1 AC 34

 

 

April 25, 2017 at 07:40PM

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from Charles Foster

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Syria: LafargeHolcim chief steps down after Syria investigation

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The head of cement maker LafargeHolcim, Eric Olsen, is stepping down from the role following an investigation into the company’s activities in Syria.

The firm recently found that managers of a factory in Syria had paid local armed groups in order to stay open.

Mr Olsen said he had not been involved in any wrongdoing, and was standing down to bring “serenity” to the Swiss-French company.

Lafarge is the world’s biggest supplier of concrete, cement and aggregates.

In its latest update, the company confirmed that the payments had indeed been made but agreed that Mr Olsen was not to blame.

This article has been summarised, the full original article can be found at bbc.com

April 25, 2017 at 05:44PM

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United States: Panama Papers law firm boss says fallout has spurred tax shelter boom in US

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The co-founder of the law firm at the center of the Panama Papers scandal says the fallout has set off a “thriving” boom in the creation of tax shelters in the United States.

Juergen Mossack, who partnered with Ramon Fonseca to create the Panamanian firm Mossack Fonseca, said in a document obtained on Thursday (April 21) by AFP that after the Panama Papers leak a year ago, the number of new tax shelters created has fallen by 30 per cent in Panama and elsewhere.

The full original article can be found at straitstimes.com

April 25, 2017 at 05:44PM

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World: Report Finds Fashion Supply Chains ‘Not Transparent’: Dior, Prada And Giorgio Armani In Bottom 10%

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Few fashion brands are implementing measures to disclose details on their supply chain, according to Fashion Revolution. Any ethical breaches within many of the world’s 100 leading brands may be undetected. Worse still, they may be undetectable.

Fashion Revolution, a campaigning NGO, assessed the transparency scorings of brands’ supply chains. The research was conducted through a combination of questionnaires sent directly to the brands and direct research from websites and published policies.

Among the worst scoring brands were Abercrombie & Fitch, Amazon, Dior, Giorgio Armani and Urban Outfitters.

This article has been summarised, the full original article can be found at forbes.com

April 25, 2017 at 05:44PM

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