Consent Treatment Patients - Health Dissertations - Free Essay Example

Sample details Pages: 24 Words: 7096 Downloads: 6 Date added: 2017/06/26 Category Health Essay Type Analytical essay Did you like this example? Chapter 1-Introduction 1.1 In modern society, everyone has the basic right to consent to medical treatment. However, this is a recent development as consent was not always considered a critical issue in medical treatment. Hippocrates himself, advised doctors that they should conceal the effects of medical treatment from their patients, his reasoning being he believed that when patients were given relevant information they would take a turn for the worse. Don’t waste time! Our writers will create an original "Consent Treatment Patients Health Dissertations" essay for you Create order It was not standard practice for patients to question a doctors decision or authority. Recent changes have contributed to this change in attitude and as such altered the method of practice of a doctors obligation. The final years of the twentieth century as witnessed the most dramatic shift in the reputation of the medical profession within the United Kingdom, due to scandal after scandal plaguing doctors. Major news headlines left the doctor-patient relationship in a state of concern, for example, Doctors who steal organs face jail.This headline refers to the Bristol and Liverpool Hospital where it was discovered that they were retaining childrens organs, without consent or knowledge of the parents. It became apparent in the Bristol and Liverpool reports that organ retention, of both children and adults was widespread practice. Another significant humiliation for the medical profession was the case of Harold Shipman, a general practitioner who was convicted of murdering fiftee n of his patients. Whether these circumstances are due to the actions of individualist or media influence makes little difference to the effect they had on societys viewpoint. There was need for change and this brought about the introduction of regulations and guidelines that protected both the patient and the doctor. 1.2 Informed consent was seen to break the doctor knows best concept and established a liberated choice for the patient. The locus classicus for informed consent is contained within the case Schloendroff v Society of New York Hospital, where it was held, â€Å"Every person being of adult years and sound mind has a right to determine what shall be done with his own body.† There are many examples within the UK system which confirms this principle of law, one being the case Re A (Minors) in which Robert Walker L.J stated, â€Å"Every human beings right to life carries with it, as an intrinsic part of it, rights of bodily integrity and autonomy The principle und erpins the common law concerning consent to treatment within the UK. The consent that a patient has the right to choose is a fundamental part of receiving medical treatment. No considerations need to be examined whether the choice is rational or irrational, as the patient has an absolute right. 1.3 The Department of Health 1993 stated, â€Å"Consent is the voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of its success and any alternatives to it.† Meaning any permission given under any unfair or undue pressure is not consent. Consent may be expressed or implied, however the validity of informed consent does not depend upon the form in which it is given 1.4 This dissertation will firstly consider the development of informed consent, as the English courts initially had reservations of its establishment and for this reason was gradually introduced in stages, until the case of Chester v Afshar which saw the full acceptance of the doctrine. It needs to be considered how the medical profession dealt with this change and in addition how patients themselves are exercising such powers. The effect in which the Human Acts 1998 has had on the courts decision making process will also be analysed to observe the relevance this may have had on informed consent. Another factor of informed consent includes giving sufficient information and the patients understanding of this. For informed consent to exist, the patient must have all the relevant information and capability to make an informed choice as to the treatment they decide to receive. This was made apparent in the case Reibiu v Hughes, where Laskin J stated, â€Å"the genuineness of consent to medical treatment depends on proper disclosure of the risks it entails† For informed consent to exist within the UK; provisions need to be made for those who are s imply unable to give an informed choice. The capacity of a patient needs to be considered and if they lack this then a doctor must make a decision as to what is in the patients best interest. This can be seen to restrict informed consent as it goes against its true principle, however if a patient can not make an informed choice for themselves then it is only passable that someone has to act on their behalf. This dissertation will examine the procedure for this and how the law enables decisions to be made fairly and respectably. Chapter 2-The Development of Informed Consent 2.1 The area of law that needs to be established is the nature and scope of the duty to inform and the extent to which this has been incorporated into the English legal system. The existence of a duty to warn came about when the relationship between a doctor and the patient, which was based solely on trust, began to erode. There was a need for scrutiny and examination within the medical profession and thi s was achieved through the development of the law. The scope of the doctors duty of care is determined by a reference to the Bolam case. Mr Bolam agreed to electroconvulsive therapy to help improve his depression. He suffered fractures in the course of the treatment. The risk was known to his doctor, but he had not informed Mr Bolam of such. Mr Bolam alleged that the failure to warn him of the risk was negligent. The judge found that the amount of information harmonized with accepted medical practice and dismissed his claim. The judge, McNair J, directed the jury to the principle that, â€Å"A doctor is not guilty of negligence if he has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art† Therefore, the defendant doctor had conformed with a practice which was approved by a responsible body of medical opinion. This test was known as the Bolam test and it determines whether the doctor fell below  "the standard of the ordinary skilled man exercising and professing to have that special skill† 2.2 Where there is a difference of judgment between two differing medical opinions, the defendant will be given the benefit of the doubt. As a result a doctor would not be found negligent if the court is satisfied that there is a responsible body of medical opinion that considers the doctor had acted appropriately. This responsible body need not be the majority of the profession. It appears that the courts allowed the medical profession to set their own standard. A doctor simply needed to provide an expert testimony and the courts assumed that it must be responsible. In exceptional cases, the courts perceived some established practice to be substandard, however it appears that only one reported case has materialized where such a judgement has occurred. The case, Hucks v Cole, where a woman contracted puerperal fever due to her doctor failing to treat her with penicillin for he r septic toe and finger. Although a number of distinguished doctors gave evidence that they would not have administrated penicillin, the Court of Appeal found the defendant to have been negligent. The Judge, Sachs LJ, commented that the courts have to be in a position to verify that the medical opinion stood up to logical analysis and that they are not merely tailored to fit the requirements of the respective parties cases. This judgement was one of rarity, as Judges would not ordinarily cross examine a doctors opinion on a logical basis. 2.3 Often cases were even more favourable to the doctor, as is witnessed in the case Hatcher v Black. In this case Lord Denning stated, â€Å"As a matter of law it might be justifiable for a doctor to tell a lie, when he only does that which many a wise and good doctor would do.† It can be concluded from this that it is entirely for the individual doctor to determine what to inform his patient, even if the doctor went so far as to opt for what his lordship termed a therapeutic lie. Professor Michael Jones expressed the state of play as a football score, â€Å"In six medical negligence claims before the House of Lords between 1980-1999 the score stood at Plaintiffs 0, Defendants 6†. 2.4 The Bolam test which was adopted by English law focused on accepted practice and responsible profession opinion. The story was very different in America, as the American Courts rejected the professional medical standard and instead emphasised the patients right to know what the risks are inherent in the treatment. In Canterbury v. Spence a US Court stated that the prudent patient should prevail and its the doctors duty to disclose to their patient any material risk in a proposed line of treatment. The prudent patient principle emphasises what the doctor needs to inform the patient, according to what the average reasonable patient would want to know about potential risks and treatment options. This is made evident when the Judge commented, â€Å"A risk is material when a reasonable person†¦.is likely to attach significance to the risk† Contrary to the English Courts, the USA placed more importance on the patients rights and exigencies than those of the doctors. However, soon after the Bolam decision the English law was making changes towards incorporating this American style of law, to incorporating the doctrine of informed consent. 2.5 The question that needs to be examined is to what extent the Bolam test does or should apply to the duty to inform. Sidaway v Board of Governors of the Bethlem Royal Hospital was the subsequent, leading case to appear before the House of Lords that approached such a matter. While the majority of Lordships legitimatised the traditional test expressed in the case of Mr Bolam, the individual judgements were small steps towards informed consent. Four out of the five Law Lords rejected the transatlantic test that a duty to inform a patient should be based on the reasonable or prudent patient and Lord Scarman alone favoured this manner of law. 2.6 Lord Scarman made it apparent that he considered the patient to have the right to choose what happens to his body, which signified the patient needs to know the risks so can exercise an informed choice. He went on to express what he held to be the suitable relationship between a doctor and his patient, â€Å"There is room in our law for a legal duty to warn a patient of the risk inherent in the treatment proposed†. He went on to consider the doctrine of informed consent and its relevance in the Canterbury case, â€Å"I think the Canterbury propositions reflect a legal truth which too much judicial reliance on medical judgment tends to obscure† Lord Scarman acknowledged the patients rights and that the prudent patient principle made the doctors much more accountable for their actions. As such he rejected the current medical practice that a patient will be informed if he need s to be, as opposed to if he wants to be. Doctors, in Lord Scarmans view, should be liable where the risk is such that in the courts view a prudent person in the patients situation would have regarded it significant. He appears to suggest that the onus proof rests on the doctor to satisfy the court as to the reasonableness of any non-disclosure and therefore suggesting a support for informed consent. However, it must be noted that he did not find in favour of Miss Sidaway, on the basis that she failed to establish that the less than one per cent risk was such that a reasonable patient would consider significant. 2.7 In spite of this the speech of Lord Scarman has stood as a symbol of hope to those who argue for informed consent to be introduced into English law. Lord Diplock rejects Lord Scarmans scrutiny, as he maintains that the Bolam test covers all aspects of the doctors duty to care to his patient. However, he distinguished from the position where a patient asks a question a bout treatment, by stating â€Å"if the patient in fact manifested this attitude by means of questions the doctor would tell him whatever it was the patient wanted to know.† This illustrates that while Lord Diplock believed doctors were not be required to inform the patient of risks, he does not fully discount the patients rights. Lord Bridge also rejected the notion that a patient should be warned of all risks, yet â€Å"when questioned specially by a patient of apparently sound mind about risks involved in a particular treatment proposed, the doctors duty must, in my opinion, be to answer both truthfully and as fully as the question requires.† This gives the patient the option of asking for information from the doctor and if the doctor failed to do so then his duty of care could be in breach. However, Lord Templeman, expressed that this is not clear cut, as â€Å"the court will be slow to conclude that the doctor has been guilty of a breach of duty owed to the pa tient merely because the doctor omits some specific item of information.† It was important that Lord Scarman recognised the doctrine of informed consent and that the remaining four judges recognised the meaning of a patients ability to enquire and the doctor responsibility to notify. 2.8 It seemed that English legal system was initially hesitant to adopt informed consent into medical law. However, the approach taken in the case Gold v Haringey Health Authority contradicts that expressed by their Lordships in Sidaway. The claimant, in this case, indicated that she did not wish to have any more children and was advised to undergo a sterilisation operation after the birth of her third child. The operation was carried out but the claimant later became pregnant and gave birth to her fourth child. The Judge at first instances applied his own analysis as to what information the doctor should have given and found the defendant negligent. Upon appeal, Lloyd L.J held that the Bola m test should be strictly applied and he dismissed the view of the judge prior to him. He asserted that for the purposes of establishing the test as to the duty of care owed by a doctor to a patient no distinction needed to be made between advice given in a therapeutic and non-therapeutic context. In reference to Sidaway he stated, â€Å"the House of Lords could have adopted the doctrine of informed consent favoured in United States of America and Canada, but the House of Lords decided not to follow that path.† It seems clear from the Sidaway judgement that the nature to inform is more extensive than that of the Bolam test where no information is required. The decision in Gold repealed any progress been made towards informed consent and the judgement seemed to convey patient autonomy to be rather trivial 2.9 The view of Diplock in Sidaway has been regarded as the authoritative statement regarding the extent of the doctors duty. There has been a move away from the Diploc k approach as seen in the case Pearce v. United Bristol Health Care NHS Trust which altered the analysis of a doctors obligation. Mrs Pearce, who was expecting her sixth child, was two weeks past her due date of delivery. She discussed the possibility of induction with her obstetrician who warned her of the risks of induction and caesarean surgery, but did not tell her that there was a 0.1 to 0.2 per cent risk of stillbirth associated with non-intervention. Mrs Pearces child was stillborn and she alleged that failure to warn her of the full risks was negligent. Lord Woolf, in this case, held that the patient had the right to know and stated the doctor should normally inform a patient of â€Å"a significant risk which would affect the judgment of a reasonable patient.† It was decided, however, that while a doctor is under an obligation to warn, the 0.1 to 0.2 per cent risk of stillbirth was not classed a significant risk. While the Pearce judgment did not go so far as to fu lly accept the doctrine of informed consent, it adopted elements of the reasonable test. The judgement goes a certain distance to reconcile the approaches of Lord Scarman, Lord Bridge and Lord Templeman in Sidaway. It isolated Bolam, which by Professor Margaret Brazier,who has wrote many publications on issues of medical law, was considered good as Bolam was â€Å"out of control and out of context, it came close to acquiring democratic status in some quarters.† The test for duty to warn was now suggested to be that the reasonable doctor must tell the patient what a reasonable patient wanted to know. The judgement signified a more patient-friendly approach and made greater demands on the level of disclosure. Chapter 3: Further development towards the doctrine of informed consent 3.1 The medical professional has taken steps to further achieve the full introduction of informed consent into the medical world. The General Medical Council (GMC) produced comprehensive guidance to, doctors on seeking the patients consent in Seeking Patient Consent: The Ethical Considerations February 1999 (appendix I). These guidelines make particular reference to the requirement on doctors to attain informed consent, a doctrine which a few years earlier was alien to English law. Since 1992 Professor Sir Ian Kennedy LLD, a former member of the GMC, has been arguing that doctors need specific guidelines on what constitutes good practice. At that time he was the voice of the minority, however due to dramatic change in the doctor-patient relationship the GMC recognised guidelines needed to be established. The standard adopted in these guidelines resembles elements of the prudent patient test specifically that of the judgment made by Lord Scarman in Sidaway. Guidance from the GMC directs doctors to†¦take appropriate steps to find what patients want to know and ought to know about their condition and its treatment. Andrew Hockton believed that the guidelines,  "should now be considered to amount to more an ethical obligation: they provide at least, a starting-point for measuring the extent of a doctors duty of care to patients† It appears that the guidelines are considered to be a benchmark for doctors to monitor their legal duty of care, to which the Bolam test fails to create. This dissertation professes that perhaps this is the responsible body of medical opinion and it seems the medical profession are setting a higher standard for both themselves and the patient. 3.2 It must be noted the development of the Human Rights Act 1998, has extended the doctrine of informed consent in medical treatment. Incorporation of the European Convention of Human Rights under the Human Rights Act encourages the courts to focus more on the patients rights. This area of law includes Article 2 (the right to life), Article 3 (prohibition on inhuman or degrading treatment) and Article 8 (the right to respect for private and family life which include s the right to bodily integrity). The case R(on the application of Wilkinson) v Broadmoor Hospital illustrates how the introduction of the rights affected certain aspects of medical law. A mental patient appealed concerning a decision to administer treatment without his consent and under restraint. He claimed it infringed his rights under the European Convention of Human Rights 1950, Art.2, Art.3 and Art.8. The judge allowed the appeal stating that under the 1998 Act, it was no longer appropriate to forcible treat detained patients without a court judgement granting so. While the decision in this case would not have been so without the introduction of the Human Rights Act, it had little effect on the majority of medical consent cases. The Act was expected to have a great impact upon issues of medical consent, however it does not seem to have made a dramatic difference on the Courts decision making. 3.3 The most recent case that has dealt with the issue of informed consent is C hester v Afshar, where the claimant underwent surgery and suffered nerve damage leading to paralysis. The surgeon failed to warn Miss Chester of the inherent risk in surgery and the House of Lords decided that the risk was of sufficient quantity to determine the defendant had inadequately warned. The case is considered to show the importance the courts attached to the principle of autonomy, as Lord Hope reiterates when he states, â€Å"the duty to warn has at its heart the right of the patient to make an informed choice as to whether and if so when and by whom to be operated on.† The claimants evidence verified had she been warned of the risk she would not have agreed to surgery without at least seeking a second opinion on the necessity and risks of surgery. Therefore, a causation link was adopted by the courts to further prove negligence by the doctor. 3.4 In this case it was sufficient for her to prove that, if properly warned, she would not have consented to the oper ation. Dr Afshar was found to violate her right to choose, which meant she was unable to seek further advice or alternatives. Therefore, a claimant pursuing a claim in this area must prove if the information had been given, their decision as to the treatment would have caused extra consideration. Lord Steyn asserted that individuals have a right to make important decisions affecting their lives for themselves†¦in modern law paternalism no longer rules. This case was a ground breaking decision by the House of Lords, as it introduced fully informed consent and it addressed the purpose and rationale behind a doctors duty to warn. 3.5 Historically the law as taken the view that doctors are honourable and true, essentially allowing the medical profession themselves to dictate the duty to disclose. As a result of the decision made in Chester v Afshar this outlook has changed somewhat and it appears to provide a new dawn for patients rights. It has created a remedy for patients who have received insufficient information, where previously the majority of case had failed to provide such a remedy. The days of Lord Denning are long gone, meaning the doctor-friendly Bolam principle has practically been condemned worthless. While the judgement can be seen to address the reality of responsible expectations of society, it seems the judgment leaves the court with a difficult job determining who, between the patient and the doctor, is effectively legitimate when it comes to what information is disclosed. More specifically the outcome is likely to be met with distaste from doctors and there is already evidence of growing concern from within the profession. Despite the doctors concern the law of informed consent has moved on considerably from the reality where the majority of cases would fail to offer a remedy for those who had not been completely informed. As was stated by Sarah Devaney in a Medical Law Review, that back then, â€Å"It did not matter whether or n ot doctors were wearing the flak jackets of consent, as patients wishing to make claims about lack of information were in any event carrying unloaded guns. However, after cases, time and the materialization of certain events the doctrine of informed consent began to take effect in English law. Chapter 4: The Degree of Sufficient Information 4.1 Informed consent is based on the requirements of appropriate information to allow patients to make an informed choice. The law fails to formulate a standardize figure which can be consider significant and therefore it can only be gauged on previous cases and what the accepted amount has or has not been within these circumstances. More specifically, as no clear indication has been articulated, the judgement will be dependant on the individual facts of the case, as long as this coincides with the authoritative case law. What is clear is that failure to advise sufficiently as to the nature and purpose of the procedure may give rise to a n action against the doctor. If the patient is given inadequate information, then how they able to make an informed decision and therefore be said to have given real consent? 4.2 The leading case Chester v Afshar (as discussed above) contradicted any previous beliefs of the court and that of the medical profession. The case prior to Chester was Pearce v United Bristol Health Care (as discussed above) where Lord Woolf stated that the doctor should normally inform a patient of a significant risk which would affect the judgement of a reasonable patient. It considered the balance of percentages and whether this balance would have effected the patients decision to have the treatment. The risk of 1-2 per cent in this case was not considered to be sufficient to represent a significant risk. The decision in Chester made it clear that a 1-2 per cent risk was an adequate percentage for the doctor to warn the patient. Even though, the doctor appropriately informed according to the Pearce decision and the GMC standards, Chester v Afshar brought a new way of thinking to the table. 4.3 Chester disregarded the concept of what a reasonable patient would want to know and instead looked at what each individual patient wanted to know for themselves. This meant it was more plausible for the doctor to consider the patients personality, concerns and wants and information given must be relevant to the patients decision. The involvement of the causation link enabled patients to assert their rights over decision not only on the surgery itself, but in addition on the circumstances in which it was under, for example the time, place and in whose hands the operation should be performed. The causation link made it easier for patients to receive a remedy at law, as long as they could prove that had they been sufficiently warned of the risks they wouldnt have undergone the treatment. This does not mean they need to prove that they would not have had the operation at any time, jus t not at that moment in time in which they did. The doctor needs to make acknowledgment to both warn of a significant risk and risks which a patient would consider relevant, even if not below significance. It left the doctors with the delicate job of determining what information individual patients wanted to know. This contemporary approach sent shock waves through the medical profession and the GMC had to amend their guidelines, as they now failed to reach a high enough standard. The new guidelines can be found In Good Medical Practice 2006. (see Appendix II) 4.4 Professional guidelines now go further and state the doctor must do his best to discover the patients individual needs and priorities to analysis what information that individual may require. When consenting to treatment patients should be aware of certain factors such as, diagnosis, prognosis, various treatment options, probabilities of success and possible side effects. This was the situation in the case Smith v Tunbridge Wells Health Authority, where a claim was brought against a 28 year old man who was not warned of the risk of impotence inherent in rectal surgery. His claim succeeded despite the risk being considered significantly low, as the judge found failure to warn such a patient of a risk of such importance to him was neither reasonable nor responsible. The doctor needed to have balanced the small risk of importance against the importance it possessed on his life. 4.5 The most effective way of obtaining consent that is currently in the English medical system is consent forms. Consent forms place emphasis on the patients rights; it gives them a sense of control and perhaps recaptures some of the faith that is said to have disappeared between doctors and patients. There is no requirement in English law that consent forms should be in writing, however the Department of Health have recommended the use model consent forms (see appendix III). The most prominent aspect is the fact it does not shy away from informed consent and instead seems to embrace it. It attempts to ensure that patients are aware that they are entitled to ask questions and expect explanations do with the medical treatment they receive. Unfortunately this way of operating is time consuming and is limited to operations and major procedures. It would not be viable for such things as checking a patients throat or examining a patients stomach, as these everyday occurrences are too frequent and considered to be too minor. Some see the consent form as purely evidential yet other believes them to signify fairness to both the patient and the doctor. It creates patient awareness of the fact that they have the right to know and for this right to be attained the patient needs to make it aware what they specifically want to know. This does not extinguish the doctors duties, he must still follow the guidelines set out in obtaining informed consent, for example, explaining the treatment and its implicat ions. In the case Abbas v Kenny the judge stated the obligation is not placed upon the patient and it simply reaffirms their rights, yet it is still the doctors responsibility to â€Å"take into account the personality of the patient and the likelihood of misfortune.† 4.6 Even if a warning is given, it can not be consider a suitable warning if it is insufficiently clear to the patient and affects their ability to make a decision on information they fail to comprehend. The doctor must take responsible steps to ensure that advice is understood by the patient. To what extent is it the doctors duty to make sure the patient understands? Chapter 5: A Patients Capability to Understand 5.1 There is a rebuttable presumption that adults have capacity to consent to or refuse treatment. Therefore to make consent valid they must possess the capacity to understanding the method, consequences and benefits. If one fails to understand the information given and the inherent risks of t reatment then it can not be regarded as informed consent. Care must be taken to not automatically presume those with learning difficulties are incapable; it is important for doctors to not underestimate a person from their faà §ade. Capacity is not a question of decree of intelligence or maturity of the person concerned, it incorporates elements of ability and belief. 5.2 There are different functions of what must be understood. The must frequently cited case in this context is Re C (Adult: Refusal of Medical Treatment) in which, Thorpe J, held that the person must understand the nature, purpose and effect of the procedure. In other words, sufficient knowledge constitutes the general functions of treatment. Another function that capacity can occupy is that held in Re T (Adult: Refusal of Traetment) where Lord Donaldson referred to knowledge in broad terms of the nature and effect of the procedure to which consent was given. The level of understanding was made important in thi s case and that this will differ according to the gravity of the decision. More specifically, the more serious a decision the greater capacity required and accordingly patients may have capacity to make some decisions but not others. 5.3 Assessment of a patients capacity is determined by reference to the Thorpe. Js three stage test in Re C it states the courts will assess the patients ability: to take in and retain treatment information; to believe it; to weigh that information, balancing risks and needs. In this case, a sixty-eight-year old patient was being detained in a special hospital, as he survived from schizophrenia. Despite this, the Judge ruled that the patient remained capable of understanding what he was told about the proposed treatment and the proposed risks involved. By satisfying the three points, a patient can verify that information can be given by the doctor, thought through and decided on and therefore the doctrine of informed consent is followed through. Others that would normally have capacity may be deprived of it by temporary factors such as unconsciousness, confusion, pain or drugs used in treatment. Even a persons phobia can effect they ability, as seen in the case Re MB (Medical Treatment) The patient, MB, suffered acute needle phobia and refused to agree to any form of anaesthetic during a necessary Caesarian section. The Court of Appeal held that she lacked the required capacity to refuse treatment, as her phobia disabled her from making an informed decision. Although she suffered from no mental illness or impairment, temporary factors erode the patients capability. The judge stated that hercapacity was inadequate, â€Å"at the moment the needle or mask dominated her thinking and made her quite unable to consider anything else.† Her fear masked her ability to fully understand the risks of the treatment and as such the decision had to be made for her. 5.5 Similar decisions are made when dealing with patients in emergency situations as they too can often lack the ability to give informed consent. When a patient is unconscious, appropriate treatment must be given in an emergency where consent cannot be obtained. As long as there is no available evidence of a patients own wishes, then under these circumstances the law authorises doctor to perform treatment that is necessary to perceive the patients life. Examining the case Murray v McMurchy explains the courts perception of necessity. Whilst the doctor was performing an agreed caesarean section, he sterilised the patient without prior agreement. The courts held that the sterilisation was not necessity and could have been postponed. More specifically as Lord Goff stated in Re F, treatment is to be confined to â€Å"action taken to preserve the life, health or well-being of another who is unable to consent. Such treatment is justified under the doctrine of necessity. The case Re F made it clear that the basic requirement for necessity, was that a doctors duty at that hospital was to utilise their best endeavours, by way of operation or other treatment, that which is in the best interest of such patients. The principle of best interest will be covered more extensively in the next chapter. 5.6 It is important to look at the effect religion may have on ones understanding to consent fully to treatment. Article 9 of the Human Rights Act provides that everyone has the right to freedom of thought, conscience and religion. In the context of treatment, Article 9 reinforces the approach already adopted by the English Courts. Under the principle of autonomy the religious beliefs and values of a competent patient must be upheld, however illogical from the perspective of the observer. An adult can make a decision which others would regard as being wholly irrational or against his or her best interest so long as he has the requisite capacity to understand the na ture, purpose and effect of treatment. A good example of this situation arising within the law is cases involving Jehovah Witnesses. The wishes of competent Jehovah Witness must be respected, irrespective of a reasonable patients rationale or beliefs. The case Malette v Shulman illustrates such an issue, where a blood transfusion was given to an unconscious card-carrying Jehovah Witness. The judge, Robins J.A. stated, â€Å"Competent adults†¦are generally at liberty to refuse medical treatment even at the risk of death. The right to determine what shall be done with ones own body is a fundamental right in our society.† 5.7 Ian Kennedy and Andrew Grubb, two of Englands most influential experts, declare the three stage test makes capacity dependent on the information the patient receives. The doctor must take this factor into consideration and it is their duty to make the information as comprehension and uncomplicated according to patients ability. Most patients w ould not readily understand a complex explanation whereas the same information delivered in a more basic manner may be followed more simply. So the doctor must take into account the patient in which he is informing and the level of understanding they might have. So what is the procedure for incompetent adults and how can treatment be lawfully authorized on their behalf? Chapter 6: Incompetent Adults Under English law, no one is able to make an informed choice for treatment on behalf of an incompetent adult. However, this poses a problem as the patient himself may not be capable of authorizing his own treatment, and no one has the legal authority to act for him. Before 1983, section 34(1) of the Mental Health Act 1959 allowed a guardian, appointed to care for a mentally disabled adult, to consent to treatment on behalf of that patient. This was replaced by section 8 of the Mental Health Act 1983, which restricted the powers of the guardian and placed ownership of power onto the courts. The law in this area has long been unsatisfactory and has since been subjected to extensive review. The most recent amendment is the Mental Health Act 2007, which sets out the procedures that must adhere to the safeguards for patients. The Mental Health Acts, however are subject to persons detained under the Act and is not applicable to the majority of mentally disabled or ill patients living in the community. For them there are no treatment guidelines or legislation set out in UK on how to appropriately acquire consent or to act on their behalf. The clarity on this issue came in a series of cases, which set out the legality of treatment. The Department of Health advised that, It should never be assumed that people can take no decisions for themselves,† and that the doctor â€Å"must never coerce the person into changing their decision. Seeking consent is about helping the person to make their own informed choice† Care must be taken not to make presump tions that individuals with mental disabilities are incapable of consenting, they are too subjected to the competence test set out by Re C, which was looked at in the above chapter. If they possess the ability to retain information, believe it and make an informed choice then they can make an informed decision. However, if they fail to satisfy the criteria then doctors are under the legal duty to treat incompetent patients in accordance with the best interest principle. This principle can be found within the application of the Bolam test, which asserts that a professional person will not be found negligent if he can demonstrate that he acted in accordance with practices accepted by a senior body of people skilled in his field. This objective test is employed to determine the suitability of treatment for that individual patient. As in the case T v T where the Courts authorized an abortion and sterilisation on a mental disabled woman, as the parents and doctors agreed it was in her best interest. The decision empowered the doctors to decided what treatment the patient should receive as long as taken â€Å"such steps as good medical practice demands.† This has changed slightly and it can now be seen that Bolam is simply just a starting point for the best interest principle. The best interest test does not fully coincide with the Bolam test; it encompasses the broad concept yet makes its own assessment of the patients welfare. As Dame Elizabeth Bulter-Sloss P, stated in the case Re S, â€Å"the principle of best interest, as applied by the courts extends beyond the considerations set out in Bolam.† The Bolam test needs the recognition of a responsible body of professional medical opinion which supports the proposed decision to be in the patients best interest. However it fails to take into account ethical, social, moral and welfare issues. Therefore while it is important to consider the objective element, a subjective viewpoint needs to b e included in the decision. The subjective approach is based on the presumed wishes of the patient and the courts consider what the incompetent would do if she or he could make the choice. This subjective element is patient specific and focuses on what is thought to be the patients wishes and beliefs, but of course this is mostly a matter of speculation. The combination of these two fundamental features acts as a balanced approach to the best interest principle, with the medical profession deciding what is the best treatment for the patient, and the courts making the patients welfare the paramount consideration. It is important to note that the thoughts of immediate relatives or carer will be taken into account, as Lord Donaldson ascertained his view when he stated, â€Å"consultation with the next of kin has a further advantage in that it may reveal information as to the personal circumstances of the patient and as to the choice the patient might have made.† The closet to the incompetent adult can give light on the personality and nature of that person which may assist the courts come to a decision that may reflect the patients wishes. Standard practice is that doctors will decide what the best treatment is for the patient and unless the immediate family or carer disagrees, this treatment will be performed. The guidance of the court must be sought where there is doubt about a patients best interest and special category cases; these include non-therapeutic sterilisation and Persistent Vegetative State In Re S, Thorpe L.J made it clear that â€Å"if a particular case lies anywhere near to the boundary line it should be referred to the courts.† Much improvement has been made on the position of consent for incompetent adults, more regulations and guidance are in place to assure the best possible outcome. Chapter Seven-Conclusion This dissertation analyses the aspects of informed consent within the United Kingdom. When looking at the d evelopment of the doctrine of informed consent it seems that initially the courts were reluctant to incorporate it into the legal system. At first the courts left the power in the hand of to the doctor, much to the dissatisfaction of the patients. It seemed to leave them struggling to assert their right of an informed choice and perhaps confused on exactly what this right actually entailed. When informed consent was fully accepted through he case Chester v Afshar it seemed to clear these clouds of confusion and hand the reigns over to the patient. It enabled the patient to exercise a choice and placed regulations on the doctors to make sure patients had all the tools to do so. This is where perhaps doctors became discontented, as it now seemed there job to provide the patient with sufficient information and make sure they understood it. It was a dramatic transition for health professionals as it required more time, which was already considered to lack.

A Brief Look at the Underground Railroad - 1335 Words

For 300 years captured slaves in the United States had no hope for freedom. In the 1800s everything changed when the Underground Railroad had gone into effect as the system kept on growing and there were more than 100,000 slaves escaped from the South and gained their freedom. The journey for a slave to gain freedom was difficult and dangerous under the circumstances in the nineteenth century. Not even slave owners were looking for fugitive slaves, governments also imposed laws to restricted the rights of fugitive slave, causing their escape as an illegal movement. Runaway slaves faced lots of struggles through their escape, they not only encountered the risk of capture from slave owners, they also faced dangers from wild animals. However, there were safe houses called stations, in which would provide safe shelters and food for the needed runaway slaves. With the help from conductors, stations, and the system of Underground Railroad, fugitive slaves had the opportunities to seek free dom of rights someday. The Underground Railroad had helped thousands of slaves escape slavery during the 1800s and it was with the help of conductors whom were past slaves that escaped slavery and went back to help other slaves escape slavery. Some notable people during that time were Harriet Tubman who helped over more than 300 slaves escape slavery and William Still who was the director of General Vigilance Committee of Philadelphia that would help ...assist Harriet Tubmans rescueShow MoreRelated The Role of Washington County, Ohio in the Success of the Underground Railroad3729 Words   |  15 Pagesthe Underground Railroad Gone, gone, --sold and gone To the rice-swamps dank and lone, From Virginias hills and waters, -- Woe is me, my stolen daughters! 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The question of being a refugee is preferable to accusations of being a Tory, as a colonist refugee would not claim British loyalty which Rip did openly saying â€Å"’ †¦And a loyal subject of the king, God bless him’† (Matthews, 2007, paraRead MoreThe Battle Of Gettysburg And Vicksburg1994 Words   |  8 PagesGeneral William T Sherman was to sail down the Mississippi with a substantial amount of men. This fleet, carrying men, would then take the Yazoo River to land and form a front there. General U.S. Grant would march his men down a railroad towards Vicksburg. This railroad was used to keep his men supplied. However, Confederate cavalry cut off Grant’s support, and Grant was forced to turn back. Sherman arrived at his destination, but without the support of Grant, his men were slaughtered. 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Global Emissions and Economic Growth †Free Samples to Students

Question: Discuss about the Global Emissions and Economic Growth. Answer: Introduction Climate change has become a pertinent issue in the world today. Climate change has been mainly in form of increased global temperatures, severe storms, and rising of the seal level. These poses a great risk in the existence of life on planet earth. According to studies, greenhouse gases are some of the primary causes of the changes in climatic conditions around the world. This becomes a matter of even greater concern given that human activities are some of the major sources of greenhouse gases. Governments, economists, scientists, and other sector which are directly affected by global change being in the forefront in trying to figure out the problems which might be faced by the change in climate. One such action was by the UK government which created a committee led by Stern in 2006(Stern, 2006) to determine whether it was prudent for the government to spend some of its money to reduce the emission of greenhouse gases. This paper examines the need for curbing the emission of greenhou se gases and specifically CO2, in the light of the Stern report as examined by Kenneth J. Arrow (2011). The issue of reducing the amount of CO2 and other greenhouse gases have largely been controversial. Those against it saying that the costs incurred are high compared to the social benefit received. With the release of the Stern report, this matter became even more controversial. Arrow, in his paper, Global Climate Change: A Challenge to Policy, Chapter 2 revisits the Stern report. Using a higher time preference value than stern and a value of 2.1, Arrow examines whether the benefits of these costs are justified. Arrow, justifies that, the costs of mitigating the release of greenhouse gases is higher than the costs that the world will suffer in future due to an increased amount of CO2 in the air. Arrow further discusses the implications of failing to act and gives examples on how emission of green house gases could be reduced. The level of greenhouse gas emissions in the world are a major cause of the changes in global climatic conditions. Carbon II Oxide forms the largest part of the total global emissions. Table 1 shows the ratio of the major greenhouse gases emissions in the atmosphere. The problem of CO2 emission may not be problematic to the current generation, but in the near future, it is expected that the level of Carbon II Oxide present in the air, would have doubled compared to the amount that was present before the start of industrialization. Rise in the level of Carbon II Oxide present in the air would lead to an increase in the global temperatures. It is projected that if no efforts to reduce the level of carbon II Oxide are established and everything continues being business as usual, then the temperatures would rise by at least 2 degrees centigrade. The following diagram shows the Mean Annual Temperature for New Zealand. The blue and red bars show the difference in the temperature averages between 1971 and 2000. The black dotted line shows the linear trend in the increase in temperature. The temperature is seen to increase at about 0.960C every 100 years (NIWA, 2010). Rise in the global temperatures means more problems of food security. In most tropical countries, agriculture will be adversely affected and this would lead to cases of drought and famine. According to Arrow (2011) the agricultural productivity in Northern Russia and Canada will be affected positively. This is so because, as at present these places are too cold for agriculture to fully flourish and a rise in temperatures would make the conditions better. He further continues to state that glaciers will melt and this will result to a rise in sea level. If the sea level rises, some coasts will be submerged and in some instances whole islands. All these would be costs that the future generations will incur if the problem of rising Green House gases is not promptly addressed. To support the assumption that lack of action right now may be costly than taking action, Arrow, goes forward and uses the social benefit discount rate formula, , to find whether an investment in the struggle to reduce the level of Carbon II Oxide in the atmosphere is truly beneficial. Stern (2006) further argues that the benefits of curbing the rise in the amount of greenhouse gases in the atmosphere are damages which are prevented from taking place. From the stern report, damages will include both market damages and non-market damages (Stern, 2006). The expected GNP of the end of the next century will be less by 13.6% than what it is supposed to be. Before considering the impacts of the climatic change conditions, the base gross rate was taken to be 1.3% per year and after considering the climatic change, then the growth rate will be 1.2%. In simpler terms, if actions were taken to reduce CO2 emission, then the growth rate will increase from 1.2% per year to 1.3% per year. Giving a value of 2.1 and a value of 8.5%, a social rate of time preference which is termed as very high (a high rate of social time preference means that people put more value to their present well-being than in their future well-being), Arrow (2011), concludes that, the present value of the cost used to mitigate climate change (considered to be at 1% of the total GNP every year), are lower than the social benefits that are received from taking action (increase of GDP from 1.2% to 1.3%). Thus, Arrow justifies that, taking action is better than taking everything business as usual. This is not to say that, there exists no market failures. A market failure mainly involves situations whereby, as individuals continue to advance their own well-being, the results of their actions are not sufficient and could be improved(Varian, 2010). One source of market failure in trying to curb greenhouse gas emissions is externalities. Externalities are defined as the costs or benefits accrued by a party who did not choose to take that benefit or cost. US for example, is estimated to contribute about 25% of the total greenhouse gases emissions. These gases travel around the world and will not only affect USA but also other countries. The cost of the effects of these greenhouse gases on other countries, will not be compensated by USA. A further example is that, the future generations will not compensate the current generation the costs that they will incur in trying to mitigate the emission of greenhouse gases. These two are examples of a market failure. Some of the ways which can be employed to reduce the level of CO2 emission in the world include, (a) using fuels that produce a higher proportion of energy in relation to the amount of CO2 they give out as a by-product of combustion, (b) improving technology to ensure that they are efficient in terms of combustion, this will mean more energy output per unit of fuel, thus reduce CO2 in the long-run, (c) developing technology that use a considerable lower amount of energy per unit of work done (reducing the use of energy means less combustion hence low CO2 emission, (d) reforestation, this is planting trees where they have been cut such as re-gazetting encroached land as forests and taking initiatives to plant trees, e) afforestation, this is planting trees where there were non, this does not only imply coming up with artificial forests but taking initiatives such as to plant trees along a highway and (f) reducing deforestation. Trees take up CO2 and give out Oxygen as a by-product. Th is will help to balance the level of CO2 in the air. Stern (2006), gave the social discount rate as . In this formula is the social rate of preference at a certain time. This is the current value that any social benefit is given compared to the well-being in future. In considering the curbing of carbon II Oxide emission. It will measure the value social benefits that would be accrued in the future in relation their valuation today. If the social time preference rate for reducing Carbon II Oxide is high, then it means that the world will be more focused on their well-being in the present time and the near future while low preference rate will mean that people are more concerned about their well-being in the further future than they are of the present. This implication means that if the is high, then the social discount rate of reducing Carbon II Oxide emission will be higher. People would not be interested in reducing Carbon II Oxide since the benefits of such an undertaking will be felt in the future not as at now. Is a projection on the growth rate of consumer consumption in the future. To properly calculate the social discount rate one must consider the change in consumption in future. is the measure of how elastic the social weight given to a change in consumption is. The two are calculated based on the economic assumption that as consumption changes presumably in the positive, then the value of consuming one more unit will decrease the social value in real terms. This is similar to the diminishing rate of marginal private utility when calculating private consumption. The term is aimed at discounting the rate of change in consumption. Any degree of uncertainty on the value of may raise the value of . This is so since, speaking in terms of say insurance, holding of stock and stock markets, people would prefer to work with a certain outcome than an uncertain outcome. People will always try to avoid risk as much as possible, where the outcome involves an uncertainty then the degree of risk is high (Arrow, 2011). Therefore, if the projected value of the change in consumption is uncertain, then the social benefits will also be uncertain. This will lower the perceived social benefit that will be accrued from any social project such as taking care of the environment. This would work negatively for any trials to reduce the amount of Carbon II Oxide being emitted. The aspect of how one treats the future is a matter of discussion between both philosophers and economists. The question is, how can the impacts of the future, specifically change in the level of consumption, be discounted to fit into the present? If the future c hanges in the level of consumption are uncertain, then measuring the social benefit discount rate becomes problematic and will result to a higher There are several implications that will arise if the social discount rate determined is high. A low social benefit discount rate will mean that the social benefits accrued from reducing Carbon II Oxide from the atmosphere today, have a low Net Present Value. This means that the benefits will be low compared to the money that is being used reduce these trace gases. With the continued involvement of human beings contribution to the rise in global temperatures this can be detrimental. Countries and people will argue that it is better to harvest the benefits of continued use of fossil fuels and other activities that may lead to rise in global temperatures today, than try to reduce such activities and in return have lower GDPs and economic growths. People have even argued that, the money which is being used to reverse global warming should be used on the worlds poor (Jonathan, 2010). Governments and individuals will therefore use less in curbing global warming and the implication is that as people continue doing business as usual, the level of CO2 would rise, world temperatures will increase, tropical storms will become more fierce, some countries costs and island might be submerged as sea level rises, weather patterns of the world will change, agriculture would be affected etc. In short, all the impacts of global warming might become a reality. It is important to notice that, in the last century, the rise in the level of CO2 in the air has much been contributed by human beings in terms of industrialization. So, as people continue to neglect the need for reduced CO2 emission, the levels might rise at a higher rate and the effects of global warming will be more evident. Table 4 shows the average rise in CO2 Emission by regions in the world due to fossil use and Cement Production (human activities). Some of the policies that have been put in place to reduce the amount of Carbon II Oxide emitted into the air have been ways of reducing the amount of fossil fuels and other fuels that have a large CO2 content used in production of energy and power. The argument being that more research should be done on renewable energy such as wind and Photovoltaic Systems (solar energy). To discourage the use of these fuels, governments have put up some of the following measures, (a) increased the tax that is charged on the use of these fuels, it is expected that with increased tax on fossil fuel such as coal, gasoline and natural gas, industries and individuals, will find it costly to be used for production of energy. They will therefore cut their usage and use only the amount that is enough for their processes and production. The idea is to make these fuels expensive and using the law of supply and demand, a higher price would mean less demand. Where demand is lower than the reduction of using these fuels would have been achieved. (b) Another approach which governments have used is setting up tighter regulations on the use of these fuels. These approaches have not always worked in the positive, as Adam Morton (2017) argues, taxation of carbon has led to a significant increase in prices of power. Most power is produced from generators running on either coal, natural gas, shale oil or diesel. A taxation on Carbon, means that producing power becomes expensive. The cost is transferred to the final consumer of power in form of prices. This has seen the price of power doubling. Strict regulations on the mining of coal and the use of generator running on coal to produce power have also been enacted. This has led to many power plants shutting down as they cannot meet these conditions. Investors are also uncertain on the future of using these fuels for production of power. This has made them to shy away from investing their money in plants that use these fuels to produce power. Table 3 shows the average increase in petrol prices in Australia. If taxation has had a direct impact on the prices of power, then this is another cost that Australians have to pay if they are to reduce the amount of carbon II oxide released into the air. Higher power prices mean more overhead costs for production companies and the transport industry. This would have the effect of raising the cost of living since the costs are always transferred to the consumer (Morton, 2017). Furthermore, as more power plants close down, those employed in these plants will lose their job. Such activities often lead to a reduce Nominal GDP. Thus, the cost of curbing greenhouse gases emission would be costly for Australians. Using the formula of the social discount rate, , to find the net present value of such approaches, then the cost of reducing greenhouse emission into the atmosphere would be considered higher. A high cost when discounted, will lead to a lower Net Present Value since the benefits of reducing the amount of Greenhouse gases will not have increased. In terms of social benefits that are gotten from such an initiative, it will mean less benefits relative to the cost that is being achieved to realize these benefits. This will therefore mean a higher value of in Australia. To Australians, reducing the level of greenhouse gases emissions would be expensive. The value of the social discount rate,can be affected by the time preference value that is given to. Where a social planner is involved in determining the value of, , then the effects could be higher. Social planners are concerned about the social well-being of any society, he or she as the decision maker, tries to achieve the best results of any social undertaking for all parties that are involved. However, in most case, the social planners are governments, in addition to achieving the best welfare conditions for their citizens, governments too have other goals too. In most cases, the public choice theory is used as an economic tool to explain the options that a government has when it comes to determining what is best for their citizens. The public choice theory also contains studies on political behaviour especially on the self-interests of all groups, say voters, politicians and bureaucrats. In most cases, the behaviour of a countys citizens will influence how the leadership of a country makes decisions (R.G, 1989). Politicians decisions are influenced by the voting patterns of voters and what the voters want. This can be explained better using public economics and game theory. Reducing the amount of carbon emissions in most cases involves increasing tax on fuels that have high CO2 waste, closing down of industries that use fuel, and reducing the amount of such fuel used in the economy. This would lead to closing of industries, worker retrenchments, higher costs of living etc. this is in contradiction of what most governments struggle to give their citizens. Such an implication will mean that social planners will give the social time preference a higher discount rate. To them, the cost of reducing the carbon II Oxide and other trace gases is costly and does not translate to immediate social benefits. A good example of such an action is by the US government which withdrew from the Paris Climate Accord which its main aim is to control global warming. The main concern of the US government being that its citizens had much more to lose as at present if these proposals of reducing CO2 were implemented. If more social planners follow suit, then the value given to might decrease considerably. An increase in the value of , means that, social planners are more interested in the well-being of a society today, and are giving it a higher value than the well-being of the society in the future. Moreover, unlike governments which have infinite lifespans, individuals have a higher time preference value since they have a short life, that means that they will be more concerned about the present than the future. Governments and social planners therefore, while calculating the social discount rate, will use a higher time preference to please the needs of their immediate society. They will as a result strive to ensure that a societys well-being at the present is maximized despite the effects it will bring in the future. This will in turn mean a reduced Net present Value of the projects undertaken to reduce the emission of Carbon II Oxide. Given the equation , the increase in the value of , will translate to the increase in the value of . How social planners value , has a direct impact on . It is the hope of Sternss report, (2006) and Arrow (2011), that social planners, in this case governments, will see the need of taking action against the increasing emission of Carbon II Oxide today. They both concur that, though the costs that will be incurred while curbing the rate of Carbon II Oxide in the atmosphere might be high today, they are much less than the costs that will be as a result of increased global warming in future. According to Stern: It is much better to act today and reduce CO2 emission than wait and suffer the consequences of failing to meet this challenge. References Arrow, K. J. (2011). Global Climate Change. A clallenge on Policy. Australian Institute of Petroleum, https://www.aip.com.au/pricing/index.htm BP (2016). BP Statistical Review of World Energy 2016. Retrieved From: https://www.bp.com/en/global/corporate/energy-economics/statistical-review-of-world-energy.html IEA (2014). Energy Statistics of OECD Countries and Non- OECD Countries. International Energy Agency, Paris IEA (2016). Decoupling of global emissions and economic growth confirmed. International Energy Agency, Paris. Retrieved From: https://www.iea.org/newsroom/news/2016/march/decoupling-of-global-emissions-and-economic-growth-confirmed.html IPCC, https://www.ipcc.ch/report/ar5/wg3/mindex.shtmlJonathan, L. (2010, January 31). Climate Change Study was Misused. Retrieved from Sunday Times: https://www.timesonline.co.uk/tol/news/environment/article7009710.ece Morton, A. (2017). Energy crisis: Wholesale power prices have doubled since the carbon tax was axed." . Retrieved from https://www.smh.com.au/federal-politics/political-news/energy-crisis-wholesale-power-prices-have-doubled-since-the-carbon-tax-was-axed-20170308-gutf8t.html Morton, Adam (2017). Energy crisis: Wholesale power prices. (n.d.). NBS (2016). Annual data on Energy; Fossil fuel data for 19982014. Retrieved from: https://data.stats.gov.cn/english/easyquery.htm?cn=C0. NIWA, https://www.niwa.co.nz/climate/faq/have-greenhouse-gas-emissions-caused-global-temperatures-to-riseNOAA (2016b). Global Gas Flaring Observed from Space. Global Gas Flaring Estimates 20122014. Retrieved From: https://ngdc.noaa.gov/eog/viirs/download.global.flare.html and https://ngdc.noaa.gov/eog/download.html PBL (2016). Are global CO2 emissions still rising? PBL Netherlands Environmental Assessment Agency, The Hague. Reteieved From: https://infographics.pbl.nl/ website/globalCO2/ R.G, H. (1989). The Median Voter Model in Public Choice Theory. Public Choice,115125. Stern, N. (2006). The Economics of Climate Change. Retrieved from https://mudancasclimaticas.cptec.inpe.br/~rmclima/pdfs/destaques/sternreview_report_complete.pdf Varian, H. (2010). Intermediate Microeconomics: A modern Approach. New York: Norton Co.

The Effect of brand image on the customer loyalty and satisfaction in the context of a telecommunication company

Introduction Brand image can be termed as evaluating the beliefs and the perception of the customers with regard to a specific product, a service, or a company (Kahle Kim 2006, p. 4). The theory has become one of the most accepted forms of marketing, as it involves satisfying the customers with their psychological need.Advertising We will write a custom proposal sample on ‘The Effect of brand image on the customer loyalty and satisfaction in the context of a telecommunication company’ specifically for you for only $16.05 $11/page Learn More This theory has been adopted and accepted by many marketers as it facilitates benchmarking of brand value during marketing (Kerin, Hartley, Rudelius 2009, p. 132). This idea is drawn from the fact that providing customers with psychological benefits creates room for loyalty, and thus increases the rate of customer turnover through repeat business. However, what effect does brand image benefits have on t he customer satisfaction and loyalty? Justification of the Question The above question is crucial since it will help the researcher to utilise the academic knowledge drawn from diverse academic literatures on brand image benefits in relation to a telecommunication firm, and in this case, the Vodafone Egypt. Thus, the researcher will be in a position of criticising the academic literature on brand image, with a focus on the role of customer satisfaction and loyalty in the in the industry. More so, the researcher will be in a position of Coming up with a up with a theoretical framework, which will help to assess the brand image benefits with regard to customer satisfaction as well as loyalty, and more so, establish the extent to which they are correlated. Relation to Previous Research Traditionally, brand image has been used as a tool of differentiating a product, service, or companies, as many people believe that it creates room for identity that customers seek while buying a product or a service from a given company (Romaniuk Sharp 2004). A number of marketing research studies affirm that brand image benefit has a positive correlation with loyalty, which helps the customers repurchase the goods or services (Brooks 2010, p. 67). In this regard, the brand benefit entails portraying high levels of relationships, showing confidence, as well as providing special treatments to customers. This theory emphasizes on creating a good customer-company relationship, as this creates an avenue for loyalty. However, other studies have affirmed otherwise, citing no relationship between quality service provision and loyalty (Brooks 2010, p. 158). This aspect of contradictory inference brings forth one prime question: do benefits of brand image have a correlation with consumer loyalty?Advertising Looking for proposal on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Dubrovski (2001) rebuffs the idea of measuring bra nd image by considering attribute measurement as the only viable instrument. Dubrovski affirms that other practical measurement tools must be included in the process, such as value and benefit that comes with buying the good or service; thus, the author forms a current theory in market research. Dubrovski’s assertion has contributed widely in establishing the rationale behind of assessing customer satisfaction with regard to brand image. Authenticating this assertion will lead is to one prime question: is there a positive correlation between customer satisfaction and brand image benefit? Another theory conceptualizes that customers become loyal to a particular firm because of a previous satisfaction they had with the brand (Schmitt Simonson 1997, p. 67). This is also evidenced by a number of market research, which has continually confirmed that loyalty has a positive correlation with satisfaction of the customers (Brooks 2010, p. 125). The studies on this issue, however, dwe ll on recommendation and intentions to draw their inferences, bringing forth one prime question: is there a positive correlation between loyalty and satisfaction of the customers? Vodafone Egypt is one of the companies that can be used to assess the brand image of a telecommunication service. However, the fact that it is a multinational company makes it challenging on evaluating ways to approach and evaluate the brand image for the company. While a number of companies use symbolic benefits to draw potential customers to their products, the Vodafone Egypt has been using functional benefits to not only satisfy the customers but also create customer loyalty (Tamer 2012). The methodology in this proposal will consider customers of Vodafone Egypt as the participants. Proposed Methods Using experimental design, the study will delve into in-depth empirical research to study the ‘effect of brand image on the loyalty and satisfaction in the context of a telecommunication companyâ€℠¢. Experimental design will prove to be of paramount importance in this study because it will help the investigator establish the cause-effect analysis of the variables. The study will make a casual inference of the following questions:Advertising We will write a custom proposal sample on ‘The Effect of brand image on the customer loyalty and satisfaction in the context of a telecommunication company’ specifically for you for only $16.05 $11/page Learn More Do benefits of brand image have a correlation with consumer loyalty? Is there a positive correlation between customer satisfaction and brand image benefit? Is there a positive correlation between loyalty and satisfaction of the customers? The study will use both quantitative and qualitative study that will allow a thorough investigation on whether the loyalty and satisfaction play a critical role in determining the brand image of a telecommunication company. To enhance the validity, th e study will investigate on the research problem using a wide range of secondary sources (Yin 2006, p.14). More so, investigation will be carried out through the primary sources in an ethnographic study. The participants will include all customers of telecommunication services across Egypt, who will be selected randomly. This cross-sectional study will provide all answers to the survey questions and interviews at the end of the study. Formulation of questionnaire will be based on the qualitative studies emanating from books and articles that are grounded with theories of brand image, customer value, as well as customer satisfaction, among others. The instruments of measurement will include diverse scales that will measure social as will as emotional connotation of the customers with regard to telecommunication services. The questions will be phrased in such a way that they will answer the brand image benefit. A Likert 5-level scale will be used to assess the questionnaire, and this will measure the attitude of the participants with regard to relationship between brand image, loyalty and satisfaction. Customer satisfaction will be measured using ten-scale instrument similar to likert scale. The customer loyalty will also be measured, with a view of assessing the brand image of the company. To answer the questions of the study, data will be entered in the computer system to measure the brand image benefits, loyalty and satisfaction. SPSS software will be employed to analyse the results of the questionnaire, where the means, standard deviations, percentages, one-way analysis of variance (ANOVA), unpaired t-Test, and Pearson’s correlation coefficient will be calculated to establish relationships (Hardy Bryman 2004, p. 54). Reflection Potential Practical and Empirical Obstacles Even though the study will attempt to employ a number of secondary sources to come up with comprehensive information regarding the effect of brand image on the customer loyalty and s atisfaction, the study will experience a limitation towards accessing some information, because there is little literature covered in the context of telecommunication service in relation to customer satisfaction and loyalty. More over, even though probability-based sampling of participants will enhance the external validity, the fact that the study is a cross-sectional one limits its chances in as far as assessing the consistency of brand image is concerned. A cross-sectional study may jeopardize the external validity since it does not take a pre and a post evaluation test to establish the short and the long-term effects of the prevailing external factor on brand image of the Vodafone Egypt (Page, Cole, Timmreck 1995, p. 92)Advertising Looking for proposal on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Conceptual and Theoretical Problems and Difficulties Even though the researcher will attempt to use books and article grounded on theories of brand image, there are a number of contradicting inferences within the sources, and this calls for a careful selection of the sources. For case in point, while some theories suggest that customer satisfaction leads to brand loyalty, which, in turn leads to brand image, other studies do not find a correlation between satisfaction and loyalty, demonstrating that they are mutually exclusive. Thus, the conceptual framework will call for a careful selection of variables. Ethics Ethical consideration will be critical in this study and will be attained by ensuring that the study gets an approval from the Institutional Review Board or similar ethics review committee, which will ascertain that the study does not infringe on the rights of the participants; thus, there will be no compulsion in recruiting participants. More so, the researcher will ascerta in the point of the participants’ interest in an effort to establish the content validity, which will help to eradicate biased responses from the participants. In this case, content validity will be established by assessing the extent to which the study represents the attitudes of the respondents (Creswell, 2003, p. 183). My Position as a Researcher in a Political Field This research study will aim at investigating the effect of brand image on the customer loyalty and satisfaction in a telecommunication context. As a researcher in a political field, I will be in a position of finding answers to a number of complex issues surrounding the brand image of Vodafone Egypt. Being a multinational company will help me provide more answers as to what extent the company is able to create a positive brand image within the country. Hence, I will be in a position of highlighting the conditions under which the political environment should cooperate with Vodafone Egypt in order to create a b rand image benefit. Conclusion The results of the study will be regarded as viable because they will be based on probability sapling of a large sample size of customers from all telecommunication services in Egypt. According to the findings, it is imperative to note that, indeed, functional role of brand image has a positive correlation with satisfaction and this is consistent with some finding in the literature. However, even though the findings will have a great impact on understanding brand image of telecommunication firm, the study will need to be replicated in order to address matters concerning sustainability of brand image in cases where all aspects of brand image, including symbolic and social benefit. Timetable April 6rd -May 16, 2012 – Fully analysing the past and present literature review pertaining external factors affecting the brand image of Vodafone Egypt May 23 –May 30, 2012- Collecting data from participants through interviews, as well as organising i t according to their topics/themes, constructs, and theoretical framework. June 5th – June 28, 2012- Further collection of data from a case study of Vodafone Egypt with regard to its brand image. July 3rd – July 27, 2012- Analysing all the data collected from the ethnographic study using diverse statistical methods. August 7, 2012- Submitting the entire report of brand image of the Vodafone Egypt List of References Brooks, 2010, The power of loyalty: 10 essential steps to build a successful customer loyalty strategy. Irvine, Calif.: Entrepreneur Press. Creswell, J 2003, Research design: Qualitative, quantitative, and mixed methods approaches (2nd ed.), Sage publications, Thousand Oaks, CA. Dubrovski, D 2001, The role of customer satisfaction in achieving business excellence. Total Quality Management, vol. 12, 920-925. Hardy, M Bryman, A 2004, Handbook of data analysis. Sage Publications, London. Kahle, L Kim, C 2006, Creating images and the psychology of marketing c ommunication, Lawrence Erlbaum Associates, Publishers. Mahwah, NJ. Kerin, R , Hartley, S, Rudelius, W, 2009, Marketing, McGraw-Hill/Irwin, Boston. Page, R, Cole, G, Timmreck, T 1995, Basic epidemiological methods and biostatistics: A practical guidebook, Jones and Bartlett, Boston. Romaniuk, J Sharp, B 2004, Conceptualizing and measuring brand salience. Marketing Theory, vol 4 no. 4, 327-342. Schmitt, B, Simonson, A 1997, Marketing aesthetics: The strategic management of brands, identity, and image, Free Press, New York. Tamer, Y 2012, Case Study: Vodafone Egypt. Web. Yin, R 2006, Case study research: Design and methods, Sage, Thousand Oaks, Calif. Appendix Summary of the Ethnography The interview process will involve collecting data concerning the views of the participants regarding brand image benefit, which include experiential, symbolic benefit, social benefit, functional benefit, as well as the appearance, in relation to customer satisfaction and loyalty. This will entail a nswering the following question: Experiential Benefit What kind of telecommunication service makes you feel good? What kind of telecommunication service would enable you to increase service usage? What kind of communication service would induce pleasure to you? Social benefit Does our bran help you feel accepted? Does our brand improve the how others perceive you? Functional Benefit Does our brand perform according to its expectation? Is our brand reliable for service? Symbolic Benefit Do you look cheap while using our brand? Do people think that you have an elegant lifestyle by using or brand? Do you normally fit well with other members of the community while using our brand? Appearance Benefit Does our brand provide a solution that is within your expectation? Does our brand portray a good impression for the firm? Is our brand more effective than other brands across the country? And in an effort to acquire qualitative information on the external factors affecting the bran d image of Vodafone Egypt, the participants will subsequently be asked to support their answers by providing an explicit explanation. 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