Donald Trump offers to help Charlie Gard after UK court rules life support machine to be turned off

[bcking 3,157]

1 minute ago, IAMX said:

Yes, and I was told my sister wouldn't survive a single relapse. This excuse to violate the Hippocratic oath doesn't resonate with me.

I've already asked... Please quote what part of the Hippocratic oath you believe the doctors at GOSH are violating.

 

We aren't discussing your sister's case. From the way you are describing it, it sounds like the doctors gave your family very poor odds, but still proceeded with treatment. 

 

Fighting cancer is not the same as this boy's mitochondrial disease. There are basic tenets of cancer biology that allow us to have a lot of weapons in our arsenal. The changes if success after initial failure might be small, but we at least know the medications were are using can combat the cancer. 

 

Additionally, unless your sister had severe bilaterally brain cancer that cause irreparable brain damage, it is even more different. They could cure this boy's disease tomorrow and he would STILL be essentially brain dead. The disease caused damage that is irreversible.

 

 

[IAMX 3,055]

8 minutes ago, bcking said:

I've already asked... Please quote what part of the Hippocratic oath you believe the doctors at GOSH are violating.

 

We aren't discussing your sister's case. From the way you are describing it, it sounds like the doctors gave your family very poor odds, but still proceeded with treatment. 

 

Fighting cancer is not the same as this boy's mitochondrial disease. There are basic tenets of cancer biology that allow us to have a lot of weapons in our arsenal. The changes if success after initial failure might be small, but we at least know the medications were are using can combat the cancer. 

 

Additionally, unless your sister had severe bilaterally brain cancer that cause irreparable brain damage, it is even more different. They could cure this boy's disease tomorrow and he would STILL be essentially brain dead. The disease caused damage that is irreversible.

 

 

Not the same doctors, not even in the same time frame. Anyways, clearly you choose to not understand the parallel I'm drawing.. cancer treatment in the early 90s for the type of leukemia she had was nothing like it is today. And that's the point, killing someone based on that statistical probability is not something I buy. It seems more like for people to excuse not treating someone with everything they can, and using this mentality that appeals to people who preferentially wish to move on from the mental drain of perceived dead weight. I had quite the memorable fights with people (particularly in my own family) who perceived my sister in this light. I'd never give up on my child like this. I'm glad Trump did what he did, even if it was a stunt.

Edited July 5, 2017 by IAMX

[bcking 3,157]

1 minute ago, IAMX said:

Not the same doctors, not even in the same time frame. Anyways, clearly you choose to not understand the parallel I'm drawing.. cancer treatment in the early 90s for the type of leukemia she had was nothing like it is today. And that's the point, killing someone based on that statistical probability is not something I buy. It seems more like for people to excuse not treating someone with everything they can, and using this mentality that appeals to people who preferentially wish to move on from the mental drain of perceived dead weight. 

I'm still waiting on your expert analysis of the Hippocratic Oath...

 

If you want people to actually have a real discussion about your sister's case you need to provide more information. Yes treatment for leukemia in the 90's is very different than it is now.

 

While I didn't practice back then, in general today no one would ever advocating not trying to treat cancer, even after relapse, if that is what the patient wants. Even with children, unless they are very young (opinions vary on when you can reliably use their input) you would continue to treat. I had a 1 month old patient once with glioblastoma that everyone thought would be gone in a couple of months, and she is now around 4 years old.

 

I don't understand the parallel you are drawing because it isn't an accurate parallel. Comparing someone undergoing treatment for leukemia is not the same as someone who is PERMANENTLY mechanically ventilated, and will remain so even after you treat their disease. Unless you tell me otherwise, I'm assuming your sister did not suffer severe permanent brain stem damage prior to her multiple bone marrow transplants and chemotherapy. This child, even if you CURE him, will never walk, talk, breath, see, hear etc... Brain damage like what is caused by a mitochondrial disease is permanent and irreversible. The "therapy" that the neurologist will give him will not reverse brain damage. So he may be transferred, get a drug and even if with some miracle he is cured he will still be on a mechanical ventilator and g-tube for the rest of his life, along with the inability to see, hear, express himself etc...

 

This case is about as far away from your example as possible. I'm sorry but you are just completely off base. This is why all this media attention doesn't help. It attracts random people to make random comments based on essentially no actual medical knowledge that contributes nothing to the discuss.

[IAMX 3,055]

7 minutes ago, bcking said:

I'm still waiting on your expert analysis of the Hippocratic Oath...

 

If you want people to actually have a real discussion about your sister's case you need to provide more information. Yes treatment for leukemia in the 90's is very different than it is now.

 

While I didn't practice back then, in general today no one would ever advocating not trying to treat cancer, even after relapse, if that is what the patient wants. Even with children, unless they are very young (opinions vary on when you can reliably use their input) you would continue to treat. I had a 1 month old patient once with glioblastoma that everyone thought would be gone in a couple of months, and she is now around 4 years old.

 

I don't understand the parallel you are drawing because it isn't an accurate parallel. Comparing someone undergoing treatment for leukemia is not the same as someone who is PERMANENTLY mechanically ventilated, and will remain so even after you treat their disease. Unless you tell me otherwise, I'm assuming your sister did not suffer severe permanent brain stem damage prior to her multiple bone marrow transplants and chemotherapy. This child, even if you CURE him, will never walk, talk, breath, see, hear etc... Brain damage like what is caused by a mitochondrial disease is permanent and irreversible. The "therapy" that the neurologist will give him will not reverse brain damage. So he may be transferred, get a drug and even if with some miracle he is cured he will still be on a mechanical ventilator and g-tube for the rest of his life, along with the inability to see, hear, express himself etc...

 

This case is about as far away from your example as possible. I'm sorry but you are just completely off base. This is why all this media attention doesn't help. It attracts random people to make random comments based on essentially no actual medical knowledge that contributes nothing to the discuss.

If you feel like people are contributing nothing to discuss when why are you discussing with them, and demanding expert analysis when it's clearly personal anecdotal experience? 

You can step down from the pedestal now, I'm not in awe. I can see that further discussion with you on the matter would be a waste of time, as your beckoning for people to provide personal information is merely a cover for talking down to them, as you already proclaimed, our opinions are worthless since we're not medical experts.

If any "medical expert" ever came into my life and any sort of scenario with my family with this attitude, sufficed to say I'd see to it another "medical expert" would be handling our situation.

Edited July 5, 2017 by IAMX

[bcking 3,157]

9 minutes ago, IAMX said:

If you feel like people are contributing nothing to discuss when why are you discussing with them, and demanding expert analysis when it's clearly personal anecdotal experience? 

You can step down from the pedestal now, I'm not in awe.

I was asking for expert analysis since you have said twice that these doctors are violating the Hippocratic Oath. I'm curious what you know about it and how exactly they are violating it. As another member of the profession I know most of us take our job very seriously and we believe strongly in what we are doing. So I am asking you to provide some modicum of evidence to your claim. A claim that essentially every ethics committee in the country would refute. GOSH did absolutely everything right, and continues to do so. If you want to claim otherwise, I'd like you to provide some explanation.

 

Unfortunately sometimes contributions can be worse than "nothing". Just saying nothing would be okay. The problem, as I previously mentioned, with media attention is people then respond by contributing things that are just plain wrong, and do more damage than if they would just say nothing. People read news reports then start spewing out anecdotal random medical accounts and act as if they are somehow related to the case, when in fact they aren't. That influences other people who aren't experts on the subject. Ignorance unfortunately can be contagious. 

 

This child's condition is so rare less than 20 have been documented with it in the world. The leap from his disorder to treating leukemia is so bad it is almost funny how uninformed it is. You would have had a much better time if you brought up some case of your grandmother who suffered a massive hemorrhagic stroke leaving her in a vegetative state. However, even that wouldn't be an accurate comparison since damage in the brain from blood can recede with time and not all of the cells die. Once the edema recedes you can regain a lot of function. That is NOT the case with this child. His brain damage is irreparable even if suddenly we could use gene therapy to cure him of his disease. That sort of nuance is something that random people giving random anecdotes don't know because, surprise surprise, they actually know very little if anything on the subject being discussed. However their examples and anecdotes spread as if they have some sort of a "valid point" within their ignorance. 

Edited July 5, 2017 by bcking

[OriZ 3,165]

1 hour ago, bcking said:

This child's condition is so rare less than 20 have been documented with it in the world. The leap from his disorder to treating leukemia is so bad it is almost funny how uninformed it is. You would have had a much better time if you brought up some case of your grandmother who suffered a massive hemorrhagic stroke leaving her in a vegetative state. However, even that wouldn't be an accurate comparison since damage in the brain from blood can recede with time and not all of the cells die. Once the edema recedes you can regain a lot of function. That is NOT the case with this child. His brain damage is irreparable even if suddenly we could use gene therapy to cure him of his disease. That sort of nuance is something that random people giving random anecdotes don't know because, surprise surprise, they actually know very little if anything on the subject being discussed. However their examples and anecdotes spread as if they have some sort of a "valid point" within their ignorance. 

This reminds me of when my wife's mom was in hospice forever and then hooked up to machines forever more. Her sister is the reason they kept her hooked up even though everyone knew she was only suffering. Eventually she passed of course but if it were up to my wife she wouldn't have had to suffer for as long as she did thanks to my sister in law. Sometimes knowing when to let go for that person's sake is just as important as fighting for them if not more.

[yuna628 9,878]

41 minutes ago, OriZ said:

This reminds me of when my wife's mom was in hospice forever and then hooked up to machines forever more. Her sister is the reason they kept her hooked up even though everyone knew she was only suffering. Eventually she passed of course but if it were up to my wife she wouldn't have had to suffer for as long as she did thanks to my sister in law. Sometimes knowing when to let go for that person's sake is just as important as fighting for them if not more.

Indeed. But was the sister the person who was responsible making decisions for her end-of-life care or any care at all? As difficult as it was for everyone else to witness, if it was her legal decision to make (albeit a selfish one)? These parents in this case are also selfish, understandably so, and I still feel it is not the government's job to take that parental right away whether it was their decision to pull the plug or to seek out other treatment. The UK has gotten themselves into such ethical dilemmas before, and it's never good (a family that sought new treatment in the EU for their daughter and were arrested for it comes to mind.. the kid is alive now and cancer free btw.. the NHS was willing to just shrug and let things run their course). This child does not have cancer and is a virtual vegetable, and the experimental treatment will not change his status in that regard, but shouldn't the parents still have the legal right to do it?

 

Boiler mentioned the loss of their pet earlier and that they had to make a painful decision to end the life of their likely beloved friend. Pets are very much like children to people. I know mine have always been. We kept our special needs puppy til' he reached age 8.. likely spent thousands on his treatment with visits, constant bloodwork, and medication. Eventually he became less and less stable and more vital organs began failing. Our vet offered an experimental treatment with no guarantee of it working and an equally high price tag. It was too much, our dog was in too much pain.. and as much as it broke our hearts we said goodbye. Now my husband didn't agree with this decision because he was willing to drain his pockets in desperation to do anything. He was not ready to say goodbye, and it's understandable why people in their grief may not be. For him he was reminded of holding his helpless nephew in the NICU and wanting someone at that hospital to do something.. anything. We often justify how we treat our pets with end of life care vs humans because of it being a different species. And yet, the deep bond and attachment I've felt with my dogs is no different than that of a baby. And it's why I still feel that if there is nothing else this hospital can do for this infant then the decision should be left up to the parents. The parents will have to live with the decision that they make.

 

 

[bcking 3,157]

6 minutes ago, yuna628 said:

Indeed. But was the sister the person who was responsible making decisions for her end-of-life care or any care at all? As difficult as it was for everyone else to witness, if it was her legal decision to make (albeit a selfish one)? These parents in this case are also selfish, understandably so, and I still feel it is not the government's job to take that parental right away whether it was their decision to pull the plug or to seek out other treatment. The UK has gotten themselves into such ethical dilemmas before, and it's never good (a family that sought new treatment in the EU for their daughter and were arrested for it comes to mind.. the kid is alive now and cancer free btw.. the NHS was willing to just shrug and let things run their course). This child does not have cancer and is a virtual vegetable, and the experimental treatment will not change his status in that regard, but shouldn't the parents still have the legal right to do it?

 

Boiler mentioned the loss of their pet earlier and that they had to make a painful decision to end the life of their likely beloved friend. Pets are very much like children to people. I know mine have always been. We kept our special needs puppy til' he reached age 8.. likely spent thousands on his treatment with visits, constant bloodwork, and medication. Eventually he became less and less stable and more vital organs began failing. Our vet offered an experimental treatment with no guarantee of it working and an equally high price tag. It was too much, our dog was in too much pain.. and as much as it broke our hearts we said goodbye. Now my husband didn't agree with this decision because he was willing to drain his pockets in desperation to do anything. He was not ready to say goodbye, and it's understandable why people in their grief may not be. For him he was reminded of holding his helpless nephew in the NICU and wanting someone at that hospital to do something.. anything. We often justify how we treat our pets with end of life care vs humans because of it being a different species. And yet, the deep bond and attachment I've felt with my dogs is no different than that of a baby. And it's why I still feel that if there is nothing else this hospital can do for this infant then the decision should be left up to the parents. The parents will have to live with the decision that they make.

 

 

The right that parents have for their children is to make the decisions in the BEST INTEREST of the child. They don't have free reign to decide whatever they want.

 

There cases go to court when every medical and ethical expert consulted at the hospital agree that the decisions the parents are making are no longer in the interest of the children. I hate the word selfish because it has a negative connotation, but unfortunately for parents it is very hard to separate what is best for them (keeping their child alive) and what is best for the child.

 

The line is slightly different for different doctors but we aren't just passive members in the care of children. We are the ones continuing the interventions that cause suffering at the parent's insistence. In certain circumstances it goes beyond what we feel is ethically appropriate. When that happens we seek out colleagues who are more comfortable with providing the care in that situation, or we seek the ethical board to help us feel ethical okay with continuing therapy despite futility. If all of our colleagues and the ethical board all agree it is futile and unethical to continue therapy, that is when we sometimes need to take it further. We don't do it lightly, but we are acting in the interest of the child.

[OriZ 3,165]

28 minutes ago, yuna628 said:

Indeed. But was the sister the person who was responsible making decisions for her end-of-life care or any care at all? As difficult as it was for everyone else to witness, if it was her legal decision to make (albeit a selfish one)? These parents in this case are also selfish, understandably so, and I still feel it is not the government's job to take that parental right away whether it was their decision to pull the plug or to seek out other treatment. The UK has gotten themselves into such ethical dilemmas before, and it's never good (a family that sought new treatment in the EU for their daughter and were arrested for it comes to mind.. the kid is alive now and cancer free btw.. the NHS was willing to just shrug and let things run their course). This child does not have cancer and is a virtual vegetable, and the experimental treatment will not change his status in that regard, but shouldn't the parents still have the legal right to do it?

 

Boiler mentioned the loss of their pet earlier and that they had to make a painful decision to end the life of their likely beloved friend. Pets are very much like children to people. I know mine have always been. We kept our special needs puppy til' he reached age 8.. likely spent thousands on his treatment with visits, constant bloodwork, and medication. Eventually he became less and less stable and more vital organs began failing. Our vet offered an experimental treatment with no guarantee of it working and an equally high price tag. It was too much, our dog was in too much pain.. and as much as it broke our hearts we said goodbye. Now my husband didn't agree with this decision because he was willing to drain his pockets in desperation to do anything. He was not ready to say goodbye, and it's understandable why people in their grief may not be. For him he was reminded of holding his helpless nephew in the NICU and wanting someone at that hospital to do something.. anything. We often justify how we treat our pets with end of life care vs humans because of it being a different species. And yet, the deep bond and attachment I've felt with my dogs is no different than that of a baby. And it's why I still feel that if there is nothing else this hospital can do for this infant then the decision should be left up to the parents. The parents will have to live with the decision that they make.

 

 

Well it technically wasn't her legal decision to make, the husband had power of attorney. However, she greatly influenced his decisions and both went against my wife's mom's wishes(as well as her own being she actually cared about them) which was to NOT be on life support with a feeding tube, etc. Since this child did not obviously have any wishes written down I do agree that while we can personally disagree with them, they do have the right to make that decision and it should not be the government's decision. However I believe in situations where someone has their wishes in writing(as her mom did) family members should not be allowed to go against it. My wife always says if it was up to her sister her mom would still be laying in that bed. All for selfish reasons, so she can "go visit" with her even though there was nothing really left of her.

 

I agree pets are like children, I know ours are. That's why we paid for a ticket that was almost as expensive as our own to fly our cat here from Israel. Some people were like it's just a cat you can get another one...umm excuse me? Would you leave your child in a different country and "get another one"? The example of your husband reminds me again of that same sister - when her dog was sick she spent thousands on chemo etc which only added a few month to his life...mind you he already outlived most dogs(I think he was like 17). That's just a tad bit ridiculous if you ask me.

 

 

 

 

 

 

Edited July 5, 2017 by OriZ

[bcking 3,157]

13 minutes ago, OriZ said:

Well it technically wasn't her legal decision to make, the husband had power of attorney. However, she greatly influenced his decisions and both went against my wife's mom's wishes(as well as her own being she actually cared about them) which was to NOT be on life support with a feeding tube, etc. Since this child did not obviously have any wishes written down I do agree that while we can personally disagree with them, they do have the right to make that decision and it should not be the government's decision. However I believe in situations where someone has their wishes in writing(as her mom did) family members should not be allowed to go against it. My wife always says if it was up to her sister her mom would still be laying in that bed. All for selfish reasons, so she can "go visit" with her even though there was nothing really left of her.

 

 

Children are different, as you pointed out. He never got a chance to provide any insight or choice. When that happens the default decision maker is the parents but that is with the ASSUMPTION that the decisions they make are in the interest of the child. That right to make decisions can be lost if the parent's decisions aren't in the best interest of the child.

 

The difficulty of course is deciding when that happens. That is why large hospitals have ethics committees filled with people who study this as their profession. It isn't decided upon likely.

 

It should also be noted that there are cases where parents choose to withdraw care and the doctors intervene in order to continue care. Doctors aren't always the ones advocating for death.

 

We do our best to advocate in the interest of the child. While we do get attached, we have the benefit of being further removed compared to parents, which in very difficult and emotional circumstances can help us be more objective about what is benefiting the child and what is harming them.

[OriZ 3,165]

1 minute ago, bcking said:

Children are different, as you pointed out. He never got a chance to provide any insight or choice. When that happens the default decision maker is the parents but that is with the ASSUMPTION that the decisions they make are in the interest of the child. That right to make decisions can be lost if the parent's decisions aren't in the best interest of the child.

 

The difficulty of course is deciding when that happens. That is why large hospitals have ethics committees filled with people who study this as their profession. It isn't decided upon likely.

 

It should also be noted that there are cases where parents choose to withdraw care and the doctors intervene in order to continue care. Doctors aren't always the ones advocating for death.

 

We do our best to advocate in the interest of the child. While we do get attached, we have the benefit of being further removed compared to parents, which in very difficult and emotional circumstances can help us be more objective about what is benefiting the child and what is harming them.

Parents make many decisions that are against the best interest of their child. I don't see children being taken away from people who, for example(and I gave this example before) smoke around their children, as much as sometimes I wish they would be. Still their (horrible, non parent worthy) decision to make. No offense to you personally but from my experience dealing with doctors many time they are wrong. I am not arguing that they are in this case, just that the parents have the right to believe they are because many times that is the case. If the parents want to still believe there is something they can do I say let them.

[smilesammich 10,727]

1 minute ago, OriZ said:

Parents make many decisions that are against the best interest of their child. I don't see children being taken away from people who, for example(and I gave this example before) smoke around their children, as much as sometimes I wish they would be. Still their (horrible, non parent worthy) decision to make. No offense to you personally but from my experience dealing with doctors many time they are wrong. I am not arguing that they are in this case, just that the parents have the right to believe they are because many times that is the case. If the parents want to still believe there is something they can do I say let them.

but parents' beliefs can often put their children through pain and suffering just the same. i don't think this is a one size fits all dilemma and it's not on par with smoking around your kids. though there are some laws concerning that now, in vehicles anyway.

doctors can be wrong but i don't think that's an issue in this case.

[Boiler 47,526]

The problem here is the Parents, they really should have been given proper counselling.

[OriZ 3,165]

12 minutes ago, smilesammich said:

but parents' beliefs can often put their children through pain and suffering just the same. i don't think this is a one size fits all dilemma and it's not on par with smoking around your kids. though there are some laws concerning that now, in vehicles anyway.

doctors can be wrong but i don't think that's an issue in this case.

I agree they can. And I disagree with them in this case, that's why I brought up what my sister in law did. Nevertheless to me it boils down to how much power are we willing to give the authorities over our decisions concerning our children? As you said the current laws about smoking are only in vehicles(and only with a fine). It might not be on par but I do think it is a classic example of how parents can hurt their children but still their decision to make. Their decision to smoke next to their children can cause a life of suffering or death. Like I said I don't think the doctors are wrong in this case but if the parents believe they are then they shouldn't be forced into blind trust. It might start with something we all know the doctors are right about, but who knows where it ends. 

[yuna628 9,878]

41 minutes ago, bcking said:

The right that parents have for their children is to make the decisions in the BEST INTEREST of the child. They don't have free reign to decide whatever they want.

 

There cases go to court when every medical and ethical expert consulted at the hospital agree that the decisions the parents are making are no longer in the interest of the children. I hate the word selfish because it has a negative connotation, but unfortunately for parents it is very hard to separate what is best for them (keeping their child alive) and what is best for the child.

 

The line is slightly different for different doctors but we aren't just passive members in the care of children. We are the ones continuing the interventions that cause suffering at the parent's insistence. In certain circumstances it goes beyond what we feel is ethically appropriate. When that happens we seek out colleagues who are more comfortable with providing the care in that situation, or we seek the ethical board to help us feel ethical okay with continuing therapy despite futility. If all of our colleagues and the ethical board all agree it is futile and unethical to continue therapy, that is when we sometimes need to take it further. We don't do it lightly, but we are acting in the interest of the child.

I understand your position and of course acknowledge what the medical community decides is not taken lightly. But I will still always be libertarian-minded in this regard. Things start getting sticky when the government is in the business of over-ruling personal liberty. It's one reason why I don't believe the government should have any business telling a woman what to do with her body or that of her unborn child. It's further disturbing to me, that the government and hospital could force and over-rule the parents to pull the plug on the infant. It's one thing to rule that whatever treatment they want is useless and not in it's best interests, and quite another to strip all parental rights. I'm very much into ensuring that end of life decisions are written down and very legally clear - for infants this is not possible, but parents are routinely given the right to make decisions on behalf of their children in all things.

 

How do you feel about the Ashya King case? Where a child with cancer was being told the therapy they wanted was unavailable via the NHS and suffered such delays and red-tape the parents fled with him to a different country in order to get him life-saving treatment that would put him into remission. The doctors wanted to use cheaper alternatives that may or may not have had the same effect and is more aggressive on the body. They also believed he was not 'suitable' for the newer treatment. Once there they were arrested for trying to save his life before finally being allowed to go on. The court in this case ruled the parents could continue the treatment elsewhere. After the therapy he remains cancer free though the parents believe he is still not receiving appropriate treatment on the NHS. Were the doctors and the government wrong in this case? Was this family badly treated? Should they have stayed with conventional treatment that may have had the same outcome even though they believed it to be unsafe?

 

The doctors in the Gard case may be likely 100% correct. The man from Baltimore who advocates that the treatment his child received could help this family may be offering false hope, because his similar condition is not the same condition. But are the hospital and doctors willing to try the treatment also wrong? What makes one group of doctors correct and another wrong? Were there ever any communication between the two facilities? Were they given the opportunity to have proper discussions with all involved?

24 minutes ago, OriZ said:

Well it technically wasn't her legal decision to make, the husband had power of attorney. However, she greatly influenced his decisions and both went against my wife's mom's wishes(as well as her own being she actually cared about them) which was to NOT be on life support with a feeding tube, etc. Since this child did not obviously have any wishes written down I do agree that while we can personally disagree with them, they do have the right to make that decision and it should not be the government's decision. However I believe in situations where someone has their wishes in writing(as her mom did) family members should not be allowed to go against it. My wife always says if it was up to her sister her mom would still be laying in that bed. All for selfish reasons, so she can "go visit" with her even though there was nothing really left of her.

 

I agree pets are like children, I know ours are. That's why we paid for a ticket that was almost as expensive as our own to fly our cat here from Israel. Some people were like it's just a cat you can get another one...umm excuse me? Would you leave your child in a different country and "get another one"? The example of your husband reminds me again of that same sister - when her dog was sick she spent thousands on chemo etc which only added a few month to his life...mind you he already outlived most dogs(I think he was like 17). That's just a tad bit ridiculous if you ask me.

 

 

 

 

 

 

Absolutely agreed.

13 minutes ago, Boiler said:

The problem here is the Parents, they really should have been given proper counselling.

What constitutes proper counseling though?