Monday, 17 April 2023

Medical Progress?

 The last few Blog entries on organ transplants raise fundamental questions: where on earth is medical 'progress', science and new technology taking humanity. Do we really want to go there? Who is calling the tune?

Many of us have witnessed the distress of parents called to a hospital bed after an accident when a young person (under 25 years old) seems unlikely to survive. We can but imagine the further distress at being told that the young person's organs are required for transplantation into somebody else's body. It would seem appropriate to open a public forum on the ethics and desirability, not only of transplants but also of procedures surrounding abortion, contraception, and embryo research. For at least the last decade, many girls who have been prescribed the contraceptive pill to alleviate heavy periods have taken this as a green light to 'safe' sex.

In 1989 Pat Spallone raised the question of ethics in respect of the new reproductive technologies:

"On 25 July 1978, in England, the world's first 'test-tube' baby, Louise Brown, was born to Lesley and John Brown. The birth marked the realisation by a research scientist, Robert Edwards, and his colleague, gynaecologist Patrick Steptoe, that fertilisation of a woman's egg and a man's sperm which took place outside the female body and in a laboratory dish could be placed back into the woman's body and develop to term. The first live birth from 'test tube' fertilisation, or what scientists call in vitro fertilisation or IVF, came after years of experimentation: experimentation which included removing eggs from women's bodies, growing the eggs under laboratory conditions, and eventually entailed inserting the fertilised eggs into women's wombs in the hope that pregnancy would result.

"IVF, the procedure which first entails physiological manipulation of women's bodies to extract eggs, was an invention of the natural science, biology. IVF is one of many biological 'breakthroughs' of the second half of the twentieth century, along with genetic engineering. Biological science, like physics and chemistry before it, has come of age. We are in the midst of a revolution in biology, where control of human reproductive capacities are considered of great importance. In his 1968 book, The Biological Time-Bomb, Gordon Rattray Taylor discussed the IVF research then being conducted, the implications of 'pre-natal adoption' of embryos created by IVF [surrogacy?], sex-choice, artificial wombs, and the future prospect of 'baby factories'. He discussed all these in the context of other scientific breakthroughs, such as organ transplantation, genetic engineering, and the creation of living viruses from non-living molecules. It was a decade before the first 'test-tube' baby was born." (Pat Spallone (1989) Beyond Conception: The New Politics of Reproduction, Macmillan Education p8).

From 1968 these developments have been researched by employees of commercial companies with very little, if any, public debate. As a result, would-be mothers find themselves presented with a range of recommended procedures they never fully comprehend, only to discover, more often than not, that they have unwittingly become research guinea pigs. For many grandparents, the processes in course of development seem indeed, to be 'beyond conception'.

COMMENT: This series of blogs, posted from 10 April 23 (I, Daniel Blake Reviewed) raises issues crying out for further research by specialists and non-specialists alike, for group discussion and practical action at local community level worldwide.

Friday, 14 April 2023

Organ Transplants PART VI and discussion


Organ Transplants

Only Fully Informed Consent Valid

If a fair offer of organs is to be made by this means, the wording on Donor Cards must clearly be altered to indicate the true circumstances in which the offer may be taken up. And, given the lack of relevant knowledge and comprehension of these matters which seems to prevail in the general population, it may be that the signatory should be required to acknowledge that he has received a full explanation and understands what is involved.

The same considerations regarding explanation and understanding should, of course, apply when a relative is asked for the organs of a loved-one dying on a ventilator. In this tragic context, real comprehension may be particularly difficult to achieve. However, without it there must remain serious doubt about the validity of the consent sought and given. As things are, it may seem paradoxical that such care is taken to ensure that consent to relatively minor therapeutic surgical procedures is given on a fully- informed basis while consent to the evisceration of a relative is usually sought by staff who are not medically qualified but who - perhaps for this reason and their sympathetic demeanour - achieve a higher percentage of assents to the removal of organs than do the doctors.

It is this great concern that ordinary, public-spirited people have not clearly understood which has been one of the great driving forces behind my efforts to protest during the past decade. Because I feel so strongly that the "harvesting" of hearts etc. is a totally unacceptable abuse of the dying which should not be going on in a civilized society, I have the greatest difficulty in understanding why it is so tolerated. The likely explanation, it seems to me, is that the facts are not well enough known. Some of those who do know and understand - such as nurses and anaesthetists who have been involved - have simply left the transplant scene, usually without public comment. Even some of the surgeons who have been responsible for the removal of the organs have confided to me that they were uneasy about it and did not like doing what they felt they had to do. These pangs of conscience, and their expression, give me real cause for optimism. As one of my advisers commented, some doctors seem to prefer to fudge the scientific issues rather than face the facts about what they're really doing. While that attitude is understandable, it cannot be right or successful in the long term. Sooner or later the truth will out. When it does, I trust that we shall see an end to this misconceived and, to my mind, abhorrent activity — one of the wrong directions taken by Medicine as a consequence of unrestricted technological advances.

Original Editor's Note: Dr. D. W. Evans MD, FRCP retired early from his position of Consultant Cardiologist at Papworth Hospital because of his firm conviction on this matter.

FN :* This refers to so-called "cadaveric" donation. A technique for the removal of a part of a liver from a healthy relative, for transplanting into the recipient, has recently been developed in the U.S.A. While this procedure is not free from ethical problems, they are not of the kind which this paper addresses.

* * * * *

Round Table Discussion

True, the essay on organ transplants was written three decades ago. How has the situation changed, in law? in practice?

How many parents of a young person dying from an accident are presented with the demand to cut out vital organs. Is this a 'good thing' to do?

Note that "Even some of the surgeons who have been responsible for the removal of the organs have confided to me that they were uneasy about it and did not like doing what they felt they had to do". Discuss the moral implications, especially off the last four words.


Organ Transplants PARTS IV and V

More Rigorous Test Omitted

It should be noted that steps are taken to prevent the donor from becoming short of oxygen while the ventilator is temporarily disconnected for these test purposes. This is to preserve the donor organs from anoxic damage which would impair their suitability for transplantation. However, this inevitably means that the vital centre in the brain stem which 'controls the breathing - the respiratory centre - is not subjected to the ultimate stimulus (lack of oxygen in the blood reaching it) to see if it can make a last-gasp effort. It is, in fact,tested only for the ability to respond to the less-powerful stimulus of a high carbon dioxide content in the blood still reaching the brain stem.

It should also be noted that the vital centres in the brain stem which control heart-rate and blood pressure are not tested at all under the U.K. protocol. That they are still active in some, if not most, organ donors is shown by the fact that many of them continue to maintain their blood pressure naturally after the declaration of "brain stem death," and by observations of cardiovascular response to the trauma of organ removal which are almost certainly brain stem mediated.

The long and short of it is that these tests are nowhere near adequate to exclude residual life and function in a damaged brain. And, as if that were not bad enough, not even all of these tests have to be done when it is desired to certify death for transplantation purposes. In other countries, there is at least some attempt to test for residual activity in the higher centres of the brain. In the U.K. there is none. If persisting electrical activity (EEG waves) were sought here, it is certain that it could be found in many of these so-called "cadaveric" organ donors. Some would retain function in a part of the brain which controls glandular secretions. These discomforting facts are simply ignored by those who wish to call a donor's brain dead. They dodge the issue of their relevance by not doing the tests which might demonstrate such activity.

The Brief: to Provide Organs in Good Condition

In effect, exhaustive testing for residual life in the brain is proscribed. All in all, the rules governing the diagnosis of "brain death"in this country must be seen for what they are - a simplistic code developed in response to a brief to provide vital organs in good condition for the transplanters. A colleague has likened the process of their formulation to the activities of a committee of foxes taxed with the design of a hen house .....

From the scientific point of view, it is most unfortunate that attempts to diagnose true death of the brain, while some independent bodily functions continued, ever became involved with transplantation. As we have seen, the idea that it might be diagnosable, in some circumstances,was seized upon by those seeking viable human organs, long before it had been adequately thought out or tested. The transplanters simply assumed that what they wanted to believe was true - and have steadfastly refused to consider, or even see, the substantial body of evidence that denies their belief. Had they not become involved, with the consequences that ensued, we might by now be further along the road towards the possibility of secure diagnosis of the true and total death of the brain as an independent phenomenon.

Should that become a scientific reality, the term "brain death" would be an appropriate description. And I, for one, would be prepared to consider the proposition that a patient with a truly dead brain was no longer a human being, i.e. because there is persuasive evidence that the brain is the quintessential organ and the home of the inner self.


A Better Criterion

However, the final 'cessation of all activity in every part of the brain would be a prerequisite for consideration of this proposition because Man does not yet know very much about the workings of his brain and we cannot, therefore, safely assume that pockets of residual activity here and there do not matter. That being so, we should need clear evidence of the absence of all metabolism, with no possibility of its resuming, in each and every part of the brain. Reliable evidence of the final cessation of blood flow (at normal temperatures) everywhere within the brain would be acceptable for this purpose and it is possible that techniques with the power to demonstrate this reliably (while the body is still alive) may one day become available. At the moment, we can only be sure that the cerebral circulation has ceased for ever when the bodily circulation has finally ceased, i.e. when the patient's heart, or some other pump such as those used in operating theatres to take over the heart's function while it is operated upon, finally stops. This, of course, is the commonly understood criterion of death and the one still used by the majority of the world's doctors to diagnose well over 99% of all deaths.

To sum up, I would urge that:-

(1) The attempt to force upon the professions and public the notion that true death of the brain can be ‘diagnosed reliably, while the body is still alive, be resisted. Likewise the contingent notion that a patient pronounced "'brain dead" on current criteria is truly dead.

(2) It it be argued that the state defined by the "brain stem death" tests is, while not death itself, yet so close to death as to make no practical difference, let the inaccurate and misleading term be abandoned in favour of one which makes the situation clear, i.e. that neither the patient nor his brain stem is really dead at this time, though doomed he may well be. Full understanding of this essential point will perhaps for the first time, enable the opinion-formers of our society to debate the ethics of transplantation in an enlightened frame of mind. Up till now, the highly successful confusion of the dying and dead states, andthe use of weasel-words such as "beating-heart cadavers," has manipulated thought to the exclusion of serious criticism.

(3) The misleadingly-worded Donor Cards be withdrawn immediately.

Many selfless prospective offers may have been made on a basis of serious misunderstanding; the signatories may have thought that the words "after my death" on those cards meant after their deaths in the commonly-understood sense of the term. Indeed, I know that some highly-intelligent and otherwise well-informed people have carried these cards thinking that they were thereby authorising removal of their organs after the final disconnection of the ventilator and the subsequent final cessation of their circulation. When disabused of this cosy notion, some have expressed horror and some disbelief. Most, when the truth has dawned, have destroyed their cards; a few have continued to carry them after modification, e.g. specification that a general anaesthetic be administered during removal of the organs.

To be continued ...

Wednesday, 12 April 2023

Organ Transplants Parts II and III


The Dying are not yet Dead

However, even if the tests could infallibly forecast death in the commonly-understood sense of the term within a few hours or days, would it be right (or logical) to hold that the patient satisfying these criteria is - to all intents and purposes maybe - already dead? I maintain that it is not correct, or proper, to confuse this state in which he is doomed to die soon - however certain that may be - with death itself. To my mind, a comatose patient without brain stem reflexes and dependent upon a mechanical ventilator is still a living human being; as such he is deserving of our every care, without intrusion of any third party interest, right up to the time when his circulation finally ceases and he can be truthfully described as a cadaver.

I continue to maintain this view despite its being dismissed, by the transplanters, as reactionary and akin to the stance of members of the Flat Earth Society The implication is, I suppose, that it is somehow improper to examine too closely the fundamental concept and science involved in this novel re-definition of death because it has made possible such wonderful surgical advances. In other words, the spectacular achievements are held to justify the means - which (they appear to suggest) are therefore best left decently veiled. I think that a very dangerous philosophy. And having said so, I also have to say that I am far from convinced that transplantation of these vital organs really does constitute a lasting therapeutic advance. There is, in fact, no scientific evidence that - taking all relevant factors into account - these transplant procedures do more good than harm. As a perceptive colleague remarked, cardiac transplantation probably increases rather than decreases the sum of human misery. But the over-statement of the benefits, the impossibility of knowing the natural prognosis, and the many other clinical and logistic difficulties are - like the prospects for alternative ethical treatment strategies - another part of the story.

Correcting a Misleadingly Rosy Impression

Had the public been fully and frankly informed on all the relevant aspects, it might not have been persuaded that it wants transplantation at almost any cost. That it has been so persuaded - as I am frequently assured it has - offers ample testimony to the power of the media in forming public opinion. My hope is that the many sincere and highly talented people involved in journalism and broadcasting will, now that they are beginning to understand the facts of the matter, wish to use that same power to correct the misleadingly rosy impression of this really rather macabre activity which they may hitherto have helped to propagate. But their task will be far from easy, given that Society seems now to demand of Medicine that it shall provide an answer to Man's mortality.

To return to the fundamental issue, I must record my surprise and disappointment that theologians, philosophers and lawyers appear to have accepted the propriety of certifying and treating as dead, a patient on a ventilator who - though almost certainly doomed to die soon - still has his own natural blood circulation and other bodily and brain functions at the time. Some of them, apparently, see no essential difference between this late stage in the dying process and death itself; once the tests have pointed to a fatal outcome, he is "as good as dead," they say, and can be dealt with accordingly - though few, I imagine, would bury or cremate a man with a beating heart.....

Others, including members of the judiciary I'm told, do understand the factual difference between the dying state called "brain stem death" and true death but do not think it matters in practice. The useful life of the patient on the ventilator is clearly over, they say, so why should his organs not be removed while there is still life in him if this is necessary for them to be of use to others? The fact that the donor has to be certified "dead " - by some doctors using arbitrary criteria which many or most doctors would not deem sufficient for the purpose - has to be accepted as a necessary preliminary to the surgery (to avoid the obvious legal and ethical difficulties). The rights and wrongs of such certification are, they say, beyond their understanding and a matter for "the medical profession."

There is, in the U.K., no legal definition of death and so, where the Law is concerned, a person is dead when a doctor certifies him "dead." By this means, the legal profession sidesteps the fundamental issue. But what would happen, I wonder, if one or more doctors certified a person dead and others (like me and many more) were willing to testify that he was still a living human being, and certainly not a corpse, when he was being operated upon for the removal of his vital organs? Or if the precise time and date of death mattered very much in the settlement of a civil action and one doctor said the deceased was dead at the time when the " brain stem death" criteria were sought and satisfied while another said he was not dead at that time and did not actually die until his heart was removed some hours or days later?


Where might it Lead ?

Such legal niceties apart, it seems to me that it is important not to allow confusion of "dying" with "dead" simply to avoid facing up to the ethical problems, e.g. allegations of active euthanasia, which beset even today's secular, utilitarian society. The "slippery slope" argument seems to me to have some force in this context. If utterly helpless young people being kept alive by mechanical ventilators today, whom will it be deemed appropriate to use as sources of organs and for experimental purposes tomorrow? Newborn babies with little or no forebrain (anencephalics) but who cannot, by any stretch of the imagination, be regarded as "brain stem dead " have already been used thus ....

It occurs to me that those theologians and others who have accepted the notion that "brain stem death = death" may have been misled, for this is the stated basis for the move, in 1979, by those satisfied there is no function remaining anywhere in the brain and no possibility of any such function ever returning, whatever may subsequently be done. It would not be surprising if they had been so misled for this is the stated basis for the move, in 1979, by the Conference of the Medical Royal Colleges of the U.K. from use of the"brain stem death" criteria as a justification for turning off the mechanical ventilator (so that natural death might be allowed to occur) to their use as a basis for the certification of death itself. This change of use was clearly prompted by the perceived need to provide hearts and livers in a state suitable for transplantation; it served no other purpose, there being no need to certify death before discontinuing life-support solely in the interests of the patient (and his near and dear).

It was to provide a consensus basis for that most onerous decision,i.e. to terminate what was clearly otiose and unkind therapy, that so-called "brain stem death" criteria were promulgated by the Conference in 1976. The criteria were a distillation of those we had been using informally for some years and in which we had developed confidence with regard to their ability to forecast death within a short time of their fulfilment. I did not object to their propagation for that stated purpose for it seemed to me that their general adoption would make such decisions more comfortable, particularly for those faced with the problem only occasionally. However, in retrospect, I should perhaps have been suspicious that the stated purpose (in 1976) was not the only purpose even then envisaged because the Memorandum publishing the criteria acknowledged the involvement of the Transplant Advisory Panel .....

Policy Confuses Prognosis and Diagnosis

Be that as it may, Conference - the policy-making body to which the D.H.S.S. appeals for advice - simply decided, in 1979, that the sesame criteria which we had been using for purely prognostic purposes should henceforth be used, without modification, for the diagnosis (and certification) of death itself, i.e. while the 'circulation and other vital functions continued naturally. The justification offered for this enormous leap was that by the time these criteria were satisfied "all functions of the brain have permanently and irreversibly ceased." The redundant terms are interesting, and may betray lack of confidence in their momentous edict. To almost anyone of a truly scientific disposition, and particularly to those with experience of the biological sciences, such a claim must have seemed at the very least incautious and - given that the criteria do not require that the greater part of the brain be tested at all - perhaps frankly ludicrous. But to understand the full absurdity of this claim, some knowledge of the tests used to diagnose "brain death" is necessary and I will therefore attempt to outline those in use for the purpose in this country.

It is, of course, a requirement that the patient be deeply comatose (though grades of unconsciousness are, in point of fact, quite difficult to determine) and unable to breathe spontaneously, i.e. air is being delivered to his lungs by a mechanical ventilator. It is worth mentioning that this is the only function of this so-called "life-support machine"; it does not take over the circulatory function, as a lot of people seem to think. The blood flow through the body and parts of the brain, in such a patient, is maintained naturally by the beating heart.

It is a requirement that the cause of coma and ventilator dependence be known; common causes are severe head injury and bleeding into the brain but in some cases the brain damage is due to a period of anoxia and its extent may then be less easy to determine. When,after a few hours or several days, it seems likely that a (fatal outcome will inevitably ensue, some of the reflexes with pathways through the brain stem - the stalk that connects the major part of the brain (the cerebral hemispheres) to the spinal cord - re tested. This involves looking for eye responses to light and to touch, and to the indirect stimulation provided by irrigating the ears with ice-cold saline. There?must be no movements in the head and neck area in response to stimulation of any part of the body. Nor must there be any response to stimulation of the throat or windpipe. Finally, to test the all important supposition that the patient will never again be able to breathe on his own, the mechanical ventilator is disconnected for 10 minutes; if there is any sign of a spontaneous inspiratory effort during this time, then the criteria for "brain stem death" are not satisfied. If there is no sign of any attempt to breathe, mechanical ventilation is resumed and an unspecified period of time is allowed to elapse before the brain stem reflexes are again sought. If they remain absent the ventilator is again disconnected for a similar test period. If there is still no inspiratory effort, and if temporary influences such as drugs have been excluded, the criteria for the diagnosis of "brain death" - U.K. style - have been satisfied and the patient is certified dead.

Mechanical ventilation is continued thereafter, sometimes for days, while the complicated arrangements are made for removal of his vital organs and, of course, throughout the surgical procedure involved in acquiring them.

To be continued ...

Tuesday, 11 April 2023

Transplants PART 1


Discussion Document

Organ Transplants and the "Brain Death" Fallacy

David W. Evans

Home Quarterly: A Review of Policies as seen from the home. Vol. XLIII, No. 1. July 1990


Let me say at once that I believe heart, liver and lung transplantation to be Wrong. This is because, to be useful for transplant purposes, these organs have to be removed from living bodies, i.e. bodies which are respiring, pink and warm, and which bleed freely when cut. The donor's blood circulation is maintained by his own heart - right up to the moment when it is stilled by a chemical solution and itself removed.

The body reacts to the trauma of this evisceration just as it would to ordinary, therapeutic, surgery. It has to be paralysed with muscle relaxant drugs to prevent the movements and spasms which, if they were allowed to occur, would make the procedure difficult or impossible. Even so, there may be dramatic increases in blood pressure and heart-rate in response to the incision and the further trauma of organ removal; these responses are identical with those seen in lightly anaesthetized patients undergoing ordinary therapeutic surgery and, in those circumstances, are an indication to the anaesthetist to deepen anaesthesia in case his patient may be feeling pain or, perhaps, have subsequent recall of intra-operative events. It may be that this everyday experience is the reason why some anaesthetists in charge of organ donors give them an inhalational anaesthetic as well as the muscle relaxant; others, being persuaded that the obviously living body is that of a dead person, may aver that they give the general anaesthetic agent only for its effects in controlling the unwanted cardiovascular reaction.

To operate thus, not for the benefit of the life-long inhabitant of the body but to acquire his vital organs for the use of others, might seem an odd thing for a caring surgeon to do. It might even seem a procedure of doubtful legality. It has been made possible in both respects by the invention and successful propagation of the notion that, although his body is undeniably alive, the donor can be regarded (and certified) as already dead before the operation commences because he appears to be deeply unconscious and a few simple clinical tests have indicated that he has no prospect of recovery. This is the syndrome which has—unfortunately and misleadingly—become known as "brain death " or, in this country, "brain stem death."

It is fallacious to equate the state so defined with true and total death of the brain and I am therefore unhappy about the terms used to describe it; this is no mere semantic quibble but a real concern that use of these imprecise terms may manipulate thought. Indeed, I know it has done so in academic circles and I think it likely that a distraught parent who is told that his son—who looks alive—is nevertheless dead, because the tests establish "brain death," will take this to mean that all possibility of residual life in the brain has thereby been excluded. This is, of course, not the case.

It is also basically fallacious to assume that the tests used have the power to forecast, with the absolute certainty claimed,. the true death of the patient (i.e. the final cessation of his circulation) within a few hours or days of the diagnosis of "brain stem death." There are, in some ways regrettably, no absolute certainties in Medicine. And in this context one need perhaps look no further than the reports of "'brain dead " mothers giving birth to normal babies several weeks after the diagnosis to provide food for thought about timed prognoses—and, maybe, about the wider question of live births to mothers allegedly long dead.

Part 1 of 6: to be continued

Beyond Materialism

Quite by accident I recently came across some articles from the 1990s that have not dated with the passage of time. Thirty years ago many were debating the ethical issues surrounding vivisection, abortion, spare part surgery, IVF, the oncoMouse and gene manipulation in general. (The oncoMouse was specially bred to be susceptible to cancer, in order to facilitate cancer research). Then, as now, scientific research in general, and medical research in particular, was proceeding apace with very little overview of the legal framework under which such procedures were being introduced and virtually no public debate about the desirability of such procedures. The general public were presented with nothing more than the smiling faces of the happy couple beaming at the babe in their arms. The fact that for every success there were at least ten failures was never mentioned.

Many issues are raised that are crying out for public a debate, an urgent debate that has, time and again, been stalled by clever publicity of successful procedures benefiting loved ones and their families. Older wisdom holds true: because something can be done, it does not follow that it has to be done in practice. All too often, decisions are being made in times of crisis and stress, things that might, on more mature reflection, be left to take their course.

With these thoughts in mind, I have taken an article written by David W. Evans and published in Home Quarterly in 1991 as a basis for debate on these issues. The article, entitled "Organ Transplants and the 'Brain Death' Fallacy" is long, so it is posted up in seven instalments.

Monday, 10 April 2023

I, Daniel Blake Review



Film Review, I, Daniel Blake; Mark Kermode

Ken Loach’s latest Palme d’Or winner, his second after 2006’s The Wind that Shakes the Barley, packs a hefty punch, both personal and political. On one level, it is a polemical indictment of a faceless benefits bureaucracy that strips claimants of their humanity by reducing them to mere numbers – neoliberal 1984 meets uncaring, capitalist Catch-22. On another, it is a celebration of the decency and kinship of (extra)ordinary people who look out for each other when the state abandons its duty of care.

For all its raw anger at the impersonal mistreatment of a single mother and an ailing widower in depressed but resilient Newcastle, Paul Laverty’s brilliantly insightful script finds much that is moving (and often surprisingly funny) in the unbreakable social bonds of so-called “broken Britain”. Blessed with exceptional lead performances from Dave Johns and Hayley Squires, Loach crafts a gut-wrenching tragicomic drama (about “a monumental farce”) that blends the timeless humanity of the Dardenne brothers’ finest works with the contemporary urgency of Loach’s own 1966 masterpiece Cathy Come Home.

We open with the sound of 59-year-old Geordie joiner Daniel Blake (standup comic Johns) answering automatonlike questions from a “healthcare professional”. Having suffered a heart attack at work, Daniel has been instructed by doctors to rest. Yet since he is able to walk 50 metres and “raise either arm as if to put something in your top pocket”, he is deemed ineligible for employment and support allowance, scoring a meaningless 12 points rather than the requisite 15. Instead, he must apply for jobseeker’s allowance and perform the Sisyphean tasks of attending CV workshops and pounding the pavements in search of nonexistent jobs that he can’t take anyway.

Meanwhile, Squires’s mother-of-two Katie is similarly being given the runaround, rehoused hundreds of miles from her friends and family in London after spending two years in a hostel. “I’ll make this a home if it’s the last thing I do,” she tells Daniel, who takes her under his wing, fixing up her flat and impressed by her resolve to go “back to the books” with the Open University. Both are doing all they can to make the best of a bleak situation, retaining their hope and dignity in the face of insurmountable odds. Yet both are falling through the cracks of a cruel system that pushes those caught up in its cogs to breaking point.

“We’re digital by default” is the mantra of this impersonal new world, to which carpenter Daniel pointedly replies, “Yeah? Well I’m pencil by default.” Scenes of Blake struggling with a computer cursor (“fucking apt name for it!”) raise a wry chuckle, but there’s real outrage at the way this obligatory online form-filling has effectively written people like him out of existence. Yet still Daniel supports – and is supported by – those around him; from Kema Sikazwe’s streetsmart China, a neighbour who is forging entrepreneurial links online (the internet may alienate Daniel, but it also unites young workers of the world), to Katie’s kids, Daisy and Dylan – the latter coaxed from habitual isolation (“no one listens to him so why should he listen to them?”) by the hands-on magic of woodwork. Having lost a wife who loved hearing Sailing By, the theme for Radio 4’s Shipping Forecast, and whose mind was “like the ocean”, Daniel carves beautiful fish mobiles that turn the kids’ rooms into an aquatic playground. Meanwhile, their mother is gradually going under.

“A scene in a food bank in which the starving Katie, on the verge of collapse, finds herself grasping a meagre tin of beans is one of the most profoundly moving film sequences I have ever seen. Shot at a respectful distance by cinematographer Robbie Ryan, the scene displays both an exquisite empathy for Katie’s trembling plight and a pure rage that anyone should be reduced to such humiliation. Having seen I, Daniel Blake twice, I have both times been left a shivering wreck by this sequence, awash with tears, aghast with anger, overwhelmed by the sheer force of its all-but-silent scream.”

They’ll fuck you around,” China tells Daniel, “make it as miserable as possible – that’s the plan.” For Loach and Laverty, this is the dark heart of their drama, the use of what Loach calls the “intentional inefficiency of bureaucracy as a political weapon”, a way of intimidating people in a manner that is anything but accidental. “When you lose your self-respect you’re done for,” says Daniel, whose act of graffitied defiance becomes an “I’m Spartacus!” battle cry that resonates far beyond the confines of the movie theatre. Expect to see it spray-painted on the walls of a jobcentre near you soon. Mark Kermode

COMMENT: This review was published in The Observer, Sunday 23rd October 2016 and reprinted in The Social Artist, Winter 2016. A DVD of the film is now available. Also Darton, Longman and Todd have published a Study Guide by Virginia Moffatt entitled Nothing More and Nothing Less, based on the film.