Terminally ill Noel Conway loses Supreme Court appeal

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assisted suicide, medical school interviews topical issue of the week, topical medical issue of the week

Noel Conway, 67,  has motor neurone disease,  a condition that results in progressive  weakness of the muscles including respiratory muscles. He was a fit healthy man who used to enjoy a range of sports such as skiing however he now has virtually no movement and needs a ventilator to help him breathe. He argued that he wanted a doctor to be allowed to prescribe a lethal dose when his health deteriorates and does not want to be entombed in his body.

Before his illness Noel Conway was a keen cyclist, skier and climber

Currently any doctor helping him to die would face up to 14 years in prison. He argued that the alternative would be pulling out his breathing apparatus which would lead to an uncomfortable and distressing death by suffocation. He said he could either bring about his own death while still physically able to do so, or await death with no control over how and when it came.

Assisted suicide is in the news a lot and is often the subject of ethical scenarios at medical school interviews.

Arguments against assisted suicide
1.‘Thou shalt not kill’ is one of the oldest moral commands. It has been a key part of medical ethics for centuries. The original Hippocratic oath states ‘I will give no deadly medicines to anyone if asked, nor suggest any such counsel.’ Many religious people contend that only God has the right to give or take life.
2. Those that are infirm may be pressurised to die or made to feel selfish or a burden if there was this option. Peter Saunders, from the Care Not Killing Alliance, said the decision was right “because of the concern that vulnerable people might be exploited or abused by those who have a financial or emotional interest”.
3 Slippery slope arguments. The ‘slippery slope’ argument holds that if assisted suicide was practised for people like Mr Conway then it would become acceptable to allow it for less clear cut cases and eventually you may end up with a situation as in Nazi Germany where those deemed to be defective were killed.
4. With good pain control and counselling, suffering will be minimised.

Arguments for assisted suicide:
1. The person’s right to autonomy, control over his or her life. According to polls most people in the UK feel that they should be able to have some control over when and how they die. In many philosophical traditions ‘egoistical suicide’ [death for one’s own reasons such as to avoid pain] is considered selfish and wrong. However the aim of ‘altruistic suicide’ which is carried out for the love of others or for the religion [eg Jesus praises a man who lays down his life for others [John 15;13] ] is more acceptable to most religions. It can be argued that someone who wishes to die in order not to be a burden is following the same principles.
2. Some, such as Debbie Purdy, who had multiple sclerosis, have argued that if her husband faced prosecution for helping her to commit suicide she would travel to Dignitas earlier while she could do so alone. However if the law permitted her to have help she would delay dying.
3. Even with the best palliative care [treatment of the dying] suffering and pain are common. Dr Ann McPherson, who set up the charity and website ‘Teenage Health Freak’ and supported a change in the law on assisted dying, died recently from pancreatic cancer. Her daughter wrote in the BMJ ‘our mum died slowly and in pain. …The law needs to change to allow terminally ill but mentally competent people the right to a more dignified death than my mum’.

Euthanasia
Active euthanasia is when death is brought about by an act – for example when a person is killed by being given a deliberate overdose of pain-killers.
Passive euthanasia is when death is brought about by an omission – i.e. when someone lets the person die. This can be by withdrawing or withholding treatment. Eg stopping a ventilator.
Active euthanasia is illegal while passive euthanasia is legal. ‘Thou shalt not kill but need’st not strive officiously to keep alive.’ [Arthur Clough 1850’]. It has been argued that often the moral difference between acts and omissions is tiny. The Catholic Church for example sees no difference between the two – ‘The act or omission which, of itself or by intention causes death in order to eliminate suffering constitutes a murder.’ [Catechism of the Catholic Church] NB In common language euthanasia is often used to mean active euthanasia.

What society thinks is usually reflected in the laws of a country. Assisted suicide is presently illegal but the view of the general population seems to be shifting with about three quarters of the population now reportedly backing assisted suicide. This is reflected by the lack of prosecutions of those helping loved ones go to Dignitas [the clinic offering assisted suicide in Switzerland].‘The law has a stern face but a kind heart’ is how Baroness Finlay described the present situation. However Lord Falconer has said:
‘No one has the stomach to enforce the current law, because it is inhumane and further provides no protection for the vulnerable. The threat [of prosecution] forces some people to die alone and earlier than otherwise for fear of what may happen to those who accompany them.’

The Director of Public Prosecutions was asked by Debbie Purdy a multiple sclerosis sufferer under what circumstances her husband would be not be prosecuted if he helped her travel to Dignitas. He produced a set of guidelines in 2009 in which he stated that the patient had to have shown that they had come to a ‘clear, settled and informed decision’ to commit suicide and that the loved one who aided them was entirely motivated by compassion.

Gosport and Whistleblowing

.Whistleblowers are people who bring attention to the failings of the organisation they work for. They have been described as a combination of hero and disloyal sneak, which illustrates exactly what a difficult position they are put in. They are rarely popular, are denied promotion and often have to sacrifice their careers.

Changes to how NHS whistleblowers are treated are to be introduced in response to the patient deaths scandal at Gosport War Memorial Hospital, the health secretary Matt Hancock  has promised.

More than 450 patients died at Gosport Hospital between 1987 and 2001 Nearly all were elderly with complex medical histories but most had been admitted for rehabilitation and were not regarded as terminally ill. Most died after being prescribed dangerous doses of pain-killing drugs. Dr Jane Barton was the doctor in charge of the community ward, she was supposed to have worked with visiting consultants but it seems she was not properly supervised. She unilaterally judged patients to have a poor quality of life and would write ‘please make comfortable’ in the notes as an instruction to nurses, which was a euphemism, in the hospital, for the giving of high dose drugs to patients at high doses which would kill them.

At the end of life doctors are allowed to give opiates at doses to relieve symptoms. Any such decisions should be discussed with the patient, if possible and their families. This was not done at Gosport and the drugs used were given at doses higher than needed to simply relieve symptoms. In many cases the patients were not terminally ill.    

Matt Hancock said he would “strengthen protection” for staff whistleblowers. He also said that he plans to appoint Guardians to support staff who wanted to speak up about concerns over patient safety. Gagging clauses exist in a lot of companies and many NHS staff have a gagging clause in their contract to prevent them reporting concerns. Matt Hancock said gagging clauses had been unacceptable in the NHS since 2013 “and I will do what it takes to stamp them out”.

The scandal at Mid Staffordshire NHS Trust was one of the last major scandals in the NHS. About 500 people were estimated to have died of negligence and appalling standards of care as a result of cost cutting by management. It emerged that staff who tried to bring the crisis to the attention of their superiors were bullied into silence. Sir Professor Brian Jarman of Imperial College heads the health analytical company Dr Foster which looks at hospital statistics [It was the statistical analysis from the Dr Foster unit at Imperial which first led to questions being asked about the standard of care at Mid Staffs] he stated that the NHS still continues to foster ‘a culture that allows suppression of the truth and victimisation of whistleblowers.’ Carol Parkes wrote in the BMJ at the time

‘If no one dares to ask the unpopular questions and everybody keeps their heads down, the organisation can succumb to poor thinking, poor strategy, and poor leadership.’

The GMC states ‘make the patient your first concern’  Whistleblowing is an obligation. A doctor can be struck off the GMC registrar if he fails to report concerns. Patient care and safety should be a doctor’s primary concern. If you don’t report such matters you may not be an abuser but you can be viewed as a collaborator. It is always hard to speak out against your colleagues and employers but it is essential.

NHS staff have the knowledge and the understanding to know when care is not being properly provided by their organisations. Patient feedback is valuable but enabling staff to speak up about faults within the NHS is probably more important in the effort to improve the NHS than employing countless expensive management consultants. The Francis Report into Mid Staffordshire stated that junior doctors [who frequently move posts as part of their training schemes] and are less inured or entrenched in the ways of working of departments ‘are the eyes and the ears of the NHS.’  In my local area the CCG has a  ‘MAD’ button on its website which stands for ‘Make A Difference’. Clinicians like myself press it if we feel there is a problem with care and I am pleased to say it is investigated.

Numerous scandals over patient care have occurred over the years. We had the Bristol Heart scandal in which incompetent surgeons operated on babies [the anaesthetist who reported it to the press had to find work in Australia], the Winterbourne Home scandal  and Mid Staffs. NHS staff spoke up in all these cases but were not listened to! More needs to be done to protect the whistleblower!

Rationing. The problem of limited resources

a problem of limited resources

Health budgets in the developed world are under pressure from an ageing population with greater health needs, increasing obesity, and the cost of new drugs and technologies.   

Flash glucose monitoring by Free Style Libre has rightly been hailed as a major advancement in diabetic care for type 1 diabetes. A sensor in a patch measures glucose levels and patients can get glucose readings by scanning it with a mobile phone app. It avoids the numerous finger prick tests that a diabetic needs to make in a day and an provide continuous readings over 24 hrs thus illustrating the blood sugar control much more accurately than before. Patient can adjust their insulin requirements accordingly, However like most advancements it is expensive. It has been available on prescription privately. There was an outcry when Theresa May, who is a Type 1  diabetic was shown wearing it with many stating that it should be funded by the NHS so that those poorer than her could benefit.

Last month it was agreed the NHS should fund it. However most CCGs [clinical commissioning groups who are responsible for budgets in an area] will only fund it for those with poorly controlled insulin dependant diabetes, not other diabetics and some CCGs will not fund it at all. NICE [the National Institute of Clinical and Care Excellence] was set up to look at the evidence regarding drugs and technologies and to produce guidelines for their use. It takes into account the cost of such drugs or devices. If it meets NICE criteria CCGs are supposed to prescribe it. It was formed to achieve consensus on treatment and funding to avoid what is termed the postcode lottery. However as the rows over Freestyle Libre show, this has not really ended.

In all health systems there is not the money to cope with rising demands. There is a limited budget for the NHS and if more money needs to be spent in one area, it means less in another, unless taxes rise substantially. What gets funded by the NHS is often an ethical dilemma.  The fourth pillar in medical ethics is the one of Justice which includes the fair distribution of resources. We usually state that the NHS should pay for peoples needs, not necessarily for their wants. Should the NHS pay for IVF – is a baby a need or a want, gastric bypasses for obesity, cosmetic surgery, Viagra? What do you think?

 

Medical School Interview Course -all proceeds to MSF.

Dear Mona. I do hope all is well with you? I thought you might like to know that so far no one who has had an interview has had a rejection! It is impressive and two thirds of the Medics have offers. I am sure this is partly due to your excellent help with the preparation. Kind regards as always

Course Outline
10.00: Introduction
-What are interviewers looking for?
-Why do you want to do medicine?
-How should you discuss your work experience?
: Interview Technique
-Body language, voice tonality, dress
-Sell yourself without sounding arrogant
-The STAR Technique
-Discussing your personal statement. How to discuss extra-curricular activities, hobbies, gap year etc
-How to discuss articles that you have read.
-Common questions asked at interview: what are they looking for?

11.30 Coffee Break

– MMI Practice

—Lunch—

13.40: Ethics
-GMC Good Medical Practice and Duties of a Doctor
-The Four pillars, confidentiality – when should this be broken, competence, consent,
-How to approach any ethical scenario: discussing conflicts between the principles
-The slippery slope argument
-Difficult scenarios and how to practice on your own.
-Topical ethical cases e.g. euthanasia and Kier Stamer/Debby Purdy, Gillick competence, Fraser laws, HFEA,

Coffee Break

15.00:
More MMIs

16.00
– The NHS structure and function
-GP commissioning
-What is meant by ‘privatisation of the NHS and cherry picking?’
-NICE guideline/evidence based medicine
-The multidisciplinary team

END 17.30

1st December – 1 course only

£122 Voluntary donation to Medicin sans Frontiers

Address: Chatfield Health Care, 50 Chatfield Rd. London SW11 3UJ.

 

‘Self Inflicted’ conditions should not be treated by the NHS. {Past BMAT question}

 

People injured whilst participating in extreme sports should not be treated by a publicly funded health service. Explain the reasoning behind this statement.  Suggest an argument against this statement. To what extent, if any, does the statement justify a change in public attitudes to personal risk taking?

The statement states that people who voluntarily take risks with their health because they participate in extreme sports such as sky diving cannot expect tax payers to pay for their medical care if injured. It is a statement regarding social justice[fairness] because health systems such as the NHS are cash limited so that funds spent on such people will mean that less money is available for treatment for others. In a private or insurance based health system people who take risks would probably have to pay a higher premium.

 A person’s autonomy has to be respected. They have a right to decide how to live their life and to do extreme sports if they wish. It is important to be non judgemental and act in the best interests of that patient which means treating injuries. If those participating in extreme sports are denied medical treatment for their injuries a slippery slope may be created in which those suffering from illnesses which may be in part also ‘self inflicted’ such as smoking or obesity related diseases may in future also find themselves excluded from state funded treatment.

At present ethical principles held by most, including the medical profession would value the principles of autonomy and beneficence over the idea that in doing so we would not be fair to others. The statement does put a valid argument to change attitudes to personal risk taking however because of the reasons outlined in paragraph two I disagree with a change of attitudes in this ‘rights versus responsibility debate.’    

Organ donation – Opt in or out? Topical issue and past BMAT question.

 

 

Over 80% of adults in England say they would definitely, or would consider, donating their organs, but only 37% of the UK population have registered as donors on the organ donor registry. The UK Government has started a consultation this month and states that it may introduce an opt out system by 2020 where all are considered potential organ donors unless they make the effort to opt out.

The Welsh government adopted the system in 2016. Within the first 6 months the scheme had saved dozens of lives after revealing that in the first six months, of the 60 organs that were transplanted, 32 came from people whose consent had been “deemed”. ie  those who choose to do nothing, if they are 18 or over, have lived in Wales for more than 12 months and die in Wales, they will be regarded as having consented to organ donation. Families still have the right to over rule and refuse but it has led to an increase in the desperately short supply of organs. Many  die while on the waiting list for an organ.

There is a massive under supply of organs for organ transplant and each year many patients die while waiting for a suitable organ that may have saved their life. However some feel uneasy about the concept of the ‘State owning your organs and being able to do what they want with them’ even if you can opt out of the system. They argue that the poorly educated, those with a leaning disability  and immigrants would find the procedure of opting out difficult.

Various suggestions have been made. A few years ago, because of the shortages of organs NHS Blood and Transplant suggested that people who agree to donate their organs when they die could be given priority if they themselves need a transplant. This, however met with a backlash from the Church of England and patients’ groups, who say ‘such a change would mean doctors treating two patients differently – something which would undermine medical ethics.’

 

Ethical scenarios regarding organ donation are common – try this one.

An ex-alcoholic patient [who is a mother of two children], a seven year girl, a 75 yr old war hero and a homosexual man need a liver transplant. Who should have it?

 Answer

A doctor should never be judgemental. As in most complex situations a decision would only be made after consulting with senior doctors, the hospital ethical committee and the hospital legal team and/or your medical defence body. All of these are sources of valuable advice and it is important to share responsibility for any decision with them. Remember doctors work in teams not in isolation.

The case for the ex-alcoholic woman to be given the liver transplant

Some people may say that her illness was self inflicted but that is no reason to discriminate against her. Ex-alcoholics may relapse and start drinking again but many diseases affecting the liver such as auto-immune diseases may also affect a new liver and she should not be denied treatment because of this. Being the only parent to a child is a very important role but it is wrong for a doctor to value one life more than another and positive discrimination may lead to a slippery slope where people in certain important roles, e.g. national leaders, have priority in transplant waiting lists.

The case for the seven year old girl and the war hero.

Some people would say that the war hero has served his country, paid his National Insurance tax and deserves to receive his liver transplant on the NHS. Others would say that he has lived a reasonably long life while the young girl who probably has most of her life ahead of her is more deserving.  The NHS and NICE does sometimes look at QALYs [quality added life years] when deciding to fund certain expensive treatment. If a treatment costs less than £20,000 for each extra year of good health it extends life by, it will be funded. In this scenario the girl would probably benefit by gaining more QALYs than the war hero. However the use of QALYs has been denounced as ageist and it is considered wrong to discriminate because of age.

The case for the homosexual man 

His entitlement is as valid as anyone else – it would be discriminatory and completely unacceptable to think otherwise.

Conclusion

A doctor should never be judgemental and never value any one life above that of another. For this reason transplants and ‘who gets the organ’ problems are decided in this country solely on:

1. clinical urgency [who needs it most],

2. The best match [whose tissue type is most similar and least likely to reject the organ]

3. the length of time they have been on the waiting list.

 

Is Medicine A Science Or An Art? [past BMAT questions and interview questions.]

Question;  There is more to healing than the application of scientific knowledge.Explain this statement. What else is important in medicine

Answer

Medicine is both a science and an art. It has a proud scientific basis;, the application of evidence based medicine and rigor of scientific logic but a consultation with a doctor often involves a lot more than making a diagnosis and treating.

The ‘art’ of medicine renders all appointments interesting and none routine. A good doctor-patient relationship and the development of trust is therapeutic in itself. Patients are much more likely to follow advice and treatment. We are familiar with the term ‘the doctor as the drug’. A doctor’s reassurance has been shown to reduce pain scores, panic attacks and other conditions even if no treatment is given. In General Practice, where patients are seen with many different conditions over a long period of time, even visits for minor conditions can augment an important  relationship where communication skills, sensitivity and empathy all play their part, often subconsciously.

I am reminded of the story of a team of management consultants who were asked to make efficiency savings for an orchestra. They saw that there were a number of violins all ‘doing the same job’ and cut the violins down to one. Then they started to look at other instruments. More and more cuts followed. At the end they had replaced the entire orchestra with a CD player – it did the same job and cost less didn’t it?  But of course something was lost!

Question: Not everything that can be counted counts and not everything that counts can be counted (Albert Einstein). What do you think is meant by this statement?Give examples of things that count in medicine which cannot be counted. To what degree should they count?

This essay question and the one above are describing the importance  of subjective experience such as  ’the art of medicine’. You could do a similar answer for this question. 

Gene editing could bring about the end of malaria.

Imperial College London  researchers used CRISPR-cas 9 gene editing technology to wipe out a population of caged mosquitoes that are able to transmit malaria. They targeted the double sex gene, a genetic sequence that leads to male and female traits. Females with two copies of the mutated gene could not develop properly and could not reproduce but males fertility was unaffected and they transmitted the gene down to offspring. After 11 generations, they found that 100% of these mosquitoes were affected causing the population to collapse. The double sex gene is highly conserved and unlike previous attempts to alter fertility of male and female mosquitoes resistance has not been observed.

Concerns have been expressed how this might affect the ecosystem but malaria was wiped out in Southern Europe with out major repercussions. There are about 4,000 different species of mosquito. The double sex gene is different in different insects so it should be possible just to wipe out the handful of species that cause disease leaving the rest to play their part in the ecosystem.

Whether this will work outside the laboratory is not known as yet but it raises exciting possibilities that we may be able to eradicate what is the most dangerous animals on Earth – the African malarial mosquito.

Remembering the 1918 flu pandemic

 

Last week we remembered the 100th anniversary of one of the most lethal pandemics ever known to man. Known as the Spanish Flu it actually started in the USA and spread quite quickly around the  world during World War One.  It infected about 1/3rd of the world’s population [50-100 million] and killed about 10% of those affected, some  50 -100 million – more than died in battle in the first world war.

Usually influenza viruses are deadly in the very young or old who have a weaker immune system. In this case it was young, fit adults that seemed particularly susceptible. The virus originated from birds and had recently crossed over. It had not ‘adapted to humans’ and was very ‘visible’ to the human immune system. It therefore triggered a particularly large immune response which caused massive inflammation. People died from the overreaction of the immune system which lead to a ‘cytokine storm’ with white cells and ‘fluid filling up the lungs and drowning the sufferer. Therefore those with a highly reactive immune system, rather than the old, were those most likely to be severely affected.

It was known as the Spanish Flu because it was reported most in Spain as was not involved in the war and had not been subjected to press censorship. The other European countries and the USA had downplayed the pandemic as not to affect morale.  One  hundred years on annual flu epidemics are part of winter life. An influenza pandemic is a global outbreak of a new influenza A virus that is very different from current and recently circulating human seasonal influenza A viruses. Influenza A viruses are constantly changing, making it possible on very rare occasions for non-human influenza viruses to change in such a way that they can infect people easily and spread efficiently. The Centres of Disease Control monitors flu strains in order to be ready for the next flu pandemic. Flu pandemics still represent one of the greatest threats to mankind.

Fake News, The Kremlin, Russian BOTS and MMR

 

Measles is becoming a major problem again. In the first half of the year in Europe 41,000 people contracted measles and over 14 have died. In 2002 the USA declared itself to measles free but that sadly is no longer true. The vast majority of those infected in developed countries had never been vaccinated.

Measles is one of the most contagious diseases known to man, it requires vaccination rates of 95% to contain it and create ‘herd immunity’ and prevent epidemics.  A twenty year old fraudulent study by the British doctor Andrew Wakefield still holds enormous influence over the vaccination debate. This study, published in the Lancet, linked MMR to autism  but the findings were widely rejected.  The study was based on a tiny sample, other studies tried to replicate the results and failed.  It was full of flaws and he had carried out unnecessary, invasive investigations on children and he had not disclosed large payments made to him by anti-vaccine lawyers. He was struck off and lost his license to practice in May 2010. Study after study has shown that there is no link between  measles and autism yet it is still a commonly held belief by many and Andrew Wakefield is held up as a hero by the anti vaccine movement. He lives in a palatial home in the USA, is supported by Donald Trump and is dating the supermodel Elle Macpherson.

Russians, thought to be backed by President Vladimir Putin’s government have made use of social media to influence elections such as the US election and the Brexit vote and erode trust in US and European Governments by spreading “fake news”. Kremlin-sponsored social media accounts have promoted the discredited views of Andrew Wakefield to sow doubt in the West over the safety of vaccines. Russian government “trolls” voiced support for Vaxxed, a film made recently by Andrew Wakefield.  One site claimed that three quarters of the children in a Mexican village had died as a result of vaccination.[An example of a pro Russia anti-vaccine site is   https://prepareforchange.net/2016/03/05/putin-exposes-vaccines]

Infectious diseases were the most common cause of death 100  yrs ago. According to WHO and most experts, vaccinations have contributed more than even antibiotics to the amazing success in the fight against infectious diseases. When a small group of Spanish invaders arrived in South America they were able to conquer it because of the diseases they bought with them as the natives had no immunity. Measles and other viruses led to the death of  an estimated 90% of the population of modern day Mexico!

Why do vaccines now cause so much uncertainty and parental angst?  In part vaccinations have become a victim of their success. We have learnt not to fear diseases such as a polio and diptheria; they have become remote and ‘unlikely’. We are tantalising close to eradicating polio but smallpox is the only disease that has been truly eradicated world wide, probably because of compulsory vaccination. Italy and France recently made MMR compulsory to try and halt the rising incidence of measles; should we do so as well? What do you think?