medical ethics

Yep. In this week’s BMJ, is an advert for a ‘vacancy for a member’ for the Herbal Medicines Advisory Committee , which advises the Medicines and Healthcare Regulatory Agency on the ‘safety, quality and efficacy of herbal medicinal products for human use.’ Of further concern to me is that they wish their newly appointed member to have recent experience in paediatrics.

Herbal medicines are, if they work, nothing special – St John’s Wort, aspirin (willow extract), vincristine, a chemotherapy drug, which is derived from plants….they all have side effects and interactions with other drugs. In fact, one could say that herbal medicines which work are in fact just medicines, to be used with the same provisos as any other medicines.

These leaves the ‘other’ herbal medicines as the ones which don’t work. And which, by definition, we should be ensuring either aren’t used, or are properly researched so that we know whether they should be or not.

What is gained by having a Herbal Medicines Advisory Committee? Obfuscation, and the danger of having a different set of standards for one set of chemicals compared to another, I suggest.

As an unschooled observer of the money markets, I have been struggling in recent months to understand what anything is actually worth. In healthcare, there is a similar problem, though it makes for rather less exciting headlines. All NHS procedures have to be costed to the last penny, and reported on in “completed care episodes”. But just like financiers, healthcare professionals can’t put an exact price on everything.

Blood, for example, is a commodity given free of charge by people willing to sacrifice time and comfort in order to make a significant difference to someone else. Bone marrow is another “gift”, donated by those who know they will not be repaid financially for being inconvenienced. And then there are the gifts given in the aftermath of death: corneas, kidneys, livers, skin, hearts… all capable of transforming a stranger’s life.

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A very interesting paper just published in the Archives of Internal Medicine. The study followed women before and after the introduction of a breast screening programme in Norway. They were compared to a control group of women who did not take part in the screening programme, but who would have been, had the programme been started in their area. This control group were invited for a one-off screening at the end of the observation time in order to work out how many had invasive breast cancers.

When the two groups were compared, the amount of invasive breast cancers was found to be significantly higher in the group of women who had regular screening. On first glance, this may appear to be a good thing – it seems that screening picked up more invasive breast cancers. But is it? The problem is that the natural history of these “invasive breast cancers” may not be as predictable as we would like to think, in that not all may cause a life-threatening situation. The authors concluded that “it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress”.

This is but one paper in a complex field, and I wouldn’t suggest that this research alone should make women decide what to do when the invitation to breast screening comes in. However, there are already uncertanties about how beneficial breast screening is. I think this paper does emphasise that there are still a lot of unknowns when it comes to breast cancer screening. The NHS Behind the Headlines service provides a useful analysis of the news coverage of this story but concludes that “women should continue to attend screening programmes”. I think this is a bit unfair; surely the best position is to invite women to weigh up the pros and cons for themselves, as they become known. But maybe this is also unfair; most people probably don’t have the time to devote to investigating this sort of thing and they should be able to expect disinterested, fair advice from their health professionals. 

When it was announced that both the presidential candidates were allowing sight of medical information about them to be read and reported on by journalists, I was slightly perturbed. Sure, I could see that perhaps the knowledge that one had no outstanding concerns with their health might – might – have some kind of relevance to an election.

But not really. First of all, while we can say that we are fine “at the moment” who knows what may be around the corner? Not everyone has risk factors for the illnesses that they will later die of. Medical “check-ups” are seriously limited in their abilities to offer a prognosis of any value. And in the case of a declaration of illness, disease or even risk factors for disease, how then can an electorate fairly decide if this will affect the ability to hold office? Many illnesses or disabilities need nothing more than the correct type of support or treatment. The real problem with the declaration of some health issues is not so much the disability that this may or may not reveal, but the disability that the public may imagine.

Lord Owen thinks we should be borrowing pages from the US book. He writes in the British Medical Journal this week: “Everyone who wishes to put themselves forward to the electorate as a potential national leader ought to be compelled by party rules to submit to an independent health examination that doesn’t involve their personal doctors and that is assessed by people of proven independence. This would not run into conflict with any existing legislation protecting the rights of the individual. If potential candidates knew they faced independent assessment and that they had a health problem then either they would not stand or they would make it public of their own volition. For example, John Kennedy, in 1960, believed that he would never be elected president if he admitted he had severe Addison’s disease. Yet there is no reason why someone who has Addison’s disease should not be US president if it is well controlled with replacement therapy.”

This is contradictory, unfair, and oppositional to the tenet that doctors should be first an advocate for the patient, and capable of a confidential professional relationship with them. Why on earth should JFK have “admitted” (in itself a pejorative term) to a condition which Owen rightly says need have had no impact on his abilities in office?

Owen also brings up the issue of Tony Blair and his heart irregularity which he says was not, as was contemporaneously reported, a new issue, but an old one.  “I do not believe it is in the public interest that this situation be allowed to continue,” Owen writes, wishing all this information to be placed in the public domain. But these type of heart rhythms are common, and readily treatable, and I can think of no reason why this should stop someone from being PM. What is the point of the public knowing about it? None. It is personal information, and even world leaders are entitled to have privacy.

So what kind of health problem should stop people declaring themselves a potential leader? I know people with metastatic cancer who have stable health, and who are also insightful and thoughtful. I know people who have major mental illness who are not only capable but who work in partnership with health professionals such that they can remain insightful and well. I know people with heart disease who have not stopped from being the same impressive businesspeople that they always were. Nor would I wish to restrict the groups of people who would hope to lead the country to those who are happy for their medical records to be laid bare. This introduces a dangerous bias. Egotism, overconfidence and irrationality are the qualities I most fear in politicians, and none of these are medical conditions.

I am taking a break from the blog for a week or two and will catch up then. 

“GlaxoSmithKline is to make public the level of advisory fees it offers to doctors and medical academics, and will strictly cap the payments they can receive in the US to $150,000 (£88,000) a year each. Andrew Witty, chief executive of the UK-based pharmaceutical company, said he was introducing tougher new rules to impose a cap “without exception” on such payments and promised to publish the amounts.”

I’m catching up with my reading. Andrew Jack interviewed Andrew Witty, the chief exec of GSK, in the FT a week or two ago. That’s the first paragraph of a very interesting piece. 

Now, publishing the amounts GSK pay doctors is very good, but, er, 88K a year? For a couple of lectures and lending one’s name to a bit of ghost-writing? GSK, please save your cash and don’t pay any doctors not wholly employed by you for any advisory anythings. Last year the kickbacks received by orthopaedic surgeons – some up to $1m worth – in the US were revealed after a federal investigation showed just how closely doctors and the orthopaedic industry were “working”.  There is still cash being thrown at doctors in the UK. I am tired of throwing out all the invitations I get to hearing the latest on cardiac risk factors/obesity management/urinary incontience over dinner at very nice restaurants courtesy of pharmaceutical reps.

Would you want the advice of a doctor who has just been eating canapes courtesy of the latest anti-inflammatory rep? Would you take the recommendation for your type of hip replacements from someone who has just spent a few five star days giving “consultancy” to the manufacturers?

I hope not. Medicine is difficult enough without having one’s judgment impaired by biased interpretations of the evidence. There is lots of dialogue to be had between doctors and both the pharmaceutical and medical device industries. But this should be done without personal gain. 

That should be obvious. Professionals should not be technicians who can be puppeteered at the whim of the sponsor; they should be acting for the best interests of those they serve with 20/20 clarity. That’s surely the bare minimum we should expect as patients, from doctors?

Every time I have written about this I have had emails from doctors who tell me that I am a fool. You can have nice dinners and lux conference stays and still be a pro, they say, I can’t be bought! But of course you can. Anyone can. The point of being a professional is surely that you choose not to be.

There is an interesting study this week in the BMJ. The study was a mailed survey to US internists and rheumatologists about their use of placebo treatments. The response rate wasn’t great (57%) but about half said they regularly prescribed placebo treatments. Most also said they thought it was ethically permissible.

Placebos do work and the placebo response is usually a clinically useful one. The question is how to use it practically without deceiving the patient. (I am not aware of any research that explores how the placebo effect varies according to what the patient is told about what the treatment contains; do let me know if you do know of any.)

Ethically, doctors should not deceive by lying or exaggerating what is being given. Some ethicists have postulated that by giving a placebo treatment and saying something like ‘we don’t really know how the treatment we are going to give you will work, but I believe it will, and it will not cause any side effects’ is okay. My  problem is that I am not quite sure this is a good enough explanation; I find the explicit omission uncomfortable.

However, the ‘placebo effect’ can be very usefully and ethically harnessed by way of ‘placebo-like’ effects,  the effect more generally of an ongoing relationship between patient and doctor. For example, continuous care from the same doctor, longer appointment times and empathy, all result in better outcomes for patients . The political direction that primary care has been sent in, though, hardly allows for the importance of these things to flourish.

It is reported that Peter Mandelson recently ended up in hospital to be treated for a kidney stone. It is also reported that Lord Darzi, the health minister who believes polyclinics are the future, dined with Mr Mandelson, and was later called upon to see him professionally. 

Who knows what actually happened, but ‘dinner party’ consultations are an overwhelmingly bad idea.  Architects, policemen, lawyer and hairdresser friends tell me the same thing: informal, convivial advice has a tendency to end in tears and should be regarded as a bad idea for the following reasons: 

1) the consultee may not be willing, due to circumstances, to disclose full information

2) the consultee may too willing, due to cirucmstances, to disclose way too much information

3) the consultant may be very biased due to feelings/lack of feeling for the consultee and may be influenced into under or overinvestigation

4) dinner parties where the best treatment for piles and chlamydia are discussed do not make for the most fun evenings

There must be more reasons.

What happens when NICE says no? If NICE refuses to fund an expensive intervention to treat cancer, but the patient wishes it anyway, the patient must forgo all ‘free’ NHS care and pay for the intervention, plus all the rest of their care – ie be subsequently treated entirely as a private patient. Care then becomes very expensive.

There has been a lot of debate about this recently, with many arguing that this is wrong, and that patients should be allowed to pay for ‘top-up’ care for whatever additional treatments they may wish to have.

Freedom of choice is obviously desirable, but, as I’ve argued before, it has to be a meaningful choice. It is incredibly hard to look at newly generated evidence and to try and decide what it means for one as an individual. This becomes even harder when the data is 1) not free to access in its entirety 2) not yet peer reviewed (eg selected data being presented at a conference) 3) presented in ways where the best possible interpretation of the treatment is used (e.g. outcomes described as a reduction in relative risk rather than in absolute risk)  4) when the trial has been small scale and/or short term, which, among other things, may not be long enough or large enough for significant outcomes or adverse effects to be made apparent.

Excellent pieces in the New England Journal of Medicine on military medical ethics, and psychiatrists‘ position in interrogations. There are concerns that army psychiatrists are being trained in areas which could conflict with professional ethics. Doctors are not meant to either conduct or participate in interrogations. However obtained documents suggest that the Department of Defense  still wants doctors to be involved.

There is a piece in the Observer this week about the Jeremy Kyle show. The author says that people with serious mental health problems are prey to the exposure these kinds of shows bring. These shows - where aggressive confrontation and public goading are to used to provoke and taunt people about personal problems or issues – are nasty to watch. On the Jeremy Kyle show there is apparently a “qualified mental health nurse and psychotherapist” who “found no evidence of mental illness” and decided that a “contestant” was “fit to take part”.

Is there really a way to decide if someone is “fit to take part” in such an exercise? Doctors are often asked to fill in certificates claiming that one is “fit to take part” in all sorts of things from skydiving to marathon running. One can say perhaps that there is no obvious reason why one should not do certain things, but there are seldom criteria where it is possible to say that one will be capable of a task. There are a few things where there is clear demarcation of acceptable risk; for example, the criteria for fitness to drive is something the DVLA is very clear about. These kinds of shows, however, are a different thing.

The Channel 4 show Big Brother hires psychologists. These shows look for people who are going to be “good entertainment”. In this context, it usually means that the people are chosen with the belief that they will provide drama. Again, in this context, it usually means conflict with oneself or the group. Presumably the presence of psychologists provide the television company with something to arm themselves with against charges that they place people in potentially damaging situations, played out live and in the public arena. Freedom to do as one wishes is one thing.  But the presence of a psychologist does not guarantee happy endings.

I do know one thing, though. The less television I watch, the happier I am.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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