Let us start with a story in this week's Guardian.
Medical Intervention at the End of Life
This week the Guardian reported that around a third of doctors say they have given drugs to terminally ill patients, or withdrawn treatment from them, in the knowledge (or intending) that their actions would shorten their patient's life (Boseley, S. 'Third of Doctors Act to Shorten Lives of Dying', guardian.co.uk, Friday 23rd October 2009 http://www.guardian.co.uk/society/2009/oct/23/assisted-suicide-doctors-terminally-ill).
This report follows the publication of the findings of Professor Clive Seale of Queen Mary, University of London who carried out this research. Professor Seale discovered that in 211 of the cases they investigated (7.4% of the total number) doctors say they stopped treatment or gave drugs to help speed up their patient's death. In 825 cases (28.9%) doctors made a decision about the patient's treatment that they knew would probably or certainly hasten their patient's death.
This is by no means a complete summary of Professor Seale's findings (nor is it even a complete summary of Sarah Boseley's report!) but the figures I have just presented raise huge legal and ethical issues.
From a legal perspective the problem is clear, if an individual commits an unlawful act which is specifically designed to cause death or serious injury they have committed the offence of murder. Whilst it is true that the doctrine of double effect can apply in some circumstances to 'excuse' conduct which results in a death, this would not seem to apply in the cases reported upon by Professor Seale.
The doctrine of double effect states that providing the primary motive underpinning an individual's action is a good motive, the individual's actions can be excused if they also incidentally result in a 'bad' result. Thus, in a medical context, if a doctor administers a painkiller at a level which he knows carries with it an additional risk of killing the patient, he will not be liable for their subsequent death providing the primary motivation underpinning the injection was to alleviate the patient's pain and NOT to end their patient's life. In the cases reported upon by Professor Seale the doctors questioned freely admit that their actions were designed to end their patient's life.
When we examine the actions of the doctors in these terms we can see that these doctors are in breach of the law, which brings us to the second issue, whether physician assisted suicide should be illegal?
Professor Seale's study also noted that 1 in 10 patient's treated by those surveyed had requested assistance from their doctor to end their life, in 2006 a Yougov poll commissioned by the group 'Dignity in Dying' suggested that 76% of people surveyed were in favour of physician assisted suicide (so long as adequate safeguards were in place) and a survey carried out by the Times revealed that 95% of people support the right of people with a terminal illness to be helped to die (although that figure dropped to 48% in the case of patients who have a severe physical disability) - (Bennett, R. & Rose, D. 'Public Supports Assisted Suicide for Terminally Ill People', Timesonline, http://www.timesonline.co.uk/tol/life_and_style/health/article6726928.ece).
All these figures seem to point towards a groundswell in public support for moves to legalise physician assisted suicide, yet every attempt to introduce legislation in this field has, so far, been unsuccessful, but for how much longer?
Access to Healthcare
This week's health stories have also given us the opportunity to touch upon a topic that we have not yet covered in this blog - namely access to healthcare resources.
On 21st October the Guardian reported on the story of the National Institute for Health and Clinicial Excellence's decision to withhold approval for Tyverb, a drug which can give women with advanced breast cancer extra weeks or months of life (Boseley, S. 'Women Denied Cancer Drug that Could Extend Life', Guardian online, 21st October http://www.guardian.co.uk/lifeandstyle/2009/oct/21/women-denied-cancer-drug).
To understand the significance of this decision we need to briefly imapct of NICE's decisions on the way health care resources are dstributed in the United Kingdom.
The simple truth is that there is only a limited amount of money available to fund the healthcare needs of the nation and so careful thought needs to be given to how those funds are to be spread around, which is where NICE comes in. NICE is an organisation, created by the government, tasked with producing guidance in three main areas (see http://www.nice.org.uk/aboutnice/):
- Public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- Health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
- Clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS
A detailed examination of what QALYs are and how they assist NICE to make decisions about which treatments to approve is beyond the scope of this post. Suffice to say that the QALY calculation results in a figure representing the cost per Quality Adjusted Life Year of a particular course of treatment. This figure can then be used in one of two ways. It can be compared with the cost per QALY of alternative types of treatment for this patient (relatively uncontroversial), or it can be compared with the cost per QALY of treating alternative patients (much more controversial). In this way the QALY calculation can be used to determine which treatments to fund, and/or which patients to treat. Of course the converse is also true and so the QALY calculation can also be used as a tool to help decide which treatments not to provide and/or which patients not to treat. In this way NICE has a definite role to play in limiting access to the types of care provided free of charge on the National Health Service.
The decision in this case is particularly controversial. NICE had already rejected Tyverb on aprevious occasion on the grounds that it was too expensive for the benefits it provided from a QALY perspective. Nevertheless the manufacturers of the drug, GlaxoSmithKline (GSK), asked NICE to reappraise it in light of new guidance published earlier this year governing end of life treatments.
NICE has a ceiling on how much per QALY it is willing to spend after which it will no longer approve funding for the treatment (according to the Guardian the figure currently sits at the £30,000 mark). The guidance in question, published by NICE, advised that this ceiling should be raised when considering cancer treatment at the end of life. However, NICE did not actually set out what the new ceiling should be in such cases.
It would be nice to think that we have unrestricted access to health care as and when we need, but nothing could be further from the truth. It seems as if there is a price the government is not willing to pay to keep the nation's health from ticking over. Nevertheless, we have to accept that the government are faced with an unenviable task. Difficult decisions have to be made about how the available resources are to be distributed. If we are unhappy with the current methods for deciding how those funds get spent, what are the alternatives?
An Unlimited Supply of 'Spare Parts'?
In light of the previous story and the underlying message about the limited availability of resources to fund treatment of the UK's population this final choice of story seems very appropriate.
On 20th October 2009 the Guardian reported that advances in medical technology would soon allow us to combat some of the physical deterioration associated with old age (Boseley, S. 'Replacement Body Parts Offer Active Old Age for Future Pensioners' Guardian Online, 20th October 2009 http://www.guardian.co.uk/society/2009/oct/20/scientists-promise-body-parts).
Improvements in medical technology have meant that patients in modern times are now surviving conditions that decades ago would have proven fatal, and we can now keep patient's 'alive' on life support machines seemingly in perpetuity (a point made by the House of Lords in Airedale NHS Trust v Bland). Furthermore, recent reports have suggested that babies born from 2009 onwards stand a much greater chance of reaching the ripe old age of 100 (Anon 'Half of Babies 'Will Live to 100'' BBC News Online http://news.bbc.co.uk/1/hi/health/8284574.stm). The problem is, of course, that our bodies are not designed to go on forever, the ever increasing incidences of dementia in our population is a testament to this fact.
Nevertheless, the University of Leeds has received £50 million of funding to co-ordinate a project which will focus on developing artifical joints, as well as creating skin, cartlidge and heart valves which will never be rejected by transplant patients. The goal is, ultimately, to try and give those over the age of 50 a further 50 years of active living.
This incredible sounding development raises questions about how far we are prepared to allow technology to develop? At what point do we step in and say 'enough is enough'? Do we really want to live for ever? Then we have the inevitable questions about how we are going to pay for the treatment costs of our ever ageing population? We have enough problems meeting existing requirements. Still, at least if we have a population which is capable of remaining active for longer, perhaps we'll be able to work for longer as well!?!
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