Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Ethical Screening?
- David Iles (25 November 2006)
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Dilemnas in clinical practice
- Dr. Adil Y. Kadri (2 December 2006)
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NICE should be answerable to the British government - to hell with the pharmaceutical giants
- Anton E Joseph (6 December 2006)
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Such NICE people
- James W Hawkins (13 December 2006)
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David Iles, GP Locum Romsey, Hampshire, UK, S051 8pd
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The debate over Herceptin can essentially be encapsulated by Beauchamp and Childress'(1979) four concepts of medical ethics ie Autonomy, Non-maleficence, Beneficence and Justice. Of most relevance in Rationing is the dilemma between Autonomy (or patient rights) and Justice/Equity otherwise known as Utilitarianism (or responsibilities to society). It seems to me that, philosophically, Autonomy and Utilitarianism are at opposite ends of the spectrum. Thus, as society creeps ever towards one end of the spectrum it must move away from the other end. Patient advocacy groups clearly place great emphasis on Autonomy but what do they say about Utilitarianism? The rapid responses use the "cake" analogy to describe this dilemma with some suggesting that maybe there is more cake available and so the slices need not be thinned! But in a world where ultimately everything is in limited supply, this seems to miss the point-and that is as we all know "you can't have your cake and eat it!".Sadly, it seems,having it all is exactly the message the government and moreover the media have misled the general public into believing! Competing interests: None declared |
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Dr. Adil Y. Kadri, Psychiatrist Cefn Coed Hospital, Swansea NHS Trust, Wales SA2 0GH
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NICE guidance, as we know is evidence based on all available information from randomised control trials, etc. Studies are based on poulations and robust as the results may seem these are for study populations and may not be applicable at an individual level. In everyday practice as doctors we are dealing with real patients and are often faced with dilemnas - on the one hand bodies such as NICE would recommend that a particular drug or treatment not be prescribed for a particular condition but our clinical judgement dictates otherwise. I still believe that medicine is an art and not an exact science and there is a real danger in getting bound by guidelines and costing factors which limit our clinical practice. Couple this with a vulnerable patient group such as those with dementia, who as we all know have dificulty in being heard and having their opinions taken into account, and there is the real risk that patient care will suffer. Surely this is not in the best interests of our patients who come above all else in clinical practice. I would wonder how many of us would truly decline treatment for their parent suffering from early or late stage Alzheimer's dementia basing our decision on NICE guidance? Competing interests: None declared |
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Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE
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NICE was created for the benefit of the British patients and the NHS. It has been pointed out ad nauseam that its guidance is evidence based. Its judgment should be open to challenge on clinical evidence. Its time, effort and finances, should not be expended on responding to legal challenges on any other grounds. It should be answerable to the government of this country and this country alone. Any pressure from powerful pharmaceutical companies or foreign governments, as in the case of the intervention by the US deputy secretary for health,[1] must be resisted. If the law as it stands permits this interference then the law needs to be changed. The law should require NICE to base its judgment, taking financial and other considerations into account. NICE should also be permitted to hear appeals made on the basis of priorities in different regions of the country and modify its guidance accordingly. NICE's guidance should not be on a one size fits all approach. This will help get rid of the accusations of post code lottery. Clearly this would require the role of NICE to be revisited to make it a more effective organisation. 1 Experts defend NICE against attack by US politician. BMJ 2006;333:1087 (25 November), doi:1136/bmj.39041.354074.DB Competing interests: None declared |
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James W Hawkins, Geriatric Psychiatry VA Palo Alto HCS
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The NICE people who are denying cholinesterase inhibitor treatment to hundreds of thousands of patients in the UK hope to use social services and psychological care for caregivers [BMJ VOLUME 333 25 NOVEMBER 2006 p. 1085 bmj.com]. How delightful! These NICE people are not very nice, in my opinion and they don't seem to know much about the course of dementia of the Alzheimer's type (AD) and the problems that occur in stages 5-7 of the disease. Emphasizing "social and psychological care" for such people is utterly stupid as is offering such care to caregivers in lieu of medications, which have clearly demonstrated a modest benefit for patients in the later stages of their horrible, relentlessly deteriorating, neurodegenerative disease. Where will the "social and psychological people" be when the AD patient is up all night, threatening to kill and is totally exhausting the caregiver. There are no "social" interactions that will work with such patients and I defy anyone to tell me what can be done "socially or psychologically" for the caregiver other than stripping the house of anything dangerous, putting locks on the insides of the doors, putting a heavy door with a deadbolt lock on the caregiver's bedroom and giving the caregiver a set of noise reduction earphones so she/he can get some sleep at night. No "social or psychological person" is going to be around at 7:00 PM when dinner is served and the caregiver has to feed the patient, then take him/her to the bathroom and clean up their incontinent mess as well as mop the floor from spilled food, wipe the walls from food that has been thrown all over the dining area, etc. And, no "NICE social person" will be around at 6:00 AM to clean up the messy, urine and feces soaked bed from the previous night while the patient is wandering around naked with feces and urine dripping all over the place (caregivers have difficulty splitting themselves into 2 or 3 people so they can be all over the house at the same time). Asking an 84 year old wife (or husband) to do this kind of care for their spouse of a similar age is subjecting them to cruel and unusual punishment for an illness based in bonafide neuropathology and not based in "social or psychological problems." Denying these advanced dementia patients the modest help that is clearly given by the cholinesterase inhibitors plus memantine means that the burden of caring for such patients is worse that it currently is and must continue to be if the patients are denied appropriate treatment. Each of the NICE people should be required (and I mean a mandatory requirement) to care, alone, for a violent, incontinent, messy AD patient in stages 5, 6 or 7 for a minimum of 3 months. They should have to do this alone and be with the patient 24 hours per day, 7 days per week, have no respite, have no medication to give the patient and have no time off for holidays or anything else they might enjoy doing. I doubt that one of the NICE people has ever cared for an AD patient or even provided geropsychiatric care for hospitalized AD patients. And I doubt they have talked with the caretakers of such patients. Most likely, as do most bureaucrats and highly placed academics, they just sit around a table and talk about "psychosocial remedies" for patients with a disease based in neuroanatomy gone haywire. I hope the legal challenge survives politically motivated judges and that there are still some people living in the UK who have a little more sense than NICE bureaucrats who KNOW NOTHING in spite of, most likely, having multiple advanced degrees and high bureaucratic positions. James W. Hawkins, MD Geriatric (Old Age) Psychiatrist Adjunct Clinical Associate Professor, Stanford University 240 Kenwood Way San Francisco, CA 94127 jwhawkins@stanford.edu Competing interests: None declared |
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