Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Acknowledgement
- John Firth (20 April 2007)
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Is Mr. Brown in an information vacuum?
- John Perry (20 April 2007)
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Duty of Candour
- Som Prasad, Wirral, CH49 5PE (21 April 2007)
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Naivety or Conflicts of Interest?
- Jay Ilangaratne (22 April 2007)
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Rationing by ignorance denies patients their fundamental rights
- Gerhard B. Holt (23 April 2007)
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Physicians as gatekeepers
- Luis Justo (23 April 2007)
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All that is needed is for good men to say nothing
- Graham Kyle (24 April 2007)
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Re: Rationing by ignorance denies patients their fundamental rights
- Jay Ilangaratne (24 April 2007)
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What about obligations to sick friends or colleagues?
- Anonymous Health Professional (24 April 2007)
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The inverse care law working again
- peter b hadfield (25 April 2007)
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Flawed example
- Martin Gerken (3 May 2007)
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Happiness
- Andrew Montgomery (4 May 2007)
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Further comments on obligations to inform patients about treatment options
- John Firth (6 May 2007)
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Not the doctor's choice any more?
- Steve Choong (6 May 2007)
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Ethics 101
- Andrew Montgomery (8 May 2007)
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John Firth, Consultant Physician CB2 8QQ
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For reasons that are opaque to me the BMJ 'don't tend to include [acknowledgements] in editorials and opinion type pieces'. I therefore write here as suggested by a member of the BMJ editorial team to say that I am grateful to Prof Tony Hope for helpful comments on a first draft of my article. Competing interests: None declared |
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John Perry, General Practitioner Cambridge CB4 1GL
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John Firth has done his best with a very short straw and moved the debate from the general question to a very specific patient. Mr. Brown is that rarity in today’s society, a person disinterested in his medical condition and bereft of sources of information or indeed of friends, relatives or campaigners who will give him information he may not want. He is vulnerable to hearing about erythropoietin in the renal clinic waiting room, from his GP, from other renal patients in his home, etc. My concern would be that when (not if) he receives the information, and then appreciates that the doctor failed to inform him, his trust in that doctor and the profession in general will be undermined. People with ill health have to face many uncomfortable and distressing changes in their lives and whilst doctors do have a duty to comfort this cannot mean protecting patients from information that is both empowering and uncomfortable. Doctors cannot know what resources their patients may have or be able to rally. Competing interests: None declared |
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Som Prasad, Consultant Ophthalmologist Eye Department, Arrowe Park Hospital, Wirral, CH49 5PE
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I'm afraid, I'm at odds with Dr Firths opinion about not telling the patient about a reasonable treatment option (whether NHS funded or not). Both GMC guidance and BMJ ethics commitee statements make it absolutely clear that there is a duty of candour to the patient. A doctor who does not do this is being negligent, and should face censure. I agree that society can't fund all treatments, some of which are extremely expensive, but the duty of rationing rests with the comissioners (and vicariously with politicians), who must take the responsibility for thier comissioning decions, and answer any queries which arise. Whilst doctors will need to work within protocols, and perform only those procedures (or treatments) funded by comissioners, thier first duty is to the patient (and this takes precedence over thier duty to thier employer). Thus, it is negligent if a doctor does not offer a reasonable treatment option just becuase the current funding regime will not pay for it. This is both a dissservice to the patient, and really bad medicine. Whilst I hope that this issue will be resolved amicably, I fear that it will only be settled when a few high profile cases will be dragged through the courts. Thanks You Som Prasad Consultant Ophthalmologist and Clinical Director Wirral Hospitals NHS Trust Competing interests: None declared |
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Jay Ilangaratne, Founder www.medical-journals.com
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As already indicated by another respondent, John Firth has certainly failed in his duty of candour to a patient. Not only such conduct is likely to be negligent,but could also lead to wider loss of confidence in the medical profession; surely, that is something which no responsible profession could afford. Perhaps, Firth's revelations are a timely reminder to other doctors that the overriding duty of care to one's patients should not be compromised for commercial reasons or in order to appease one's employer.If Firth was driven to his professional judgement in this case by rather overzealous altruism(with regard to public funds),then again it confirms that he has failed to appreciate his foremost duty to a patient.From whatever angle one looks at this issue, it is clear that Firth's position is hard to defend either morally or legally.If Firth's account is in relation to a real patient of his, then given he has chosen to air this matter most publicly,it might not be too late to contact his indemnity insurer if he hasn't already done so. Competing interests: None declared |
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Gerhard B. Holt, Medical Student University of Sydney - 2006
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A patient presents with a serious or life threatening disease (for example : lung, breast or colon cancer). Evidence suggests that this sort of patient might benefit from a new and expensive treatment that isn’t covered (yet) by the public healthcare system, or even possibly by private insurance (for example : Erlotinib, Trastuzumab, or Cetuximab). The patient isn’t informed about the potentially beneficial new treatment –at all. As a result, the patient happily agrees to undergo the publicly available treatments, despite the fact that evidence may indicate a potential substantial benefit in terms of mortality and/or morbidity to pursuing the newer - and undisclosed - treatment option. This sort of scenario is one example of “rationing by ignorance”.(1) [Bernstein 2006] In “rationing by ignorance” a patient does not receive (or even have a chance to receive) a potentially attractive treatment option because she does not know that it exists and/or that it might be beneficial for her. (Note : For clarity, I will use the terms “her” and “she” in this discussion, although similar situations would clearly also apply to male patients). The word “autonomy” – is inappropriately weak in this context. It neuters, depersonalizes, and de-emotionalizes the issues at stake. The issue is not “autonomy” (suggestive of a recalcitrant idiosyncrat insistent on going off on her own and doing things her way). The issue is one of fundamental freedoms – the right to choose what is done to one’s body, and the right to self defence. Rationing by ignorance denies patients their fundamental
rights, including the rights to : 1) fully informed consent, 2) self defence – defined as using one’s resources to protect oneself from death and or serious bodily harm, 3) creative problem solving – a patient who is uninformed cannot try to bring her creative problem solving skills to bear to try to find a “third way” to improve her access to care. (4) freedom of speech – a patient who is denied potentially lifesaving care due to lack of funds has a right to be angry and has a right to voice her anger publicly. By keeping the patient uninformed, the clinician has robbed the patient of her right to freedom of speech, and her right to try to sway the political debate in favour of supporting better care for all patients, (5) freedom of thought – even if all else fails – a patient has a right to know the truth about her care and why she is suffering or dying. This right to freedom of thought – extends beyond practical, utilitarian, or transactional considerations. It is an end in itself, not just a means to an end. Freedom of thought is at the core of a patient’s dignity. Rationing by ignorance also denies the patient’s family and friends of similar rights. Rationing by ignorance denies the society a powerful and important debate on the resources allocated to healthcare. Few people can be as powerful advocates of potentially beneficial change a person who is suffering from or dying of an illness. Few people can offer the passion and personal experience of such a patient or their families. Such advocacy and strength of purpose has been crucial in developing political support for research and treatment initiatives for many medical disorders and other societal ills. Even if the clinician’s personal politics opposes such initiatives, and advocates reduced spending on public healthcare, even if the clinician’s personally advocates that society should spend its resources in other ways, the patient and her family should not be silenced. Rationing by ignorance pre-emptively silences the patient – which damages the healthy debate that is so essential to the effective functioning of a pluralistic democracy. Rationing by ignorance in serious illness violates many of a patient’s fundamental rights, and transgresses a doctor’s ethical duties. It should be avoided. References : (1) Bernstein J. Rationing. Working Paper and Private Communication. June 7th, 2006. Competing interests: No significant competing interests. |
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Luis Justo, Researcher, former pediatrician Universidad Nacional del Comahue, Argentina
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Should we, as physicians, behave as public funds gatekeepers? The answer is not an easy one, but it depends on several factors. One is the intensity of democracy in our country, allowing or not for meaningful public deliberation about health spending and rationing. Another is the certainty we may (or may not) have about the effect of the possible treatment. A third one is the quality of the patient-physician relationship, which doesn't seems to be very good in the presented case. Of course, maintaining a straightforward conversation with the patient about treatment options including expensive ones is time consuming, but a conception of the patient-doctor relationship as a merely prescriptive one not only deprives it of respect for autonomy but also takes away plain humanity and interest for the other. Let's take the needed time to care. Competing interests: None declared |
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Graham Kyle, Consultant Ophthalmologist Walton Daycase Centre, Rice Lane, Liverpool,L9 1AE
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I am sure Dr Firth is a committed, caring and competent physician, but on this occassion, he has failed his patient, Mr Brown. He (and other doctors like him) are damaging all those who suffer avoidable harm through lack of appropriate healthcare resource provision. His actions are supporting the political lies and administrative sleight of hand which deny patients' life enhancing treatments. He should read the General Medical Council guidance further; after telling his employer of inadequate resources, he should 'seek independent advice' on how best to put matters right. A Primary Care Trust who refuses to fund treaments recommended by the National Institute for Clinical Excellence should be reported to the Secretary of State for Health, with a copy to the press. There are, of course difficulties with this approach; time and enegy, with overbooked clincs wearing down clinicians' resolve, as alluded to by Dr Frith; and the Clinical Excellence Award System, which was not. Competing interests: Remuneration from pharmaceutical industry for advice / lectures on ethcial and legal aspects of 'off-label' treatments for macular degeneration |
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Jay Ilangaratne, Founder www.medical-journals.com
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It is refreshing to see a somewhat legally oriented analysis of an omnipotent medical practice, particularly from a 'medical student'.With respect, may I suggest Rationing by Concealment as an alternative title to the aforesaid response. Further,given patient empowerment and Patient Choice are heavily canvassed within the NHS at present,Firth's stance is all the more surprising if not worrying. Competing interests: Have responded to Firth's view earlier. |
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Anonymous Health Professional, N/A N/A
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This article discusses obligations to patients. But what about obligations to sick friends or colleagues?
A friend of mine has metastatic disease and his clinical condition is deteriorating despite adequate nutritional support and conventional cytotoxic drugs. Today I read some papers in the scientific literature (1,2) and on the Internet (3) about the possible effectiveness of sodium dichloroacetate (DCA) in cancer patients. (I am a hospital pharmacist.) The debate around this issue (1,3) stresses that using this substance outside a clinical trial could be risky patients and could undermine the proper conduct of future clinical trials (1.3). Despite this, I think that I will cautiously tell this person that some experimental treatments of this kind have shown these effects (2) and that this debate has started in the medical literature (1). I suspect that he will discuss with his oncologist whether DCA can offer any hope to him. Information about effective treatments is always a duty. But should information about untested treatments be given (when nobody asks it) or avoided? REFERENCES 1) Pearson H. Cancer patients opt for unapproved drug. Nature 2007;446(7135):474-5 2) Bonnet S, Archer S, Allalunis-Turner J, et al. A mitochondria-K+ channel axis is suppressed in cancer and its normalization promotes apoptosis and inhibits cancer growth. Cancer Cell 2007;11:37-51 3) website http://www.thedcasite.com/ accessed on 20th April 2007. Competing interests: None declared |
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peter b hadfield, gp pe12ra
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I was saddened to read Dr Firths reply for a number of reasons. The ethical arguements really do not stand up- he has a duty of care to the patient in front of him. He makes a sweeping judgement about his patients social and economic status. Just because his patient would appear unable to pay for a treatment that the physician believes could markedly improve his quality of life is not a reason to deny him the knowledge about it. This is the reason we GPs send patients to specialists- to impart on them their knowledge and experience,to inform them about their disease and possible treatments, not to judge them. If the patient had been smartly dressed with a number of pushy, internet literate relatives in tow, would the consultation have been different? If the answer to this is yes some deep soul searching is required. To use the excuse of a busy waiting room was also poor, the patient did not seem the complaining type so was fobbed off. If you want to change the system and genuinely help such patients, at the same time maintaining the professions respected ethical position, give patients the information and knowledge they deserve. Also try informing the GP of such funding problems so they could also write to the PCT on the patients behalf. Competing interests: None declared |
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Martin Gerken, Clinical Pharmacology Bremen
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The example is flawed as the patient is likely not to benefit from having his haemoglobin increased: The Lancet 2007; 369:381-388 Competing interests: None declared |
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Andrew Montgomery, locum Auckland
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Dr Firth's response is thoughtful and compassionate - in my view. I am a locum doctor who works with a wide range of socioeconomic groups. They differ widely in terms of their ability to understand their illnesses and the usefulness of the many possible inteventions. Many are "non-compliant" with medications and lifestyle advice which if ideally applied would prolong their lives and forestall the need for expensive treatments such as dialysis and erythropoetin. I now tend to focus substantially on quality rather than quantity of life. I undersatnd that this means that they may meet a grizzly fate sooner rather than later - but the question is - how much does it matter? Day to day happiness and social integration is more important than anything a doctor can do for a patient. This does not mean adopting a laissez faire approach - but rather titrating one's responses to patient wishes. These wishes are almost by definition an expression of their world view and the neurology which underpins this view. I think there is a tendency to over intervene and overtreat many people who simply don't want to know. That said - if they clearly want to know whether they are being denied life prolonging therapy for whatever reason then it is encumbent upon their doctor to advise them of all possibilities. Competing interests: None declared |
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John Firth, Consultant Physician CB2 8QQ
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I would thank the people who have submitted responses to my article - they have made many good points, none of which surprise me, but I think the issue of what a good doctor should tell a particular patient is often a very finely balanced matter of judgement. As a working clinician I am wary of ethical arguments in a vacuum and prefer to consider particular examples. Yesterday morning I did a post- take ward round in my hospital. On this ward round I saw six patients who had been admitted to beds on inappropriate wards (less than on many occasions). I believe that these patients would receive better treatment if they had access to an appropriate bed, eg on a high dependency unit, or on a medical rather than surgical ward. As stated in my commentary regarding the prescription of epo for a man with anaemia, I have much put effort into trying to improve the lot of patients admitted to my hospital with medical emergencies and will continue to do so. But I would welcome advice from those critical of my behaviour with regard to epo ... what, if anything, should I say to a breathless man with an exacerbation of chronic obstructive pulmonary disease who is admitted to a surgical ward that has no expertise in managing this condition because the respiratory ward is full? Competing interests: None declared |
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Steve Choong, consultant psychiatrist Hill Crest,Quinney's Lane, Redditch, Worcs.
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In this debate, the different ethical positions are clearly outlined by Marcus and Firth. However, ethics have to change in line with society's expectations. Our society as a whole has moved down the road of wanting to know more about everything. At present, there is no compact with society for doctors to ration services. Therefore, the paternalism shown in Firth's interpretation cannot be supported any more. His patient should be told of the treatment. What he does with it is then up to him. He can choose to personally lobby the appropriate authorities or go through pressure groups if he wants it. Politicians and other stakeholders will deal with it accordingly. The argument about time spent on explanations and workload is irrelevant and should be addressed through doctors' line management. Even if the patient in Firth's description would have preferred not to know of the availability of the treatment, it could still be argued that he should be told. That is a cost of living in this society. Competing interests: None declared |
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Andrew Montgomery, locum Auckland
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Dear sir After reading through the various comments made in response to Dr Frith I am left feeling a little disturbed. The appropriate response to any patient is surely contextual and cannot be dictated by some all embracing ethical principle. Perhaps the best way to illustrate my point is via example ie moral reasoning 101 1. A patient is diagnosed with CJD. The outlook is hopeless. Should
the attending physicians or family decide whether or not the patient
should be advised of their fate while the patient still has sufficient
awareness?
While the two cases are superficially different the realities are the same. I know how I acted in case (1). It was straightforward. I chose on behalf of my family and instructed the medical team in attendance to not inform my brother of his fate. I invite criticism from the readers -particularly those who have found themselves’ in similar circumstances. With regard to case (2) – I would choose not to inform the patient. This is because the “availability” of a treatment is effectively a chimera. There is no hope that this patient is going to receive the drug. What useful purpose is served by informing this patient? A prior correspondent asserts that this is necessary in order to advance the common good. This utilitarian argument is flawed in my view. Firstly it punishes the individual in his/her terminal weeks. Secondly we are living in a world where technology is rapidly outstripping the capacity for vote health to deliver the latest treatments. I agree that the debate needs to be fully in the public arena. It will never be my job when I communicate with my patients to torment them with choices that they simply do not have. Competing interests: None declared |
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