Choice in matters of life and death

Calls for more money for the NHS are gaining urgency. In a stark report in May the think tank the King’s Fund warned of a financial crisis this year unless the funding gap were filled (doi:10.1136/bmj.g3048). Now three prominent MPs have added their voices, calling for an urgent injection of £15bn (€19bn; $26bn) over the next five years. The new chair of parliament’s Health Committee, Sarah Wollaston, has said, “If there is not an increase, it is hard to see how we could maintain current levels of service given the rising demand” (doi:10.1136/bmj.g4364).

Fears that the NHS won’t cope were abated in some quarters by a report in June by the US Commonwealth Fund, in which the UK health systems were lauded as the most cost effective in the world (doi:10.1136/bmj.g4080). But at the BMA’s annual representative meeting in Harrogate last week this transatlantic pat on the back merely served to stiffen resolve. Delegates asked exactly how much more efficient the NHS could become without falling over. One debate, which called for limited resources to be spent wisely on clinical care rather than for political ends, turned into an impassioned plea to doctors not to collude with austerity thinking. In times of austerity, the need for healthcare goes up, not down, and so too should funding for the NHS.

This is borne out by our investigation this week (doi:10.1136/bmj.g4300). Just over 1000 GPs responded to our online survey, of whom three quarters said that their workload had increased or significantly increased as a result of their patients’ financial hardship. Gareth Iacobucci also reports that two thirds of respondents had seen their patients’ health harmed by benefit cuts.

Clearly we must all make best use of limited resources. Overuse of tests and treatments wastes money and harms patients. The BMJ’s Too Much Medicine campaign aims to fuel this debate and inform better decisions (www.bmj.com/bmj-series/too-much-medicine). So too does the Choosing Wisely campaign, already adopted by 60 specialties in the United States and now spreading around the world, as Richard Hurley explains (doi:10.1136/bmj.g4289).

But one choice not currently available, except in a very few countries, is over when to die if we are terminally ill. In the United Kingdom, as in almost every other country, helping someone to die is against the law, and doctors’ organisations—the BMA and the royal colleges—have maintained their opposition to any change in the law. Two years ago in an editorial I argued that this was not a matter for doctors (doi:10.1136/bmj.e4075). As with abortion, doctors hold the means; but the decision rests with society and parliament. I said that a change in the law to allow assisted dying for terminally ill patients, with all the necessary safeguards, was an inevitable consequence of moves towards greater individual autonomy and patient choice. But I said that it might take a while, “and it may not happen until we properly value death as one of life’s central events and learn to see bad deaths in the same damning light as botched abortions.”

Sooner than I and others might have expected, a new bill is being considered by parliament. And in an editorial this week (doi:10.1136/bmj.g4349) I and The BMJ’s UK and patient editors express the hope that our law makers will this time rise to the challenge and make it law.