Should the NHS fund the treatment of self inflicted diseases?

Some examples of Self Inflicted Diseases:

  • Skin cancer following prolonged exposure to sun rays
  • Obesity following bad dietary habits
  • Lung Cancer due to smoking
  • Liver Cirrhosis following excessive drinking
  • Heart disease and hypertension following an unhealthy lifestyle
  • HIV following conscious high risk taking behaviour

 

We must consider three principles when answering this question:

  • Autonomy – there is an argument that we should be free to choose our activities and not and not be penalised as a result of them as long as they are not harming others. It could be argued that since some harmful activities such as smoking are addictive, and we understand the underlying neurobiological mechanism by which this occurs. There is less ‘fault’ than we think and some people may be more of a victim of genetics than their own behaviour
  • Justice  – we should optimise the use of our resources and make the most efficient use of precious funds
  • Beneficence – this principle implies a duty to treat all sufferers of a disease, regardless of the cause.

 

To many, it seems fair that those who take risks should accept their consequences.In a system where resources are scarce, it is important to prioritise how budgets need to be allocated. Public perception of the health service may be worsened if they see people who are less deserving in their eyes receive treatment when they themselves are struggling to be treated. It is also true that patients with self inflicted diseases often relapse. They may feel that they have gotten away with it before and return to their high risk behaviours. Treating them might therefore only be a temporary measure for a problem which may recur later on, e.g alcohol relapse following liver transplant. As well as this allowing treatment of self inflicted diseases may remove individual responsibility for one’s health. People will not consider some behaviour as high risk in the first place because they know that they will receive treatment if they need to. In some cases ( such as drug – related conditions), treating patients may actually be seen as encouraging illegal activities.

However it can be argued that the large majority of diseases are self inflicted to some extent, even though the link may not be obvious. Indeed, bar a small number of genetically inherited diseases, most are linked in one way or another to our lifestyle. Excluding self – inflicted conditions would restrict a health system to treating only a minority of conditions. Public perception would be greatly damaged if we could not get help for some of the most common diseases

Slippery slope

Assuming that we may want to exclude some self – inflicted diseases from NHS care, it would be difficult to determine the extent to which a disease is self – inflicted and therefore whether it should be treated or not. Where do we draw the line?

Example: A woman has unprotected sex with her long – term husband because she trusted him, but where the husband acquired HIV through a one – night stand and refused to notify his wife. Would you say that the wife’s HIV was self – inflicted? How would you know she is not lying simply to get treatment?

On public health grounds, it is necessary to treat any transmissible diseases, to control them and to prevent onward transmission.

It is also important to note that some self – infliction (such as excessive drinking or smoking) may reveal underlying issues (e.g psychiatric conditions or psychological ill – being) that may need to be identified and treated. Not allowing patients to visit a doctor for self inflicted illness may prevent the treatment of those underlying causes.

 

We are in a free society where individual choice is of crucial importance. The NHS should complement this society choice an not work against it


Ultimately, it is down to society to decide how it wants to use its own health system. Based on the arguments above, it would be very difficult to separate with certainty self – inflicted from non self – inflicted diseases and therefore such an exclusion system would not be fair or practical.

 

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The Ethics of Abortion

Abortion is one of the most frequently debated issues within medicine. In fact, it is probably still the most controversial of all the current contemporary social issues heading into the twenty-first century. It is a procedure to terminate a pregnancy using medicine or surgery to remove the embryo or foetus and placenta from the uterus. Abortion poses a moral, social, and medical dilemma that stirs up emotional responses among disputants of the topic.

Under UK law, an abortion can usually only be carried out during the first 24 weeks of pregnancy as long as certain criteria are met:

The Abortion Act 1967 covers England, Scotland and Wales and states:

  • abortions must be carried out in a hospital or a specialist licensed clinic
  • two doctors must agree that an abortion would cause less damage to a woman’s physical or mental health than continuing with the pregnancy

There are also a number of rarer situations when the law states an abortion may be carried out after 24 weeks. These include:

  • if it’s necessary to save the woman’s life
  • to prevent grave permanent injury to the physical or mental health of the pregnant woman
  • if there is substantial risk that the child would be born with serious physical or mental disabilities

Generally, an abortion should be carried out as early in the pregnancy as possible, usually before 12 weeks and ideally before 9 weeks where possible.


Usually, there are two points of view on abortion, those that are “pro-choice”  and those that are “pro-life.” Pro-lifers would argue that from the moment of conception, a foetus, or human embryo, is a living person. Abortion deprives this foetus of the chance to live and can be considered murder whereas Pro-choice believers feel that a woman has the right to choose to decide what happens to her body and whether to have an abortion.

Before we begin to make decisions about abortion we must first examine “person-hood”. What makes up person-hood? The definition of when a foetus becomes a person is a very grey area, however if we utilize medical definitions of life, we can see that a foetus is a person when its heart begins to beat on its own. This definition is clear if we look at the example of a person who has had a heart attack. Once the heart stops the patient is declared legally dead. Therefore if there is a heart beat, there is life. Since the heart begins to beat after about 3 to 4 weeks, abortion after that time would constitute killing a human being, which under most ethical views is morally and ethically wrong. These are the grounds upon which pro lifers base their argument. In addition to this, those who choose abortions are often minors or young women with insufficient life experience to understand fully what they are doing. Many have lifelong regrets afterwards and are  frequently caused intense psychological pain and stress. Putting a child up for adoption is a viable alternative to abortion and accomplishes the same result. Abortion should not be used as another form of contraception. Pro choicers on the other hand take the stance that the concept of person-hood is different from the concept of human life. Human life occurs at conception, but fertilized eggs used for IV fertilization are also human lives and those not implanted are routinely thrown away. Is this murder, and if not, then how is abortion murder?

However it may not matter in terms of pure moral philosophy, since there are cases when most people agree that even if the foetus is a person, abortion may be  justified. In the case of rape or incest, forcing a woman  made pregnant by this violent act to have a child, would cause further psychological harm to the victim. Teenagers who become mothers have grim prospects for the future. They are much more likely to leave school; receive inadequate prenatal care; rely on public assistance to raise a child; develop health problems. All in all the child will not receive an acceptable quality of life/care that it deserves. This can be true also in the instance of a child that would have physical handicap or mental defects.

Some philosophers have argued that abortion can be  justified even where there is no risk to the physical or mental health of the mother.The ability of a woman to have control of her body is critical to civil rights. Take away her reproductive choice and you step onto a slippery slope. If the government can force a woman to continue a pregnancy, what about forcing a woman to use contraception or undergo sterilization?

Unfortunately there is no agreement in medicine, philosophy or theology as to what stage of foetal development should be associated with the right to life. This does not surprise me, as the idea that there is a precise moment when a foetus gets the right to live, which it didn’t have a few moments earlier, feels very strange. And when you look closely at each of the suggested dates, they do seem either arbitrary or not precise enough to decide whether the unborn should have the right to live. Nonetheless, as a matter of practicality many abortion laws lay down a stage of pregnancy after which abortion is unlawful (because the foetus has a right to life), and the dates chosen are usually based on viability.

In spite of the vast opinions on the matter, the fact does still stand that abortion is lawful in England. I would say that this is perhaps for the best because if it were not, women would try and find another underground route of carrying out the procedure that would be risky and unsafe for both mother and child, which is the case in some countries. At least this way it is done under the government’s eye and can be regulated fully. The British Medical Association recognises the diversity of opinion amongst its membership. Advice to its members is to act within the boundaries of the law and their
own conscience. Patients are, however, entitled to objective and non-judgmental
medical advice and treatment, regardless of a doctor’s personal view.
The BMA abhors any instances of harassment or discrimination of doctors on the basis
of their views about abortion, either for or against.

 

 

Professionalism within Medicine

What is ‘Good Medical Practice’?

Good Medical Practice is defined by the GMC Guidelines Duties of a Doctor. A good doctor makes the care of his/her patient their first concern; they are competent; keep their knowledge and skills up to date; establish and maintain good relationships with patients and colleagues; are honest and trustworthy and act with integrity.

As doctors are entrusted with the lives and health of patients and are accountable for the decisions and actions they take, they must:

  • Make the care of a patient their first concern
  • Protect and promote the health of patients and the public
  • Provide a good standard of practice and care
  • Treat patients as individuals and respect their dignity
  • Work in partnership with patients
  • Be honest and open and act with integrity

 

PROFESSIONAL RELATIONSHIPS – In order to be an effective clinician, a doctor must be able to develop and maintain a professional relationship with both their patients and their colleagues. By being polite, considerate, honest, trustworthy as well as treating each patient with dignity and as an individual, a doctor will be able to effectively communicate with the patient, obtain their trust and subsequently address the individual patient needs. Good communication requires listening to the views and questions of the patient, providing information in an accessible way and collaborating to come up with a shared plan. Within the clinical environment, it is also important to work in teams. A doctor should act as a positive role model and be a supportive and encouraging influence to others involved in patient care. In order to do the above, a doctor should; respect the skills and contributions of others, encourage and support each member, communicate effectively and review each situation regularly.

Should Euthanasia be legalised in the UK?

This is a controversial question that is very often subject to debate. Does an individual who has no hope of recovery have the right to decide how and when to end their life? There are a vast range of opinions.

To gain a deeper insight into this question, we must first establish the most widely adopted definitions of the types of euthanasia. (there is intense debate in the terms used in euthanasia and there are currently no consensus definitions.)

‘Active Euthanasia’ refers to an action one takes to end a life, for example, a lethal injection.   It is when the medical professional does something that results in the patient’s death. ‘Passive Euthanasia’ occurs when the medical professional allows the patient to die, either by withholding life prolonging treatment, or withdrawing it. For example, switching off a life support machine, switching off a ventilator for a patient who is unable to breathe, etc. Finally, an important type to note, is ‘voluntary euthanasia.’ This is when the patient competently requests death himself. It is the behaviour that caused the patient’s death at his request .

We must explore the reasons for euthanasia. We have the ethical argument, that people should have freedom of choice, including the right to control their own body and life (as long as they do not abuse any other person’s rights), and that the state should not create laws that prevent people being able to choose when and how they die. We also have the pragmatic argument,that euthanasia, particularly passive euthanasia, is allegedly already a widespread practice, just not one that people are willing to admit to, so it is better to regulate euthanasia properly.

The ethical argument states that everyone should be able to choose when and how they want to die, and that they should be able to do so with dignity.The concept of “quality of life” is an important aspect of this argument. The idea put forward as part of the religious argument against euthanasia and assisted suicide that life is sacred and is therefore always better than death – is rejected. The ethical argument suggests that life should only continue as long as a person feels their life is worth living. For example, someone who supports the use of euthanasia or assisted suicide based on the ethical argument may believe that a person should be able to choose to end their life if they are living in intolerable pain and their quality of life is severely diminished.

The pragmatic argument states that many of the practices used in end of life care are a type of euthanasia in all but name. For example, there is the practice of making a “do not attempt cardiopulmonary” (DNACPR) order, where a person requests not to receive treatment if their heart stops beating or they stop breathing. It can be argued that DNACPR is a type of passive euthanasia, because a person is denied treatment that could potentially save their life. The pragmatic argument is that if euthanasia in these forms is being carried out anyway, society might as well legalise it and ensure that it is properly regulated.

However convincing the above arguments may be, these come with complications. There is significant reasoning against euthanasia.

The most common religious argument is that human beings are the sacred creation of God, so human life is, by extension, sacred. This is known as the “sanctity of life”. Only God should choose when a human life ends, so committing an act of euthanasia or assisting in suicide is acting against the will of God and is sinful. This belief – or variations of it – is shared by many members of the Christian, Jewish and Islamic faiths, although some individuals may personally feel that there are occasions when quality of life becomes more important than sanctity of life.

There is also the notion that once the healthcare service, and by extension the government, starts killing its own citizens, a line is crossed that should never have been crossed, and a dangerous precedent has been set. The concern is that a society that allows voluntary euthanasia will gradually change its attitudes to include non-voluntary and then involuntary euthanasia. Legalised voluntary euthanasia could eventually lead to a wide range of unforeseen consequences, such as the following:

  • Very ill people who need constant care, or people with severe disabilities, may feel pressured to request euthanasia so that they are not a burden to their family.
  • Legalising euthanasia may discourage research into palliative treatments, and possibly prevent cures for people with terminal illnesses being found.
  • Occasionally, doctors may be mistaken about a person’s diagnosis and outlook, and the person may choose euthanasia after being wrongly told that they have a terminal condition.

Also legalising euthanasia would violate one of the most important medical ethics, which, in the words of the International Code of Medical Ethics, is: “A physician shall always bear in mind the obligation to respect human life”. Asking doctors to abandon their obligation to preserve human life could damage the doctor-patient relationship. Hastening death on a regular basis could become a routine administrative task for doctors, leading to a lack of compassion when dealing with elderly, disabled or terminally ill people. In turn, people with complex health needs or severe disabilities could become distrustful of their doctor’s efforts and intentions. They may think that their doctor would rather “kill them off” than take responsibility for a complex and demanding case.

The alternative argument is that advances in palliative care and mental health treatment mean there is no reason why any person should ever feel that they are suffering intolerably, whether it is physical or mental suffering, or both. According to this argument, if a person is given the right care, in the right environment, there should be no reason why they are unable to have a dignified and painless natural death.

According to the UK, and most countries, the negatives outweigh the positives.

Euthanasia is unlawful in England. In fact the law treats it as murder as “mercy killing” cannot be used as a defence. However the law does not stop people from committing suicide, in fact the Suicide Act 1961 decriminalized suicide and attempted suicide. However, this does not extend to giving “claim right” to commit suicide (i.e. expect others to provide). As a result, this decriminalization should be interpreted as “liberty right”, people cannot be stopped from committing suicide but one cannot demand a suicide. Assisted suicide in the forms of aid, abet, counsel or procure suicide is a criminal offence under the Suicide Act 1961 punishable by 14 years of imprisonment.

Case Study – A 14 year old girl and the provision of contraception

You are a GP and a 14 year old girl visits the clinic alone. She tells you that she would like to go on the contraceptive pill. What issues does this raise and how would you handle this scenario?

Firstly, the doctor should find out all the relevant information at to why she wants to go on the pill. The pill is often used for other conditions, such as to regulate and control periods and treat acne but it is likely that she is requesting it because she wishes it to be used as a contraceptive.

She tells you that she has a boyfriend her age and they are thinking of having sex. When you ask if she has told her parents, she gets flustered and says that she hasn’t and does not wish to. Her parents are her legal guardians

Should you break confidentiality and tell her parents?

Beneficence – A doctor should always act in the patient’s best interests: Sex before the age of consent is common in this country and the rate of teenage pregnancies and sexually transmitted diseases in the UK is higher than in any other European country. The girl has shown that she can be responsible by seeing her doctor. It is important for the doctor to establish a good relationship with the girl, to be someone she feels she can trust. If confidentiality is broken, the child may be unlikely to trust GP again. In which case, could she face even more harm?She is more likely to take the doctor’s advice regarding protecting herself against sexually transmitted disease by using condoms if she feels that she is not misunderstood and patronized. If she is going to have sex anyway it would be in her best interest that the risk of pregnancy and sexually transmitted diseases is minimized.

Autonomy:  If she can demonstrate that she understands the risks of sex at such a young age and the risks of treatment with the pill then she has ‘Gillick competence’ and therefore autonomy.  The doctor should question her to see if she has full understanding and try and persuade her strongly to involve her parents. However if she is adamant that she does not want them to know then she has the right to confidentiality. If the doctor feels that there is a strong likelihood of sex occurring any way then he should prescribe her contraception.

Informed Consent

Obtaining ‘informed consent’ is a legal and ethical necessity before treating a patient.

But what is it and why does it matter?

Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment.  Touching/treating someone without permission could be considered assault or battery under criminal law, even if the person was helped through the doctor’s actions.

The most important goal of this is that the patient has an opportunity to be an informed participant in their health care decisions, as they have a right to direct what happens to their body.

It is the general consensus that informed consent includes a discussion of the following elements:

    • The nature of the decision/procedure
    • Reasonable alternatives to the proposed intervention
    • The relevant risks, benefits, and uncertainties related to each alternative
    • Assessment of patient understanding
    • The acceptance of the intervention by the patient

In order for the patient’s consent to be valid, they must be considered ‘competent’ to make the decision at hand and her consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel powerless and vulnerable. The informed consent process should be seen as an invitation for the patient to participate in health care decisions. The physician is also generally obligated to provide a recommendation and share his reasoning process with the patient. Comprehension on the part of the patient is equally as important as the information provided. Consequently, the discussion should be carried on in layperson’s terms and the patient’s understanding should be assessed along the way.

Children aged 16 or 17 are presumed to be competent to consent to treatment. Like all consent, this is dependent on their doctor’s belief that the individual is competent to make this decision. In addition refusal of life-saving treatment can be overruled.

If a person does not have decision making capacity (such as a person with dementia) a surrogate decision must be found. This usually either falls into the hands of the patient’s family, or if further deliberation is needed, the medical courts.

Patient confidentiality Within Medicine

When practicing medicine, doctors have an utmost duty to maintain patient confidentiality, including after death. This is taken extremely seriously and has been an integral part of healthcare for centuries. It is highlighted in the Hippocratic oath:

“And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings, I will remain silent, holding such things to be unutterable.”

In my opinion this makes total sense, and I think it is a crucial feature with regards to the doctor – patient relationship, or any healthcare provider for that matter. Patients routinely share personal information, and they should be able to feel as comfortable as possible in doing so. If this confidentiality were to be breached, trust in the doctor would be diminished and patients would be less likely to share sensitive information, which could negatively impact their care.

It is important to create a trusting environment by respecting patient privacy as this encourages patients to seek care and be as honest as possible during their health care visit. For conditions that may be stigmatizing, such as sexual or psychiatric health concerns, confidentiality assures that private information will not be disclosed to family or employers without their consent.

Failure to uphold patient confidentiality, is seen as betrayal and can result in: Being struck off, paying patient compensation, or even criminal proceedings.

Are there situations where you can break confidentiality? Or indeed, when you MUST?

Of course there are. Like anything ethically/morally related, there are occasions that can arise where the normal proceedings cannot be carried out.

The duty of confidentiality is not absolute. Confidential information can be disclosed where:

  • the patient has capacity and consents to the disclosure; or
  • it is required by law; or
  • it is justified in the public interest (the General Medical Council gives the example of there being a potential public interest in protecting individuals or society from risks of serious harm, such as serious communicable diseases or serious crime).

There is also a presumption that information can be disclosed to fellow health professionals involved in the provision of treatment to the patient, on the basis of implied consent. Where particularly sensitive information is concerned, for example involving sexually transmitted disease or psychiatry, this presumption should be confirmed explicitly by asking the patient if he or she consents.

Overall, confidentiality plays in a huge role in the medical world.