Monthly Archives: October 2014

An easy death – whose job is it?

The vexed issue of ‘assisted suicide’ has surfaced again in recent weeks, thanks to the media reports of the elderly lady who starved herself to death, in the absence of any state-sponsored mechanism for achieving her desired end.

Some of these reports once again bemoan the fact that doctors are not allowed to assist people to commit suicide (I say ‘people’ advisedly, because they won’t all be ‘patients’ –  we actually need a name for those who wish to take advantage of any relaxation of the regulations around euthanasia, perhaps ‘departees’ would fit the bill?). Why is it always doctors who are put forward as the appropriate profession to pull the plug on those who have decided they have had enough? It’s no longer necessary to give lethal drugs by injection – and even if it was, you don’t need to be medically qualified to get a needle into a vein. ‘Ah’ you say, ‘even with orally-administered drugs, you still need a doctor to provide the prescription’. Well no, you don’t actually – nurses and other paramedical professionals are already authorised to prescribe and administer drugs under controlled conditions (see below).

Of course, it’s true that doctors will be involved in the treatment of many of the departees, because they will be suffering from terminal illnesses. They will therefore be responsible for their treatment, and for advising them on prognosis and on the options available for terminal care, but that doesn’t mean that they should be the ones to pull the metaphorical trigger should their patient opt for early release.

Then there are all the applicants who are either not suffering from any identifiable illness, or who have conditions which are non-terminal. It’s worth noting that the lady identified in the recent reports was complaining of back pain and fainting attacks, both of which are eminently treatable conditions, and which would not have qualified her for assisted suicide under the terms proposed by the supporters of a change in the law. To involve doctors in the killing of these people gives them the status  of state-sanctioned executioners.

Why does any of this matter? It matters because medical practice is based on trust between patient and doctor. Patients who are suffering need to know that their doctor’s one concern is to ease that suffering, something which is nearly always possible, but which occasionally requires doses of drugs that may hasten death. This is an accepted part of medical practice, and is qualitatively of a completely different order to the termination of those who have simply decided that they have had enough, regardless of the presence or absence of treatable disease. Patients need to know that their doctor will not be involved in any abuse of the assisted suicide legislation aimed at achieving their premature departure.

Because, however carefully any new law is drafted, it will be abused. If you don’t believe me, look no further than the 1967 abortion legislation. It was never the intention of David Steele and his colleagues to make abortion available on demand*, but that is what we now effectively have. The same will happen with changes to the law on assisted suicide, and the medical profession should refuse to be involved.

And they don’t need to be involved. If, after they have received any relevant medical treatment and advice, a person wishes to take advantage of relaxed regulations concerning  assisted suicide, their care would pass from the medical into the social sector. After receiving the appropriate counselling (which would hopefully be part of any new legislation) and filling in the necessary forms, they would then qualify for state-assisted suicide. This could be carried out in purpose-built (or converted) premises – I have always thought that ‘thanatorium’ would be a good name for these, although I suppose it might result in a premature end for the patients of short-tongued doctors who really intended to refer them to a convalescent facility.

For those wishing to die at home, there would be flying squads who could bring the necessary drugs and expertise to the departee’s bedside – I wonder how long it would be before someone (probably the Daily Mail) christened them the ‘angels of death’? And one of the consequences of qualification for the service would be that those drugs could be prescribed under an appropriate Patient Group Direction,  the legislation having added employees of the new service to the list of those authorised to administer drugs covered by a PGD. Then all that remains is for someone to hand the tumbler of poison to the departee, assisting them to drink it if necessary.

So there – job done! If society wants  assisted suicide, then society, through its politicians, must devise the necessary legislation and infrastructure. The proponents of a relaxation in the law must not be allowed to get their way and then wash their hands of any responsibility for or involvement in the killing  by offloading it on to the medical profession.

* I use abortion as an example of the ‘mission creep’ which can subvert even the best-intentioned legislation, I’m not expressing an opinion as to the desirability or otherwise of abortion on demand.

 

More political healthcare madness

Over the past couple of weeks we have been blessed with two political ‘initiatives’ on healthcare which would tend to confirm my long-held belief that politicians are not only completely ignorant concerning the science which underpins medical practice, but also incapable of logical reasoning. In the interest of political balance, one of these gems comes from the government (well, NHS England, but it’s the same thing), and one from the hapless Ed Milliband.

First, Ed’s stated intention to ensure that investigations on patients believed to have cancer will be completed in seven days. This compares with the current government’s two week waiting target for these patients. It’s not clear which patients he is talking about: if he’s saying that any patient who might have cancer will be dealt with in seven days, then the NHS will grind to a halt, because just about every symptom known to man could be due to cancer, but usually isn’t. The two week waiting target has already skewed priorities, with the result that some clinics have been swamped with patients whose problems are not really urgent, thus increasing the delay for those with genuinely alarming symptoms.

So let’s give Ed the benefit of the doubt, and assume that he’s talking about patients who have been seen and assessed by a GP and referred to the appropriate specialist, and where there’s a genuine concern that they may be suffering from a malignant condition. If he’s saying that their investigations (imaging, biopsy if indicated, blood tests and so on) must be completed in seven days, that’s a more realistic target. But still completely unachievable. Let me concentrate on the imaging aspects (x-rays, scans, ultrasound), because I’m a retired radiologist and know a bit about it. Even if we had enough equipment to push patients through this quickly, the scans still need to be reported by a radiologist. Giles Maskell, the President of the Royal College of Radiologists issued this press release in response to the initiative. He makes the point that the UK has 48 trained radiologists per million population; Germany has 78, and Sweden and France have well over a hundred. Add to that the fact that demand for imaging services has been increasing at 10% per year for as long as most of us can remember, and it’s clear that any attempt to set new targets will need top address the issue of consultant staffing as well as infrastructure, and this cannot happen overnight – and certainly not within the five year time horizon of politicians.

And of course, it would probably be a waste of time anyway. Despite the public impression that cancers rampage through the body, spreading their tentacles deeper into the normal surrounding tissues like a forest fire, the fact is that most tumours develop over a timescale measured in years rather than hours, so chopping a few days off the investigation schedule is unlikely to make any difference to outcome. There are much better ways to spend £750 million in the NHS.

Which brings us to NHS England’s asinine plan to give GPs £55 for every case of dementia they diagnose. I mean, what exactly are they supposed to do with the money that will make diagnosis more likely? Is the suggestion that GPs currently just can’t be arsed to do their job properly, and that a couple of quid in their back pocket will induce them to behave professionally? This is where I begin to despair of the ability of NHS chiefs and their political masters to construct a logical argument. I cannot conceive of any way in which this piddling payment will have any effect on the diagnosis of dementia. Yes, late diagnosis is a problem, but that’s because patients present late, not because GPs are too stupid or lazy to recognise the condition when they see it. The money would be far better spent on public education to increase awareness of the early symptoms and signs of dementia, and improving the support service available to sufferers and their carers. But of course, that wouldn’t be eye-catching enough, and wouldn’t attract any headlines.

Ebola is scary, but much more scary is the intellectual poverty of the political class which produces this sort of crowd-pleasing nonsense.

GMC vindictiveness

Imagine the scene. You are a doctor in the Royal Army Medical Corps. You have been posted at short notice to Basra, and you are working alone, in temperatures around 40C in a hostile active service environment, with no readily available advice or supervision from more senior army medics. Your requests for training for your new role were refused, because the remainder of the detachment (from a regiment you had never worked with before) had already received theirs before you were suddenly drafted in.

This was the situation that faced Derek Keilloh on 15 September 2003, at the height of the Second Gulf War. He was a young doctor who had joined the Royal Army Medical Corps as a medical student, and was still 6 months short of completing his training as an army GP – in the UK, he would not have been working unsupervised. When he arrived, he found that, in addition to the troops in his unit, the base housed a detention centre. He was given no clear instructions concerning his role and responsibility, if any, in relation to detainees, or how to deal with them.

This latter omission became relevant on that September evening, when Dr Keilloh was called urgently to see a prisoner who had collapsed. There was no electricity in the stifling detention block, and he had to examine the patient, Mr Baha Mousa, by moonlight. Realizing that he had suffered a cardiac arrest, Dr Keilloh commenced resuscitation procedures, then moved him to the adjacent medical centre, where there was at least some illumination from a single flickering fluorescent tube. Resuscitation attempts by Dr Keilloh and his hastily-assembled team continued for some time, but were ultimately unsuccessful.

Like all doctors following a failed resuscitation attempt, I’m sure he went over the events of the night in his mind, wondering what more he could have done, but to this day, no-one has suggested that he has any cause to reproach himself. There is universal agreement that the treatment given by Dr Keilloh was exemplary, and that Baha Mousa’s death was not due to any shortcomings in the medical care he received.

Dr Keilloh left the army in 2005 at the end of his fixed-term commission, going on to become a successful and highly-regarded GP in Northallerton. When evidence emerged that some detainees at Basra, including Baha Mousa, had been mistreated, a court martial tried four soldiers, one of whom was found guilty and sentenced to one year’s imprisonment. Dr Keilloh was called as a witness at that time, but no charges were made against him. He subsequently appeared before the Baha Mousa public enquiry in 2008, and again there was no suggestion that he had lied about events in Iraq.

Subsequently, a delayed complaint concerning Dr Keilloh was made to the General Medical Council (GMC). They are strangely coy about the source of the referral, but there is general acceptance that the complainant was Phil Shiner, whose Public Interest Lawyers (PIL) specialize in bringing cases against British soldiers for alleged war crimes in Iraq. This is the same PIL which was recently forced to admit that there was no evidence to substantiate their claims that troops in Iraq had illegally killed up to 20 civilians. The al-Sweady enquiry initiated by PIL collapsed earlier this year, by which time it had been sitting for 167 days, consuming £22 million of public money. To some observers familiar with Dr Keilloh’s case, much of the evidence in that enquiry sounded familiar, despite the fact that it related to different events and was delivered by different witnesses.

Shiner alleged that Derek Keilloh must have seen evidence of Baha Mousa’s mistreatment and should have reported it to his superior officers. This assertion was largely based on the fact that photographs of Baha Mousa’s body appear to show evidence of physical abuse. The photographs concerned had been taken six days post-mortem, after his corpse had been driven 20 miles in a body bag to the nearest morgue. Dr Keilloh has repeatedly and consistently denied seeing any such evidence of mistreatment as he struggled to revive his patient in the gloom and heat of Basra, and it is widely accepted that bruising can evolve post-mortem even in the best of conditions. These were not the best of conditions.

Nevertheless, the GMC decided there was a case to answer, and their Medical Practitioners Tribunal Service (MPTS) hearing commenced in June 2012. After unacceptable, stress-inducing dithering, they finally reached a verdict just before Christmas 2012. Let’s hear some of the things the panel said about Derek Keilloh: he was ‘a man of good character; a highly respected and dedicated doctor with excellent clinical skills who is trusted and respected by colleagues and patients alike; an honest, decent man of integrity’. They concluded: ‘The Panel is satisfied that you do not pose a risk to patients. It has a large amount of information before it that you are an excellent doctor’.

So – not guilty, then? Back to work with you? Not a bit of it. They decided that, ‘on the balance of probabilities’ (the standard of proof required by the GMC to deprive a doctor of his profession and his or her patients of their doctor), he had lied about his awareness of the mistreatment of prisoners, and that they had ‘no alternative’ to erasing his name from the medical register. When the GMC was criticized recently by the High Court in relation to another unsafe verdict against a GP, their lawyer defended the organization by re-iterating its overriding responsibility to protect the public. But just who were they protecting from Derek Keilloh – this ‘honest, decent man of integrity’, this ‘excellent doctor’?

I worked in a military field hospital in the Middle East, and can imagine the conditions that faced the young, unprepared Dr Keilloh. The MTPS panel claimed to recognize and allow for this, but then proceeded to judge him as if he were a civilian GP working in a pleasant, UK surgery with ready access to advice and support from his seniors. Reading the transcript of the hearing it is difficult to avoid the conclusion that their verdict was based on a desire to punish, rather than on a proportionate response to the facts of the case, or concern for the welfare of patients.

Compare this to the case of Mohammed Kassim Al-Byati, a doctor who appeared before the MPTS in 2013, again on the basis of events in Iraq many years earlier. It found that he had known that his patients had been tortured, and that they would be tortured again when they left his care. Did the MPTS erase his name from the Register? No, they merely suspended him from practising for ‘up to 12 months’. So, despite the panel’s assertion, there were alternatives available, even if they thought Dr Keilloh was guilty.

Judith Nicholls, Derek Keilloh’s mother-in-law, says ‘my family have suffered a great wrong and I won’t rest until I’ve done all I can to clear his name and help to change the system that caused the damage’. His patients in Northallerton offered spontaneous support, and have campaigned vigorously for his return to work. A petition asking that his case be reconsidered has attracted almost 2000 signatures, and can be found at: https://you.38degrees.org.uk/p/support-Derek-Keilloh.

Later this year, Parliament are due to review the legislation relating to the GMC’s disciplinary role, and not before time. Although the Professional Standards Authority can investigate GMC verdicts which are thought to be too lenient, there is no mechanism of appeal for doctors who feel that they have been too severely treated. At the suggestion of William Hague (her MP) Judith Nicholls sent her ideas for the new legislation to the Department of Health, but they refused to look at them, and suggested she send them to the GMC. Not surprisingly, she sees little I hope of a favourable reception in that quarter.

The GMC runs the risk of alienating both the doctors it is supposed to be regulating, and the public it should be protecting. Its disciplinary decisions often seem to be inconsistent and conflicting: on the one hand, they deprive Derek Keilloh’s patients of the services of a GP who they themselves declare to pose no risk; on the other, they have, for example, been criticised for allowing doctors convicted of sex offences to remain on the register.

But for now, Derek Keilloh’s career is effectively over, and his patients have been deprived of the care of a GP recognized as ‘excellent’ by the GMC, at a time when GP services are under greater pressure than ever. All this because the disciplinary panel decided he might have fallen short in his duties as a whistle-blower in the heat of war 11 years ago. If anyone thinks that is fair or sensible, they will need to explain it to me. Carefully.

Baha Mousa undoubtedly suffered a great injustice, which cost him his life. Derek Keilloh, the man who tried to save him, is still alive, but he has been deprived of his career. He is the second victim of the Baha Mousa affair.