Sunday, September 16, 2007

Assisted dying in the news

Media coverage on the Green Party policy to support assisted dying was excellent. This is from the Guardian:

"The Green party today called for assisted suicide to be legalised, despite fears it could cost the party votes.

"The party took the decision earlier today - the second day of its conference, taking place in Liverpool - amid warnings that it would be unpopular among voters with strong religious views.

"The policy sets out a framework of safeguards for individuals wishing to end their life and healthcare professionals involved in the process."

Friday, September 14, 2007

Voluntary Euthanasia

The Green Party has come out in support of a sensible framework for voluntary euthanasia. We have been working on this policy for a long time and it is great to see it enter as party policy.

There is increasing discussion on end of life care and this amendment seeks to establish a Green Party position in this highly emotive area. The amendment has been constructed from examples of end of life policies across the EU and seeks to establish a safe and fair framework for people to have an assisted death.

The Green Party recognises that medical decisions taken towards the end of a person's life should never be undertaken lightly. We believe that when the quality of life is poor (e.g. due to severe dementia) life prolonging treatments such as influenza vaccines and antibiotics should not be given routinely without consideration of the whole situation including the wishes of the patient and relatives.

Many medical interventions provided at the end of a person's life will both relieve suffering and hasten death. We recognise that this can cause concern amount health professionals and the public and will introduce clear guidance to protect all parties.

Assisted death presents moral and legal concerns to health care professionals and the public. We believe that people have a right to an assisted death within the following framework:

* The appointment of an independent advocate must be made when either diagnosis of terminal illness is made or the person receiving care expresses the desire to end their life
* Counselling must always be offered to every patient considering an assisted death
* Alternatives, such as palliative care must be discussed with the patient
* The patient's ability to make the decision must be established by joint assessment of two independent doctors, one of whom should ordinarily be the patient's GP, unless impractical in the circumstances, in which case it may be the patient's medical consultant, one of which must be a psychiatrist and a third independent registered health or social care professional who has undertaken approved training in this area and who has no prior knowledge of the patient.
* This decision must take into account evidence provided by the independent advocate.
* Treatable illnesses that may impinge of the decision making ability, e.g. depression, must be treated and excluded from the rationale for requesting an assisted death
* The patient has the right to appoint individuals either during or prior to the process who will have access to their medical and other records and whom they wish to be involved in discussions
* The patient's informed consent must be clearly documented, full discussion of the outcomes of both the illness and the assisted death must also be provided in a language and form understandable to the patient
* The patient's close family should be involved in all discussions
* There should normally be a waiting period of at least 7 days, set by local policy, for the patient to reflect on their decision.
* Patients could orally revoke the request at any point
* Healthcare professionals can refuse to be party to any stage of assisted deaths for their own moral reasons
* Assisted death will be notifiable

We will introduce legislation based on this framework to ensure the protection of all parties.

Wednesday, September 12, 2007

Diesel fumes

From the Independent today:
"The World Health Organisation estimates that air pollution causes 800,000 premature deaths worldwide and a recent US study suggested long-term exposure to traffic fumes increases the risk of death from heart disease and stroke by 76 per cent."

Diesel fumes

From the Independent today:
"The World Health Organisation estimates that air pollution causes 800,000 premature deaths worldwide and a recent US study suggested long-term exposure to traffic fumes increases the risk of death from heart disease and stroke by 76 per cent."

Monday, September 10, 2007

Peak oil, health care and emotional issues

There are 1.3 million people employed in health care in the UK[1] and 5% of all traffic journeys [2] are connected with health care. Medical technologies increase in complexity year on year and with complexity comes increasing centralisation requiring longer journeys for treatment. Small units are no longer considered 'safe' as complex procedures require greater throughputs of patients to ensure clinicians remain practiced.

'Choice' and the health care market means that patients can choose a health care provider that doesn't have to be local, meaning even longer patient journeys. Medical technologies and medicines are founded on the princple of unlimited energy, developing new medicines is energy intensive and complex machines use increasing amounts of power to run and develop.

The new economics foundation / NHS Confederation report, Taking the Temperature [2], talked about the NHS's role in climate change with "energy use in NHS healthcare facilities costs £400 million annually and results in a net emission of around 1 million tonnes of carbon". There were other useful analyses such as the energy wasted from PCs being left on each year being enough to fly 26,000 people from London to New York and back, and that recycling 40% of its waste would save equivalent energy to driving a car 550 times round the equator.

The energy embodiment in health care consumables has not been properly assessed, but consider the plastic syringes, disposable bedpans, dressings, gloves and so on. Then multiply what you see on one ward by 20 to get to a hospital sized amount and then by 200 to get to the UK size and then add in 10000 GP surgeries and the amounts of consumables, all being produced with large amounts of energy derived from oil, are staggering.

The solutions to reducing CO2 emissions and preparing for peak oil are broadly the same. They focus upon system redesign to reduce the need for use of carbon based energy. This system redesign is multifaceted and, sadly, can be highly contentious escpecially as it clashes head on with clinician and public desire for a Rolls Royce service rather than the 'Honda' version described by Dan Bednarz[3]. The Honda model focuses upon good public health and not on increasing technological advances and could be paralleled to the Intermediate Technology concept developed by Schumacher[4].

Peak oil, with its outcome of rapid price increases, will result in our current cost of health care (about 9% of GDP in the UK) rising rapidly in line with oil. When these rises are placed alongside the predictions made by Derek Wanless[5] who forecast spiralling costs of health care unless public health was improved rapidly, then we have a pretty daunting future in the UK. Unless improvements in public health are made then the attempts to reduce oil dependency in the NHS will be wiped out.

The challenge is for people to understand that reducing energy use in the NHS and improving public health can go hand in hand - less illness reduces the need for health care and therefore reduces early deaths. The difficulty will be with people protesting that the lack Rolls Royce care will mean that some individuals will die. This stark reality can be offset by a rational discussion on lives saved through better public health, but does that help when there is a sick child involved?

The public perception and media focus on a sick child that could be denied treatment through the adoption of a Honda service is extremely powerful. Currently in the UK there is a stream of media attention on cases of rare childhood diseases that the NHS can't treat. These may spawn campaigns to fund the child to fly to other countries for experimental treatments, with scorn being poured on the NHS for not being good enough. Again, the rational argument says that these rare diseases will be rarer with better public health, less reliance on plastics, less pollution and so on, but it is certain that they will still occur. If they occur to a close family member, especially a child, I suspect we would all react in the same way - no one wants to be told that there is nothing that can be done.

We therefore have a dicotomy effectively driven by emotion, a chasm that is widened by media pressure and therefore likely to spill into a political arena. Politics and healthcare are poor bed fellows in the UK, and much must be done to address this. All the time politicians are made to bow to emotional pressure and health care nimbyism, there will be no progress. We can have localised services, but they will not be as high tech as centralised ones. This is the stark choice we face and this arguement is occuring now, without the drivers of climate change or peak oil. Across the UK there are protests about the closure of A&E services and reconfiguration changes that are, it is claimed, led by the need for high enough catchment areas to ensure safety. If people want to have local services then they may need to accept that there is a reduction in clinical safety.

With any system of health care people will die - death is a natural as taxes! Grief is the proper response to death, not anger, media furore or political intervention, but it is anger and media furore that will be the hurdles to overcome when moving to the Honda system of health care. Explaining that vast numbers of people are living longer with less morbidity as a result of lower obesity levels should be a good counter argument to the inability of a system to provide high tech health care to a minority, but it can be derailed by media furore - after all what would sell more papers, a sick child 'denied' tretament or a headline about millions living longer and more healthily? Michael Ben-Eli [6] talks of various domains that are required to understand sustainability and heading his list is the spiritual domain, identifying the attitude and understanding for right conduct. This suggests that we need to grow as individuals as well as a society to be able to deal with the realities of life.

It has been said that we should look to Cuba for a first rate example of how health care can survive peak oil. According to Megan Quinn, Cuba went through its own peak oil crisis in the 1990's when the Soviet Union collapsed and it was maintenance of free health care that helped Cuba survive[7]. Cuba's health care system is provided at around 7% of GDP, yet has a doctor to person ratio of about one to 170, compared to one to 500 in England[8]. Cuban health care provides a focus on health improvement with general practitioners based close to people and having a close relationship to to their patients. Cuba has a phenomenonly low infant mortality rate that puts many richer nations to shame, including the US (infant mortality is a good indicator of a nation's general health). Through Cuba's early peak oil crisis the country has localised food and reduced dependancy on cars, and their diet is low in meat and physical activity is high. Increased activity and reduced meat intake are a good response to peak oil and an extremely good way of keeping healthy.

Peak oil could be disasterous for health care in the UK, and no doubt the media will spin post-peak oil health care in that light whatever is done. The UK needs a managed transition to a Cubaesque model of health care, rather than rapidly escalating costs followed by a collapse. A managed transition towards Intermediate Technology for health care, a switch to localism of food production, and move away from jumping in cars to go round the corner! Managing these changes in the face of media driven hysteria will be the biggest challenge of all.

2. Taking the Temperature (2007) new economics foundation & NHS Confederation
3. Bednarz D (2007)
4. E F Schumacher (1973) Small is Beautiful
5. Wanless D (2002)
6. Ben-Eli M (2007) Resurgence
7. Quinn M (2006) The Power of Community: How Cuba Survived Peak Oil
8. Hansard (2002)