Should Doctors Be Trained to End Lives?

Doctors are trained in the ways of prolonging life, does that make them best suited to assisting death?

So the Terminally Ill Adults (End of Life) Bill has passed all rounds in the House of Commons and now finds itself in the committee stage of the House of Lords. The bill aims to legalise assisted dying in limited circumstances and assigns us doctors a central role: assessing eligibility, confirming capacity and prognosis, prescribing lethal medication and being present at the death.

A recent piece in the Journal of Medical Ethics argued for taking the debate in a different direction. The authors do not argue for or against assisted dying. Instead, they ask a second question:

Even if assisted dying becomes law, should doctors be the ones who do it?

Their answer is no. If legalised, assisted dying should be delivered by a new, distinct profession: the Assisted Dying Practitioner (ADP).

Is it a Medical Treatment?

Unlike abortion or palliative care, the bill does not define assisted dying as medical treatment. They call it a state-sanctioned response to autonomy, which means for doctors, participation is not mandatory, and refusal would not affect their professional standing, even though the Bill positions doctors as facilitators.

The Bill clearly acknowledges that, as doctors, we are well-suited to explore patients’ reasons and discuss alternatives, along with assessing capacity. Given that most of us could perform a four-stage capacity assessment in our sleep, there doesn’t seem much to argue about here.

Issues begin to arise when we talk about doctors prescribing lethal drugs and remaining present until death. It is here that opinion becomes divided amongst doctors. You may believe you have extensive experience in pharmacology, but the authors of the JME article believe that no UK doctor has training in the prescribing of these lethal medications, and rather, the psychosocial expertise that is needed to have these discussions may lie outside of medicine and our current curricula.

One thing is for certain: significant additional training would be needed, and with our ever-growing curriculum, some doctors are left asking where the time will come from.

It is for this reason that the authors argue for the creation of a new ADP role as a novel and regulated profession with dedicated competencies and research. Doctors would also be able to “opt in” and undertake separate, additional training if assisted dying were a special interest for them.

The David Disparity: Why Private Work Is a Man’s World

Engaging in the private sector is often viewed as the main way to achieve financial autonomy, particularly in regions where the cost of living continues to spiral out of control. Yet, there remains no established manual for navigating a successful private career; instead, doctors rely on informal networks and "word-of-mouth" to gain an edge.

A common strategy for consultants to supplement their NHS income is to join private hospital groups. These groups handle the administrative burdens of private practice, allowing surgeons to focus on clinical delivery. However, while significant progress has been made in diversifying medical school intakes and postgraduate training, the private sector remains a bastion of gender disparity.

Just six per cent of surgeons in private hospitals are women. That amounts to only 488 of the total 7,934 surgeons working at the country’s biggest private hospital chains. If we compare this six per cent in the private sector to the NHS, we know from the RCS that in the NHS, women make up around 17% of consultant surgeons.

Nuffield Health lists 22 Orthopaedic surgeons named David, more than all the female orthopaedic surgeons they have, which totals 18. As always, stating the statistics is the easy part; explaining them requires the greatest attention to detail. Whilst unconscious preferences are often cited first, it would seem that the additional societal expectations on women and significant unpaid work detract from the time that could be spent undertaking private work.

What Good Is Research If Doctors Can't Break Old Habits?

Why change in science and medicine is nothing to be fearful of

Many in our resident doctor community will be preparing for interviews where clinical governance repeatedly crops up. So along these lines, we want to ask why we so often resist change in medicine? Many practices in medicine have existed long enough for people to accept them without further reasoning.

The Intensive Care Consultant Matt Morgan mentioned some of these practices in the BMJ recently, such as intensive care units giving stress ulcer prophylaxis, despite a landmark trial 8 years ago showing no meaningful improvement in patient outcomes.

And Dr Morgan is right. We do place such huge value on “Bench to Bedside” and innovation in medicine. Everybody wants to create the next novel therapy, and this can easily distract from another noble quest, that of verifying pre-existing practices. Innovation is such a buzzword in medicine that it is almost always followed by a round of applause, but “cessation” never quite carries the same positive reaction. If we are to follow the maxim of “First, Do No Harm”, maybe we should focus on elevating “cessation” to these heights.

If we find a practice to lack a good scientific base, or worse, have the potential to cause harm, then pulling it from practice should be the source of celebration.

Does Faith Exist In Science?

Funnily enough, despite the fact that Dr Morgan was one of the authors of the paper that found the futility of stress ulcer prophylaxis, he admits to still prescribing the same medications. Many of us still adopt technologies and therapies based on “faith in basic science from many years ago”, even when large, higher-quality evidence studies prove them useless many years later.

Some people believe the fact that science changes is a stain on its character. We know it is a strength. There are no truths that are eternally protected in science. No conclusion is off the table for revision and scrutiny when new evidence arrives. Just because we have done some things for long periods of time, often in times when the evidence base was weak, does not mean we need to continue them in perpetuity, especially when evidence suggests the contrary.

“There are so many careers and sub-specialities within medicine that one can go into, I always struggle to believe it when someone tells me that absolutely nothing appeals to them. Unfortunately, our careers often don’t allow us to explore all of our options before it’s time to decide”

“Interview season is upon us. What is your interview go-to? Suit, shirt and tie, shirt no tie or more casual than that?”

“For docs with children, I once read that 75% of the time we spend with our kids in our lifetime will be spent by the time they reach 12.”

“MPs given a 5% pay rise this year, DDRB, I am watching you very, very closely.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Patients are disclosing more and more sensitive information to Artificial Intelligence tools and arriving at consultations with this information. Despite this, Doctors continue to believe that their roles are safe due to the empathetic presence they can provide. This BMJ article goes about challenging this assumption through decades of research.

Amidst the tumultuous and difficult news we are waking up to on a daily basis, there are some reasons to be cheerful when thinking about UK healthcare. The 10-Year National Cancer Plan aims to have 75% of patients who were diagnosed with cancer be cancer-free or living well five years on from the diagnosis. Find the link to the plan behind the approach above.

Weekly Poll

Last week’s poll:

Which of these do you think best predicts who will be a good speciality trainee?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

Do Consultants Feel The Financial Pinch?

Is it possible to be on a Consultant’s salary and feel the financial pinch? Back in 2003, a new term was created that has populated online forums since: HENRYs - High Earners, Not Rich Yet. Like many, you may wince at such acronyms that describe people who may be a touch withdrawn from reality.

HENRY tends to refer to people earning over £100,000 who may have high salaries on paper, but still feel the pinch month to month, especially when it comes to building wealth. Amazingly, 60% of people earning that amount of money feel like they are “average” on the income scale.

How do we explain this? Well, a good start would be to focus on our environment as a factor sculpting our judgment. Opinion polls suggest that Londoners believe true affluence requires an annual income of £289,000, whilst good old Northerners believe a salary of £80,000 would do the job. We can’t help but look around us and not only compare to our environment, but also to our close social circle.

Add in sub-inflationary pay rises, the brutal £100k tax trap and frozen tax thresholds that face our Consultant colleagues, and it becomes apparent why the financial situation is more bleak than ever.

Our On-Call tips will remain the same: Avoid lifestyle creep, build a solid emergency fund and learn about investing early using tax-efficient accounts like ISAs.