Steve Walker wrote:
bealoid wrote:

I see that I haven't been clear enough, so here's an example:

Fred self harms.The A&E doctor tells Fred that Fred has caused
some damage that requires surgery.
snipped for brevity
The surgeon turns up and says something along the lines of "You've
done this before, you'll do it again, there's no point giving you the
surgery" and chooses not to do the operation.

OK - Here's another example :

A very good example, but there's a big difference between something
that's a feature of a complex illness, that's addictive and impulsive
etc, and tattoos.

There's also a difference between the outcomes; having a tattoo doesn't
physically stop you doing anything. Not being able to move your (for
example) little finger does.

There's another difference: Choose and Book means that Fred can go to
his GP and ask to see a number of local surgeons.

Stuart A. Bronstein wrote:

I don't think it's a matter of simply refusing to give care when
someone has contributed to his condition. But there is not an
unlimited budget for health care, and there are not an unlimited number
of organ donors. When resources are scarce and the doctors must make
choices, that is one way they make them.

From a legal standpoint you have to ask if this kind of discrimination
is made on a rational basis and not arbitrary. And while I don't
advocate withholding medical care from anyone in need, I think the
answer has to be yes, this kind of decision is rational, reasonable and
as a result legal.

See my other posts for some clearing up of the alcoholic/smoking thing.

The real world example did feel as if the surgeon was 'punishing' the
patient for past behaviour, refusing to give care because the patient
has contributed to their health problems, and leaving the patient with
permanent physical disability that'll be harder (and more expensive) to
treat - but that will be treated by someone else, on the NHS, thanks to
Choose and Book.

The real world example felt very arbitrary; the surgeon made no attempt
to find out what the mental health of the patient was currently, or
when the last time the patient had self harmed (before this incident)
was, or if there was any reason why the patient had self harmed on this
occasion.

Would this surgeon have applied the same criteria to, for example, a
rugby player? I very much doubt it.

On Jan 7, 7:55 pm, (Andrew Cook) wrote:
Terry W. wrote:
But, of course, any surgeon (or any other doctor)
must take all possible actions to save the life of a person in his/her
care.There is no such requirement. The doctor must exercise his clinical
judgement.

If that judgement is the patient is better off dead, there is no
requirement to act.

Can you please be more specific? This sounds highly tendentious.

See this website http://www.ethox.org.uk/Ethics/eendlife.htm

("Ethical Issues/End of Life Issues")

"Sanctity of Life Doctrine

The argument underpinning this doctrine is that all human life has
worth and therefore it is wrong to take steps to end a person's life,
directly or indirectly, no matter what the quality of that life."

"A duty to act in the patient's best interest (Beneficence)

The duty of beneficence, that is to act in a way that benefits the
patient, is an important ethical principle in health care. In treatment
decisions at the end of life the dilemma often revolves around what
course of action will be in the patient's best interests. It is
difficult to see how death can be a benefit or in the patient's
interests, but in some circumstances, if existing quality of life is so
poor, or treatment is very burdensome, then the balance of harms and
benefits may suggest that continuing treatment is not a benefit to the
patient."

Resource issues are clearly a fact of life, but I don't think that
doctors are supposed to take that in to account when dealing with
individual patients.

Nick

bealoid wrote:

The real world example did feel as if the surgeon was 'punishing' the
patient for past behaviour, refusing to give care because the patient
has contributed to their health problems, and leaving the patient with
permanent physical disability that'll be harder (and more expensive) to
treat - but that will be treated by someone else, on the NHS, thanks to
Choose and Book.

Perhaps the other surgeon who agreed to treatment had more resources
available at that time, so was less restricted on what cases he could
offer treatment to.


The real world example felt very arbitrary; the surgeon made no attempt
to find out what the mental health of the patient was currently, or
when the last time the patient had self harmed (before this incident)
was, or if there was any reason why the patient had self harmed on this
occasion.

Would this surgeon have applied the same criteria to, for example, a
rugby player? I very much doubt it.



I don't really think a rugby player is in the same category as a
self-harmer. A person chooses to participate in a physical pursuit
hoping that they don't suffer accidental injuries as a consequence (and
most of the time they probably don't), whereas a self-harmer
occasionally pursues actions that are explicitly intended to bring them,
well, harm.

Overall, though, it's obvious that there are limited resources for the
NHS and this will vary from area to area. As indicated elsewhere in this
thread, if a health professional determines that the resources to hand
are better spent on another case (or cases) then I imagine he/she would
be remiss for not acting on that belief. Although that's obviously not a
satisfactory position, I don't really see much of an option during a
time when the NHS is so cash-strapped.

Styx

Styx wrote:

[snip]

Perhaps the other surgeon who agreed to treatment had more resources
available at that time, so was less restricted on what cases he could
offer treatment to.

Remember that other doctors and medical staff in the same hospital
thought the surgery was needed. "Fred" was admitted to the ward and
prepped to the point of having marker pen lines drawn on him.

The surgeon made no mention of cost; he just said "You've done it
before, you'll do it again". He made no effort to see how long the
person had gone without self-harm, or whether there had been some
unusual trigger.

[snip]

Would this surgeon have applied the same criteria to, for example, a
rugby player? I very much doubt it.

I don't really think a rugby player is in the same category as a
self-harmer. A person chooses to participate in a physical pursuit
hoping that they don't suffer accidental injuries as a consequence (and
most of the time they probably don't),

I accept that there are differences, but what about the person who
keeps getting injured after playing rugby? (If someone can provide a
better 'similar case' I'd be grateful.)

[snip}

Nick wrote:

Resource issues are clearly a fact of life, but I don't think that
doctors are supposed to take that in to account when dealing with
individual patients.

That is exactly what a waiting list is, resources allocated to
individual patients. Prior to Noo Labour making things worse, a patient
with great need would be placed higher in the list than one with lesser
need. I suspect it is more difficult to do that now.

--
Old Codger
e-mail use reply to field

What matters in politics is not what happens, but what you can make
people believe has happened. [Janet Daley 27/8/2003]

bealoid wrote:

There's another difference: Choose and Book means that Fred can go to
his GP and ask to see a number of local surgeons.

Ask to see *one* of a number of surgeons at a maximum of four pre
determined hospitals. If the waiting list at the selected hospital is
greater than, I think, 12 weeks they can refuse the referral and the
whole process has to start again with a different surgeon at a different
hospital. Prior to 1997 a doctor could refer a patient to *any* NHS
hospital and that hospital *had* to accept the referral.

--
Old Codger
e-mail use reply to field

What matters in politics is not what happens, but what you can make
people believe has happened. [Janet Daley 27/8/2003]

On Jan 8, 5:05 pm, Old Codger wrote:
Nick wrote:

Resource issues are clearly a fact of life, but I don't think that
doctors are supposed to take that in to account when dealing with
individual patients.That is exactly what a waiting list is, resources allocated to
individual patients. Prior to Noo Labour making things worse, a patient
with great need would be placed higher in the list than one with lesser
need. I suspect it is more difficult to do that now.

Not necessarily. I work on a contract basis for the NHS though not
currently.

A number of the Freedom of Information requests that we received and
which I was responsible for managing dealt with my PCT's commissioning
policy for particular treatments.

I think it in the general discussion about these sorts of things this
is known as the "postcode lottery" ie depending on where you live
certain treatments or medication is/is not made available.

So if the policy of the PCT is not to provide this treatment their GP's
will not be able to put forward their patients for this particular
treatment or prescribe that particular drug.

In a few high profile cases, Trusts have been taken to court over this.

See possibly

http://society.guardian.co.uk/nhsper...395004,00.html

(although this is from 2000)

Nick

On Jan 8, 9:30 am, "bealoid" wrote:
Steve Walker wrote:
bealoid wrote:

I see that I haven't been clear enough, so here's an example:

Fred self harms.The A&E doctor tells Fred that Fred has caused
some damage that requires surgery.
snipped for brevity
The surgeon turns up and says something along the lines of "You've
done this before, you'll do it again, there's no point giving you the
surgery" and chooses not to do the operation.

OK - Here's another example :A very good example, but there's a big difference between something
that's a feature of a complex illness, that's addictive and impulsive
etc, and tattoos.

There's also a difference between the outcomes; having a tattoo doesn't
physically stop you doing anything. Not being able to move your (for
example) little finger does.

There's another difference: Choose and Book means that Fred can go to
his GP and ask to see a number of local surgeons.

I would also like to comment on Choose and Book - leaving aside mental
health issues.

I worked closely with a C & B coordinator when I worked for one PCT.

I was therefore rather surprised to read the suggestion in this week's
Private Eye that a 78-year-old man was left by his doctor to make his
own appointment using his own PC - for some therapy, I think.

According to

http://www.chooseandbook.nhs.uk/patients/how/booking

One of the methods is:

"book your appointment with your GP or a member of the practice team"

The fault was clearly with the GP for sending him home to make the
appointment rather than making the appt for the patient at the surgery
- in fact, one of the points he made was that he didn't know anything
about the myriad options offered him - well, that is what the GP is
supposed to do with the patient.

The writer of the Eye column is, I believe, Dr Phil Hammond and it was
clearly easier to blame the NHS than his own GP colleague.

Nick

Nick wrote:

On Jan 8, 9:30 am, "bealoid" wrote:
Steve Walker wrote:
bealoid wrote:
I see that I haven't been clear enough, so here's an example:
Fred self harms.The A&E doctor tells Fred that Fred has caused
some damage that requires surgery.
snipped for brevity
The surgeon turns up and says something along the lines of "You've
done this before, you'll do it again, there's no point giving you the
surgery" and chooses not to do the operation.
OK - Here's another example :A very good example, but there's a big difference between something
that's a feature of a complex illness, that's addictive and impulsive
etc, and tattoos.

There's also a difference between the outcomes; having a tattoo doesn't
physically stop you doing anything. Not being able to move your (for
example) little finger does.

There's another difference: Choose and Book means that Fred can go to
his GP and ask to see a number of local surgeons.

I would also like to comment on Choose and Book - leaving aside mental
health issues.

I worked closely with a C & B coordinator when I worked for one PCT.

I was therefore rather surprised to read the suggestion in this week's
Private Eye that a 78-year-old man was left by his doctor to make his
own appointment using his own PC - for some therapy, I think.

According to

http://www.chooseandbook.nhs.uk/patients/how/booking

One of the methods is:

"book your appointment with your GP or a member of the practice team"

The fault was clearly with the GP for sending him home to make the
appointment rather than making the appt for the patient at the surgery
- in fact, one of the points he made was that he didn't know anything
about the myriad options offered him - well, that is what the GP is
supposed to do with the patient.

The writer of the Eye column is, I believe, Dr Phil Hammond and it was
clearly easier to blame the NHS than his own GP colleague.

If you read NHS Blog Doctor you would have noticed that he also believes
the patient has to make the actual booking. All the emphasis appears to
be on the patient having choice (actually less choice than before Noo
Labour) and therefore actually making the booking. Even the option you
reference says "book your appointment with your GP or a member of the
practice team". The clear inference is that it is still the patients
responsibility to make the booking.

I also note that that that site makes no reference to the possibility of
the hospital refusing the booking, which can happen.

--
Old Codger
e-mail use reply to field

What matters in politics is not what happens, but what you can make
people believe has happened. [Janet Daley 27/8/2003]