Posted by: Shaba Nabi26 April 2015
The award for the most ignorant headline of the month must surely go to Victoria Coren Mitchell in The Guardian: ‘If our GPs are never available, we should help ourselves to the drugs’. Which drugs would you like? Paracetamol? Penicillin? Pethidine?
Perhaps Ms Coren Mitchell’s background as a professional gambler is the reason she was waxing lyrical about the rights of patients to buy prescription drugs and take responsibility for their own risk.
Yet as naïve and sensationalist as this article seemed to be, it did highlight an ongoing debate about the limits of the ‘nanny state’ in medicine.
In truth, the stifling of personal autonomy doesn’t stop with prescription medicines. One example is the introduction of seatbelt laws in 1983, which has cut road fatalities by 50%. I am a competent adult and live in a country where gambling is legal, yet I am forbidden to play Russian roulette with my own life when in a car. But perhaps this is a bad example, as there are few disadvantages to wearing a seatbelt except, I suppose, if you are fat.
So what about something with a more balanced scorecard of risks and benefits?
As doctors, we welcome absolutes. When there is clear guidance about a drug’s contraindication, we feel secure. UK Medical Eligibility Criteria (UKMEC) category 4 for contraception is one example, and we can inform a woman that once she hits the age of 35, she either stops smoking or stops the combined pill. We know that if any complaints arise, we are backed by UKMEC, NICE, WHO and Cochrane.
But is this cautious approach fair for a competent patient?
We all take risks in one form or another and differ in the degree we will accept. I am writing this on holiday in Tenerife, where I have just accepted the risk of a three-hour boat trip, kids in tow, storing our lifejackets under the seats instead of wearing them.
With prescribing, it is often hard to balance the principles of ‘do no harm’ and ‘respect autonomy’. We do not want to prescribe the combined pill to a 40-year-old smoker or HRT to a 69-year-old who has already been on it for 20 years. There are alternatives; it is not a life-or-death situation so we will do no harm. We will override a patient’s wishes when they appear kamikaze.
But we are poor at translating relative risk for patients and when there is guidance we don’t even have the conversation. There are many reasons: time pressure, a belief patients won’t take on the information and possibly that we don’t understand the risks ourselves.
Ultimately, case law and Bolam’s test set the precedent for our actions. Increasingly, the law does not expect patients to take responsibility, and doctors are being sued for delayed diagnoses – even where patients play a part in the delay. It’s hardly surprising that we have become less accepting of patient autonomy.
So my message to patients is this: the more you sue us for negligence, the less we’ll respect your autonomy. After all, the house always wins, and in this case, that means the lawyers.
Dr Shaba Nabi is a GP trainer in Bristol