Medicine

 

Why keep us alive?

 

Robin Downie

 

I have heard the view expressed that nature intended old women to collapse under huge burdens of firewood and then be eaten by hyenas. Judging by reactions to Professor Phil Hanlon's recent lecture (as reported), some critics seem to think he is advocating this policy.
     It could not of course become a realistic policy because health boards would not be able to fund the hyenas. In fact, Professor Hanlon seems to be making two entirely sensible points (I can't be sure because his book is not out yet). The first is that the NHS cannot go on with its present level of expenditure on the increasing elderly population, and the second is that many of the assessments and aggressive interventions which the elderly may encounter are unnecessary and inhumane. Indeed, some people may live longer without such aggressive interventions, and the majority may have a more peaceful end. I shall give some examples of aggressive interventions, and of unnecessary treatments.
     In 2008 the UK national confidential inquiry into patient outcome and death reported that in a study of 600 patients who died within 30 days of chemotherapy the chemotherapy caused or hastened the death of 27% and caused severe toxicity in 47%. Were these risks adequately explained? Is it a good risk to take if you are in any case elderly?
     Another aggressive intervention is the attempted resuscitation of the sick elderly. Patients, including the sick elderly, are asked if they would like resuscitation to be attempted in the event of cardiac failure. But they may not be told, or they or their relatives may ignore the information, that survival after attempted cardio-pulmonary resuscitation is virtually nil for sick and elderly patients. An unnecessary treatment might be the continued prescription of cholesterol-lowering drugs such as statins for elderly patients. There is no evidence that such drugs will do any good in the case of elderly patients.
     Why are such treatments routinely considered, and indeed, judging by reactions from some patients and patient groups, approved of? There are many factors involved, some based on misunderstanding, and some based on contemporary cultural attitudes. Judging by letters to editors, some people think that if a doctor withholds or withdraws treatment on the grounds that it won't do any good this is tantamount to assisting suicide or even killing the patient. This is an absurd view.

 

     If a treatment does not work it should be withheld or withdrawn. This has been an accepted part of medical law and ethics for generations, and it has nothing to do with cost. Sometimes it is said that treatments known to be futile should be continued 'to give the patient hope'. Now there is no doubt that explaining to a patient that curative (as distinct from palliative) treatment is not going to work requires maturity and communication skills, but it seems to me to be patronising to assume that patients cannot handle this kind of information if it is humanely presented.
     Of course, not all doctors may possess this kind of maturity, and the situation is made worse by a doctor's fear of being called 'paternalistic', or of the jibe 'doctor knows best'. Powerful relatives may also press for expensive interventions. Granted these factors, it is not surprising that to have a quiet life, or to avoid the threat of litigation or media attention, doctors may go along with what they know to be futile treatment.
     Recently a consultant surgeon has questioned the value of screening for bowel cancer in populations where people are likely to die of other conditions before cancer kills them. Indeed, there is a pandemic of screening-itis; perhaps we should screen for it.
     Cultural factors also play an important role in shaping our attitudes to end of life choices. There is of course the fear of the charge of age-ism. A spokesperson for Age Concern said that the elderly must have 'equal treatment'. But what does that mean? What we all must have, young or old, is appropriate treatment, ie treatment which is cost-effective and is competently and humanely delivered.
     Equality is the wrong concept in this context. Again, there is optimism about what science and medicine can do to keep us alive. Every other day we hear of a 'breakthrough' or of treatments which will 'save lives'. And we are all expected to 'fight' cancer. But the fact remains that we all die. Health officials estimate that the NHS bowel screening programme for people between the ages of 50 and 74 could prevent 150 deaths each year.
     But death cannot be 'prevented', although, sometimes, it may be postponed a little. Suppose my GP were to say: 'If you take these tablets you will minimise your risk of cardiac failure'. Even if I believe him/her, ignore the fact that I shall be summoned for check-ups, and may need to take yet more pills to counteract the side-effects of the first ones, I still have the question: 'If you don't want me to die of heart failure what do you recommend that I die of? Cancer? Or would you rather I lived to stare vacantly at the wall?'
     The idea of patient choice is widely accepted and politically encouraged at the moment, but elderly patients may not realise that they are choosing ways of dying. Our own medieval culture had an art of dying as well as an art of living. We have turned these existential concerns into consumer choice.

Robin Downie is emeritus professor of moral philosophy at
Glasgow University