BMJ Published 13 April 1996, Cite this as: BMJ 1996;312:981
Caring for dying patients is one of the most demanding aspects of general practice, and also one of the most rewarding. A senior colleague likened it to maternity care in his day. “When you delivered a baby in a house,” he said, “that family would trust you forever. Now home births are gone, and caring for the dying is the only way to forge that kind of bond.”
Dying patients can now be kept very comfortable at home, and the palliative care movement, in particular the Macmillan Fund and the sadly defunct Lisa Sainsbury Foundation, must take credit for its zeal in getting its message across. Of course, other less philanthropic factors may also have been involved.
The vigour of this message seemed fortuitously coincidental with the launch of MST, a sustained release preparation of morphine. Strictly speaking, MST was not that much of an advance; its twice daily dosage improved compliance and eased administration, and it provided steadier plasma concentrations, but most of the benefits of morphine were already known.
However, now, for the first time, there was an economic imperative to encourage effective use and debunk the myths of side effects and addiction. I can scarcely remember a lecture on palliative care that wasn’t sponsored by Napp. The important points about morphine use were correctly covered: don’t be afraid to use it; titrate against the pain with the four hourly dose; and, when controlled, convert to twice daily dosage. Anticipate constipation; don’t be afraid to increase the dose; and always watch for the morphine resistant pain.
The more MST prescribed, the bigger the profit, and if, on the way, dying patients were much better looked after and their pain much better controlled, I’m sure the company was even more pleased. Just because our postgraduate education was driven by financial motives didn’t make it any less worth while or vital to our patients.
That is just one example. Is it any wonder that asthma is now so common and being diagnosed on flimsier and flimsier evidence, when you consider the incredible costs of all the medications and the multiple different delivery systems?
While the benefits of breast screening to the overall population remain uncertain, at least there is no doubt that it is great news for the manufacturers of the screening equipment and the people employed by the process; the most vigorous advocates of treatments are usually those who make their living from them.
There is a dark side; without the economic imperative, advocacy of any new treatment is only lukewarm. Consider how long it took the use of steroids in preterm babies to become accepted practice, and streptokinase became popular as a clotbuster only on the rising tides of alteplase and anistreplase. The anticoagulation of patients with atrial fibrillation is perhaps the best example. Although the advantages seem irrefutable, the logistics of locating and monitoring patients are simply too daunting. But imagine if warfarin was under patent to Glaxo: anticoagulation support nurses, nationwide publicity drives, patient information packs, easy-to-follow protocols, satellite conferences—the job would be done properly.
Whether we like it or not, much of the care we provide is insidiously driven by the profit motive. If a condition doesn’t generate funds for someone, it won’t have a high profile. Come on down, Betaferon, the price is right.
Footnote; I wrote this column over 20 years ago, even more relevant today.
drliamfarrell 