Is Big Tobacco's move into medical devices all bad?

In their splendid 1200-page book (no kidding!) on ethics and the law for the health professions, Professor Ian Kerridge, a Sydney haematologist and academic ethicist and colleagues, begin with a definition of ethics – ethics is deliberation about what we ought to do.

And that ought takes a thousand pages to determine; as what it means it is not always, or even often, easy to understand.

Ethics penetrates just about everything that doctors do.

Take the matter of tobacco companies now seeking to diversify into health technology.

The move everyone’s talking about is Marlboro-maker Philip Morris’s multimillion dollar deal to buy UK inhaler group Vectura that produces dry powder inhalers.

One strongly suspects its interest in inhalers has something to do with vaping device development. And profitability is likely the principal driver.

So, what ought we, as doctors, do?

For many medics, especially those who’s patients have severe tobacco-induced injury, Big Tobacco’s move into vaping for profit is indefensible.

Their view is, that the fact we’ve learned to live with tobacco is a global folly, and anything that can be done to make the life of Big Tobacco less pleasant and profitable ought to be done.

Some medical organisations, like the Thoracic Society of Australia and New Zealand, say doctors should boycott all inhaler devices produced by companies owned by Big Tobacco.

They argue that if doctors continue to prescribe them, they’re inadvertently supporting the very industry that brought about the tobacco pandemic in the first place.

"How can we in good conscience give a treatment to a patient where the funding from that treatment will be going to the company that caused the disease to begin with?" the society’s CEO, Dr Graham Hall (PhD), told ABC News in response to the Philip Morris-Vectura deal.

The aim of such a boycott would be to hit revenues, contributing to an overall decline in profitability and the availability of cigarettes.

Read more AusDoc:

• Philip Morris attempts to buy company making inhalers to treat lung disease
• After killing millions, Big Tobacco moves into healthcare

However, others have a different view. They believe the business acumen of Big Tobacco is truly brilliant.

We may not like what they do but as an example of a ‘successful’, agile (think e-cigarettes) business enterprise it is almost without peer.

So, why not encourage Big Tobacco to turn its capacity to produce stuff that is health-enhancing – rather than health damaging – like medical equipment?

This would provide them with the chance to continue to thrive, even if they had to switch to become BMI – Big Medical Infrastructure.

With medicine on the cusp of truly disruptive technological change and IT transformation – think gene science, telehealth and more – this is a good time for reimagining its future with massive profits waiting to be made.

BMI could become the Bitcoin of the next two decades.

The risk of this second viewpoint – that we ought to encourage Big Tobacco to diversify into health – is that the principles at work in big business do not include self-sacrifice.

They cannot. The business of business is to return a profit to shareholders.

And the way this is achieved is complex. For even when big business conforms to commercial law, benevolence is constrained, meaning any investment in medical research by Big Tobacco would come with a price tag.

Read more: Doctors alarmed by Big Tobacco's push to legalise 'smoke-free' devices

But let’s change tack for a moment.

There are interesting parallels between Big Tobacco and the industries that produce copious greenhouse emissions.

To mark the month’s COP26 climate change conference in the UK, McKinsey & Company questioned whether it should be advising and assisting polluters.

It argued it should, because the transition to net zero was so colossal that even big industry needed help.

“Hard-to-abate sectors represent 81% of the global economy’s carbon footprint. Like it or not, there is no way to deliver emissions reductions without working with these industries to rapidly transition,” the management consultancy wrote in its newsletter.

Similarly, Big Tobacco is subject to international constraints on tobacco production and promotion under the UN Framework Convention on Tobacco Control.

Good progress has been achieved to reduce tobacco consumption in many countries following these protocols.

But there is a long way to go.

What if encouraging tobacco companies to change their principal product, even little by little, was actually a more effective approach to stubbing out tobacco-use for good?

It’s a tricky ethical question.

What do you think we ought to do?

References

1.       Ethics and Law for the Health Professions, 4th ed. (Sydney: Federation Press, 2013).

Published in Medical Observer OPINION
8th November 2021

We should sing the praises of surgeons more often

Several weeks as a patient in a surgical ward of a Sydney teaching hospital recently gave me an opportunity for ‘participant observation’.

There are a number of features of the patient experience in the hospital setting that usually loom larger than others: the quality of the food for instance, the degree of pain, the extent to which your dignity is preserved, with the competence of the surgeon often coming far down the list of importance.

Below I list the high and lowlights which I hope serve as a reminder as to why medicine remains a fundamental social good.

I’m sorry – would you mind shouting?

I’m hard of hearing, even with aids. Understanding the speech of non-native English speakers is difficult. Interpose a face mask and hearing becomes harder. Add a perspex splash mask and I am forced to surrender.

In bed, with SARS-CoV-2 limiting the number of social contacts, I had time while staring at the ceiling to reflect on how conversation is critical for interaction, problem-solving and human contact.

In fact, to my mind, conversation is the high point of our evolution as H. sapiens.

And that is the reason why people with deafness or inability to speak find alternatives.

Despite the still common view that sign languages are artificial creations, they emerge naturally, evolving their own grammar and syntax. There are some 300 commonly used sign languages worldwide.

Unfortunately, there doesn’t seem one which can be easily acquired to deal with the circumstances faced by a patient in the hospital environment.

Dignity

Surgical tampering with bowels and related organs often leads to incontinence. I marvelled at the goodwill and coping skills of the nursing staff who dealt with this at any hour. We can easily forget how basic our needs become after surgical intervention.

Even when staff were in short supply (another COVID-19 consequence), help came quickly, the bed was miraculously changed, and comfort and dignity restored.

The surgeons

For complex reasons (available on request) my surgery took ten hours – unravelling adhesions being a particular challenge.

So along with the nursing staff,  I also marvel at my surgeons and anaesthetists.

Procedures like mine are unusual, but not uncommon. The skill, technology and patience of these colleagues is frequently assumed without question and too often goes unremarked.

We should sing their praises more often.

And I have to say the pleasure of the human interactions of daily visits from my surgical team was hugely important to my recovery.

Pain

Not too many decades ago, pain relief was viewed as an indicator of moral failure. This attitude bore some relation to women’s suffering in childbirth. I never understood why.

Patient-controlled analgesia, where the press of a button can administer a small bolus of analgesic, is another technology to be celebrated. The dosage is regulated – preventing overdosage.

There are other technologies which clearly need further development.

Ileus for several days meant a nasogastric tube. Please! Someone needs a research grant to invent a more comfortable device. Mine caused pharyngeal discomfort to the point where I needed opiates. It prevented me from coughing easily; only when it was removed did my atelectasis settle.

Contemporary anaesthetics have come a long way since the ether for my tonsillectomy 75 years ago – a trauma that lives on in my memory.

Food

My memory of hospital food was not good, and it was usually served like in the army – breakfast at 4:30am and dinner at 17:30.

Times have changed. Once I was no longer on nil-by-mouth and total parenteral nutrition, I was offered a choice appropriate to my post-operative condition.

The hot food was actually hot – served on the half-heated part of a tray with ice cream or yoghurt or fruit in good shape on the unheated half. This was a fine example of technology, perhaps induction heating, being used to great effect.

I could go on and talk about the pancakes, but I’ll stop. You can become obsessive about hospital food when you have time on your hands.

Fitness

Oh dear. Lying in bed never helped any Olympian win a medal. After two weeks, I could hardly walk. On one occasion, my physiotherapist encouraged me to go for a wander with him. After about 15 metres, I was breathless and faint. My oxygen saturation had dropped to 85%.

Recovery was swift, but the experience shocked me. Even six weeks on, I was incredibly unfit. Not that I was competing in the 400m hurdles beforehand, but it will take many weeks to get back to ‘normal’.

Friends and family

I feel so sorry for patients and their families who cannot be with them because of the pandemic. I find myself wondering whether we have exploited every opportunity to ease these restrictions.

Friends and others who have been close in past years often made contact. I found this a great comfort and the wisdom of many to keep the contact short was appreciated.

Read more: Simple manoeuvre 'curbs pain on coughing' post-surgery

The mind, like the body, is not up to much after major health interventions.

I am delighted to be home – a couple of residual problems to solve and some dodderiness to overcome.

I count myself immensely fortunate to have been the beneficiary of the skill and care of outstanding professionals and the unwavering love of family, especially my wife Kathy.

Published in Medical Observer OPINION 
5th October 2021

An MBS item to counsel smokers? It's just a load of smoke

 Tobacco smoking remains prevalent in Australia – current estimates suggest that we have about two million adult smokers.

This number has fallen in recent decades as the enormity of problems associated with smoking have become clearer.

Nevertheless, according to analyses from the Australian Institute of Health and Welfare in 2019, the proportion of pack-a-day (20 cigarettes or more) smokers increased with age.¹

Two in five people (approximately 40%) in age groups 40 and over smoked more than 20 cigarettes per day, which compared to one in five (approximately 20%) people aged 18–39. It’s ironic that smoking is more prevalent among older people at higher risk of tobacco-induced death.

 

Public health-based approaches, such as tobacco taxes underpinning massive price hikes, banning the advertising of tobacco, either directly or indirectly with zero investment in sports sponsorship since 1992, have combined with clinical counselling for smokers to cause smoking to become far less common.

But we have a long way to go.

While tobacco taxes are considered the most effective tool to reduce smoking, clinical approaches and counselling have gained in sophistication and impact, sometimes using nicotine replacement preparations in concert with advice. 

The late Dr Michael Russell, a psychiatrist with a major interest in addiction, and three colleagues including a GP, published a paper in the BMJ in 1979 that reported attempts to get 2000 established smokers in London to quit. It caused a storm.²

The study was based on the patients of 28 GPs.

The smokers were allocated into four groups; a non-intervention group, a group that was given a questionnaire about smoking, a third group that was advised by their GP to stop smoking (but nothing else was done) and a fourth group who were advised to stop smoking, given a leaflet to help them, and warned that they would be followed-up.

The effects were small with 5.1% of those in group four – who received advice, literature and follow-up – stopping smoking in the first month and still not smoking after a year.  

But here is the crucial sentence taken from the abstract of their BMJ paper: “[The results were] achieved by motivating more people to try to stop smoking rather than increasing the success rate among those who did try.”

Earlier this month, the Federal Department of Health proposed a Medicare item to fund at least 20 minutes of smoking cessation counselling with a GP, who will then be tasked with drawing up a management plan.

The health department says a dedicated item will help GPs become more familiar with updates to clinical smoking cessation guidelines and their use.

However, such an approach assumes the intervening GP knows that a patient of theirs is a smoker – but if they don’t they’re unlikely to act. 

That sounds miserable, but studies by Professor James Dickisnon and colleagues from Newcastle published in the Medical Journal of Australia have shown that between 20% and 40% of smokers presenting in general practice are not known by their GPs to be smokers.³

It is these ‘quiet Australians’ that Dr Russell and his team would have us recognise, and try to help, rather than bothering with identified smokers who make no progress, despite us spending lots of resources attempting to get them to quit.

Read more:

• Are PBS rules hampering smoking cessation?
• Another new MBS item for GP care, but will it help?

I know this proposition will not find favour with dedicated educators and clinicians who have spent much personal energy developing packages to assist practitioners counsel established smokers.

There is no reason for such efforts to be ignored or undervalued, save for the question – are we spending the health dollar wisely?  

If a Medicare item encourages a 20 minute counselling approach to smoking cessation, then the dollar won’t be available for Dr Russell-type approaches.

He argued that the success of ultra-simple interventions in general practice would see 25 long-term successes per GP every year. And if all 20,000 GPs in Britain (in 1979) adopted it, 500,000 smokers would be helped to quit in one year.

No fuss, no bother, inexpensive and time efficient.

This result would be better, Dr Russell said, than what could be achieved by setting up “10,000 smoking withdrawal clinics” a year to manage difficult and dependent patients, often with little chance of successful quitting. 

“GPs, on the other hand, see all kinds of smokers, including those who are more likely to succeed and will not necessarily need intensive treatment and support. Firm advice to stop smoking, without any accompanying treatment or support, may be as effective as protracted treatment at special withdrawal clinics,” the researchers wrote.

The fundamental point at issue is whether supporting 20-minute consultations for quitting is a wise use of public money.  

I do not believe it is when the alternative is supporting GPs to provide economical and brief support to all the smokers they encounter in their daily practice.

Acknowledgement: I am grateful to my colleague Professor Simon Chapman, emeritus professor in public health at the University of Sydney, for his comments.

References:

1.       AIHW 2020; National Drug Strategy Household Survey 2019  

2.       Br Med J. 1979 Jul 28; 2(6184): 231–235)

3.       MJA 1989 Apr 17;150(8):420-2, 425-6.

Published in Medical Observer Opinion
21st June 2021

Should AHPRA deny registration over COVID-19 vax refusal?

 The speed and skill of COVID-19 vaccine developments is impressive. The extent to which such viral vaccines prevent death and — in the short-term — serious illness has been established in randomised trials.  

But do they prevent infection and what are their long-term effects?

We don’t know yet as that information comes only from careful follow-up of many vaccinated people. The data we have at hand are incomplete but encouraging.

In a Q&A on the vaccines in the New England Journal of Medicine, Professor Paul Sax, an infectious disease specialist at Harvard Medical School, US, sums up the current information well.

 “Findings from population-based studies now suggest that people without symptoms are less likely to transmit the virus to others. It would be highly unlikely in biological terms for a vaccine to prevent disease and not also prevent infection,” he writes.¹

“If there is an example of a vaccine in widespread clinical use that has this selective effect — prevents disease but not infection — I can’t think of [it]!

“The likelihood is that these vaccines will reduce the capacity to transmit the virus to others. [But], the protective effect will never be 100%, which is why … we still recommend the use of social distancing and masking in public.

“These caveats notwithstanding, the likelihood that these vaccines will reduce the capacity to transmit the virus to others remains excellent.”

Read more: Your rights: Can your practice demand you have the COVID-19 vaccine?

In light of this, all healthcare workers — unless exempted on sound medical grounds (a rare situation) — should be expected to have the vaccine, not only to protect themselves, but to protect their patients.

This has raised the question of whether vaccination should be mandatory.

Around one third of 400 respondents to an Australian Doctor poll agreed it should be compulsory for healthcare workers in high-risk settings including GP practices, hospitals and aged care facilities.

The remaining two thirds said it shouldn’t be made compulsory. Their reasons were evenly split; first, because efficacy and safety of the current vaccines are not guaranteed and second, because vaccination should be a choice.

Several respondents said that unvaccinated health workers should be expected to inform patients accordingly.

These are valid concerns for now.

But, let’s imagine a time when it’s proven that COVID-19 vaccination prevents infection, transmission, serious disease and illness. And that is found to have no serious side effects.

---

Read more from Professor Leeder:

• Here come the vaccines - now we need a successful rollout plan
• It's not helpful to talk about herd immunity with COVID-19
• Is it wise to remove medicine's eponymous male names?

In this case, I believe compulsory vaccination for all healthcare workers would be in the public interest. 

I would even go so far as to say that vaccination could come under the jurisdiction of AHPRA — which regulates more than 740,000 doctors, nurses and other health professionals.

The regulator would deny registration to unvaccinated practitioners.

Sound heavy-handed?

Not when you consider the alternative.

Published in Medical Observer Opinion
3rd March 2021

 

'Welcome to God's waiting room': A leading doctor reflects on his retirement

 

There is something vaguely automotive about the word ‘retirement’ — it carries the faint odour of worn-out tyres.

Last century retired teachers in my secondary school returned to teach us physics and chemistry because of staff shortages.

They were known as ‘retreads’. They didn’t last long.

When I retired from the Western Sydney Local Health District on 30 June last year, at age 78, I sensed a corporate sigh of relief. 

My formal farewell was delightful, but the underlying message was clear.

“Out with the old; in with the new!” said one senior manager who wished me Godspeed.

There’s nothing like retirement to lift the lid on otherwise hidden existential realities.

“Welcome to God’s waiting room!” a fellow retiree said to me.

Look up life expectancy tables and prepare to take fright. Only 10 years left (at best)? 

Think of 10 years ago — seems but as yesterday. Already sharp by day, these figures assume dagger-like forms at 3am or 4am.

Retirement is a big deal.

Handsome young feel-good gurus on social media, with wide smiles, perfect teeth, and advice to drink six glasses of water a day, make fortunes selling psychological trusses and bandages to keep us happy in retirement. 

Nevertheless, it is a life event. It perturbs the organism. It strips us of our identity. It cancels our power and influence. Yesterday’s rooster (excuse the sexism) has become today’s feather duster.

But let’s get this straight. We doctors are incredibly fortunate to have had generally deeply fulfilling professional lives. 

Most people do not have this immense privilege. This does not cancel the existential stuff, but it does put it in context.

That we can still function well in our 60s or 70s is an uncommon luxury, not open to sportspeople, tradespeople, or miners. And generally, we are pretty financially secure.

Read more from Professor Leeder: As an 'aged and at risk' doctor, I’ve been thinking ...

If we are reasonably healthy and have loving domestic arrangements, then our privilege is even greater.

So, when to retire?

We can only answer as individuals.

Common wisdom suggests we should move on before our decline is a danger to others. We are lucky if we have colleagues who can offer some gentle counselling on such a deeply emotional issue. At times, ageing robs us of the ability to be self-critical.

Fortunate are those who look to retirement as an opportunity to engage more deeply in music, art, writing, reading, faith-based activities, creative gardening, or bushwalking and are well enough to pursue these interests.

But those substitutes may not answer our deeply held desire to do things that contribute to human well-being.

Grandparental duties may partly fill this void. But beware!

I met my late dear friend Dr Bernie Amos after lunch one afternoon in the NSW Department of Health car park.

The department’s director-general looked weary. He explained that he had been caring for grandchildren.

He asked if I knew the best part of the morning. Before I answered he reached into his pocket, smiled, withdrew his car keys, and jangled them saying: “This!”

You don’t need me to rehearse all the suggestions for self-preservation after retirement.

They usually include proposals for maintaining physical and mental wellbeing often through social groups, preferably including people young enough so that conversations are not like those you hear in outpatients where ailments, and grumbles about healthcare dominate.

Friends devote hours to crosswords and love it. Lots of fruit. Access to a good clinical psychologist if in doubt. I did.

Keeping alive intellectually as far as dementia permits is critical.

I was reminded recently by a lively American friend in his 80s of something that Carl Friedrich Gauss, the great German mathematician, wrote in 1808:

"It is not knowledge, but the act of learning, not possession but the act of getting there, which grants the greatest enjoyment."

When I have clarified and exhausted a subject, then I turn away from it, in order to go into darkness again; the never-satisfied man is so strange if he has completed a structure, then it is not in order to dwell in it peacefully, but in order to begin another.

I imagine the world conqueror must feel thus, who, after one kingdom is scarcely conquered, stretches out his arms for others.”

Read more from Professor Leeder: Should AHPRA deny registration over COVID-19 vax refusal?

To me this is rather like the lifelong journey to Ithaca, the subject of C.P. Cavafy’s truly wonderful 1911 poem.¹

But don’t hurry the journey at all.

Better if it lasts for years,

so you’re old by the time you reach the island,

wealthy with all you’ve gained on the way,

not expecting Ithaka to make you rich.

Nâzım Hikmet, the great Turkish poet died in 1963, was just 61 when he wrote compellingly about living life in the face of death in his poem On Living:²

I mean you must take living so seriously that,

even when you are 70, you must plant olive trees,

not because you think they will be left to your children,

because you don't believe in death although you are afraid of it

because, I mean, life weighs heavier.

Time to plant olive trees, I think.

More information:

1.     C.P. Cavafy, Ithaca 

2.     Nazim Hikmet, On Living

Published in the Medical Observer Opinion
16 April 2021