Welcome to the latest Applying to Medical School blog. This post focuses on a current medical ethics issue: e-cigarettes and the NHS.
It is essential you keep up to date with medical hot topics and are able to discuss ethical issues at your Medical School interview, using the 4 pillars of medical ethics.
E-cigarettes on the NHS?
E-cigarettes have been in the news this week.
Public Health England, the body charged with protecting the nation’s health, has announced that e-cigarettes are to be licensed as an aid to stop smoking as early as 2016.
Their decision is based on a new review of evidence that shows that e-cigarettes are about 95% less harmful than normal cigarettes. You can look at that evidence review here.
Whilst it is still not known exactly what the long-term health effects of e-cigarettes are, they are considered to be the lesser of two evils because they do not contain tobacco.
A note on the difference between nicotine and tobacco
Nicotine is the addictive substance in cigarettes that produces the stimulating feeling that smokers crave. It is associated with cardiovascular disease and birth defects.
Tobacco, the more traditional and popular method of delivering nicotine, also contains a host of chemicals and toxins that are associated with millions of preventable deaths – from various diseases, but most prominently cancers – worldwide.
What exactly are e-cigarettes?
E-cigarettes are battery-operated devices that mimic the experience – and the nicotine hit – of smoking a real cigarette. Smokers of e-cigarettes inhale a water vapour that delivers a dose of nicotine to the lungs. For this reason, the practice is sometimes referred to as ‘vaping’.
Lots of people start smoking e-cigarettes in an attempt to quit smoking altogether, as they are seen as a way to reduce cravings for tobacco cigarettes. There are currently 2.6 million e-cigarette users in Britain.
They are an alternative to other stop smoking treatments such as nicotine inhalers, patches and gum.
And now they are joining those other stop smoking devices as treatments that are available to smokers who want to quit on the NHS.
But smoking is bad for you! Are e-cigarettes ethical?
When doctors make decisions about how to treat a patient, they are guided by four key ideas, known as the four pillars of medical ethics.
- Autonomy: people have the right to control what happens to their bodies, so they can refuse any treatments offered to them.
- Justice: a doctor should always be fair in terms of their allocation of medical resources, and should always be able to justify their decisions.
- Beneficence: it is a doctor’s duty to improve – to benefit – the health of their patients.
- Nonmaleficence: similarly, a doctor must not do harm to their patients. But sometimes there is a risk that a treatment intended for good can unintentionally cause harm, which complicates the issue.
There has been controversy over the decision to make e-cigarettes available as a treatment for stopping smoking on the publically-funded NHS. So does the decision stand up to the four pillars of medical ethics?
The arguments:
Autonomy
This one is simple: as long as people are well informed about the relative risks and benefits, prescribing e-cigarettes as a medicine shouldn’t contradict a patient’s right to autonomy.
Justice
The main objection to e-cigarettes being funded on the NHS is that some people don’t think tax money should be spent on what is, according to some, essentially a lifestyle choice. These people would probably say that the decision contradicts a doctor’s duty of justice.
But the taxpayer already funds many treatments related to smoking. In 2013-2014, there were approximately 1.8 million prescriptions to help people stop smoking, half of which were for nicotine replacement therapies like gum and patches. This cost the NHS just under £49 million.
E-cigarette prescriptions are likely to add to that cost.
However, health campaigners argue that this cost is justified by the long-term health benefits of getting people smoke-free. Which, in the long term, could end up costing the NHS less in treatments related to the complications of smoking.
The Public Health England report concluded that:
At the moment, 80,000 people [in England] die every year as a result of cigarette smoking. If everybody who was smoking switched to e-cigarettes that would reduce to about 4,000 deaths a year. That’s the best estimate at the moment. It may well be much, much lower than that.
Beneficence and Nonmaleficence
Despite these findings, the British Medical Association (BMA) has expressed concern over the inconsistent quality of e-cigarettes, and the lack of a regulatory framework around them.
Others – including the Welsh Government, who are planning to ban e-cigarettes in public places – are concerned that prevalent usage and the promotion of e-cigs as ‘safe’ alternatives to smoking will serve to promote nicotine addiction, and actually increase levels of tobacco smokers. They are particularly concerned about younger generations who have, until now, grown up in largely smoke-free environments.
One consequence of e-cigs being available on the NHS is that they will now be considered a medicine rather than a recreational device. This means that they will have to be subject to stringent health and safety regulations, and might usher in some of the regulations that the BMA have been calling for.
Licensing and regulation will also change the way e-cigarettes can be advertised. It will be illegal to advertise them as a consumer product in the same way as it is illegal to advertise tobacco – which could go some way towards preventing any increases in the smoking population that might otherwise be brought about.
Ultimately, only time will tell if e-cigarettes really do contribute to falling levels of tobacco smokers – and whether there are any long-term health effects of ‘vaping’ that health professionals have not been able to predict.
Further reading
World Health Organization (WHO) report on the ‘global tobacco epidemic’.
Public Health England evidence review on the safety of e-cigarettes.
Cancer Research UK on some of the unanswered questions around e-cigarette usage.
