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Heart disease, guidelines, regulations, and the law
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  1. M C Petch
  1. Correspondence to:
    Dr MC Petch, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK;
    janet.barrett{at}papworth-tr.anglox.nhs.uk

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The practice of cardiology is increasingly constrained by guidelines, regulations, and legal considerations. Cardiologists, like any other group of doctors, have a primary duty of care to individual patients, but also have wider responsibilities to society in general, to their institution, and to their colleagues. In the UK these duties and responsibilities have been defined by the General Medical Council and have been described in a series of publications which have been sent to every doctor; these contain the answers to questions about good medical practice, the role of doctors in the management of health care, confidentiality and other issues.

THE DEMISE OF CLINICAL FREEDOM

Clinical freedom died around 1983.1 A number of factors sounded the death knell. Among the more important were, first, the incontrovertible results of randomised controlled trials. Many of these were in the cardiovascular field—for example, coronary artery bypass grafting for patients with angina and severe disease, thrombolysis and β blockade for myocardial infarction, and aspirin for the acute coronary syndromes. These, together with earlier trials demonstrating the efficacy of antihypertensive treatment, and subsequent trials showing the benefits of statins and angiotensin converting enzyme inhibitors, have fundamentally altered the practice of medicine. Physicians have to have good reasons for denying patients the potential benefits of these treatments.

Financial constraints were a second factor that killed off clinical freedom. These became apparent in the British National Health Service (NHS) somewhat before other countries and have led to the universal recognition that third party payers of health care should not be expected to fund treatments simply on the assertions of a doctor, however distinguished. Evidence of benefit is mandatory.

A third factor has been the gradual realisation by the public that doctors are not always to be trusted. Some have fallen off their pedestals rather publicly, so that nowadays doctors not only …

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