Struck Off in order to protect the public

The paramedic, Mr C, whose FTP hearing I attended last week, has been 'struck off' the HPC register in order to protect the public. The report of the panel is published on the HPC website. Had the case been not proven, the HPC would not publish the details. This has the strange consequence of making it appear that all the allegations pursued by the HPC are successful, which is not the case. But that is an issue for another time. What I am interested in here is discovering what it is that the public is being protected from, and what kind of public it is, that is being imagined into existence.

As I mentioned in a previous blog entry, the hearing at the HPC does not appear to be interested in the actual facts of the specific case. They are more concerned with a generalised idea (or ideal) and must rely in great part on what has already been written not in great texts by eminent thinkers in the proper scientific application of their work, but by the Professional Liaison Group set up by the HPC at the start of the process of regulation. This begs lots of questions about science knowledge and management, and calls up the spectre of Galileo.

The case was questioning the actions of Mr C in relation to one patient who he 'paced' due to low heart rate and then gave diazemul (10mg). The case against Mr C was that there was insufficient consent from the patient to 'pace', and that the justification for the diazemul was incorrectly justified (the justification should have been linked to the patient's fitting, not to the patient's stress). Mr C disputes both these allegations, so the case turns around what was said at the moment of the emergency call, and what was said three days later in a management meeting. First Mr C had framed his decision in terms of calming the patient, reducing stress, only later did he articulate it to the patient's history of fitting. It is because of this that the HPC panel were persuaded that Mr C was not of good character and so would undermine the public's confidence should it be discovered that such an inconstant man was included on the register of the HPC.

It is certainly worth considering for a moment the nature of the medication. I, a member of the public, would like to know the nature of the risk that Mr C put his patient to by administering 10mg of Diazemul.

An internet search reveals that Diazemul is a benzodiazepine and that these are used for their sedative and anxiety-relieving effects.

What I happen to know from a few years work in adult acute psychiatry a few years ago, is that this range of medication was contentious because many patients really liked them. The underlying sort of 'common sense' assumption was that people would prefer to be ill in order to enjoy the effects of the drug. A limit to their prescription was therefore encouraged on the ward where I worked as a kind of 'moral' approach to the cure. Is this why Mr C should not have administered the drug to his patient? Has this moral fear made its way into the rules of practice currently consulted by the HPC? Is the fear that the patient would have developed an immoral preference for the medication? I don't know - the knowledge behind the decision was not on show. But it does begin reveal one kind of idea that is taken for granted about 'the public'.

This exclusion of relevant knowledge is something this case shares with the case of Mr U, which I attended the week before and wrote about on this blog. In that case Mr U was accused of verbally and physically assaulting a member of the public, and the impression was that he had done this unprovoked (which was not at all the case). Nevertheless, it was not these facts that led the panel to find the case unproven against him, but that he had been contrite. It was his confession of guilt that allowed the panel to leave that man alone.

In the case of Mr C, however, there was no contrition. In fact, as I mentioned before, there was something approaching its opposite. His representative let it be known that the case was a waste of time, founded on pernicious motives, and which distorted the evidence in its favour.

On the clinical question at the heart of this case - the administration of 10mg of Diazemul - the Panel declared itself uninterested. I quote from their concluding remarks: "The Panel does not consider it necessary to dwell on the issue raised at the hearing as to the proper dose of Diazemuls. This is because the clear finding of the Panel is that no quantity of that drug should have been administered to that patient at that time. However, the Panel should record the fact that it did not find the evidence adduced by the HPC in relation to an acceptable dose to be helpful."

This statement is odd. First it says that it is not relevant to discuss the dosage of the drug, as the use of the drug was prohibited in these circumstances. Second, although the Panel finds the dosage irrelevant, it takes the time to say that the evidence the HPC furnished on the dosing of the drug was not helpful. Third the 'clear evidence' on which the HPC panel makes its decision seems mainly to be the fact that Mr C said something on one occasion, and another three day's later. These utteranes are taken as the bedrock of the case rather than the clinical facts pertaining.

I happened to hear a little of this discussion, so from my position in the public gallery, and on the balance of probabilities, I would guess that quite a bit of time had been taken up on the previous day to the question of how much diazemul was fit for the purpose that day. In fact, the HPC had gone to the trouble of bringing a witness to speak about it. This opens up a can of worms. There is, at the very least, ambiguity about this drug.

There is also some ambiguity about the nature of the public. In this case, the public is a phantom figure who seems likely to drop his trust and run screaming for this hills at the thought that Mr C said one thing on one day (I administered the drug to calm the patient) and another a few days later (not directly reported but that relates to the patient's medical history of fitting).

The other figure of the public in this scenario is that of the patient. The complaint against Mr C did not emanate from this man, nor any member of his family. He remains wholly outside the field of reference of this hearing. Only by implication can anything be deduced about him. Is it that he, a 70 year old man, could not be trusted to receive the medication Diazemul in case he developed a liking for it that Mr C's name must be struck from the register of the HPC?

Or was it that the case reveals a wobbly basis for the rule about the use of this medication - an ambiguity that is not resolved on the level of science, truth, or real life practice, but by reference to the pre-determined rules of a centralised State sanctioned committee?