Category: Archive

The available budget for the NHS seems to be a fairly constant topic of conversation within healthcare. Indeed, it formed a large part of the discussion surrounding the recent general election. Given we live in a world of limited resources for healthcare, there are various arguments surrounding how best to use the available budget.  

One notion put forward is that of personal or voluntary responsibility. This argues that individuals who have put themselves at risk through their voluntary decisions must take responsibility for the full outcomes of their decision. Any negative consequences of their action are their responsibility and if they place another individual at risk who has not made a choice to be in this situation, then the person who has made the choice forfeits their right to equitable treatment.  

An example might help illustrate the point this argument is trying to make. Organ donation is a simple example of the use of finite health resources, like the countries’ budget for healthcare. Consider the situation where you have two patients waiting for a liver transplant. One, John, is a 60-year-old man with Alcohol-Related End-Stage Liver Disease (ARESLD), who needs a new liver after several decades of drinking. The other is Marjorie, a 62-year-old woman who has End-Stage Liver Disease as a result of an infected blood transfusion she received several years ago. The blood transfusion was required due to an accident that she did not cause. Both are diagnosed and told they require a transplant at the same time. Who should have the priority if a liver were to become available? 

John now needs this transplant as a result of his life choices (if we for the moment take it in isolation of social factors such as addiction), while Marjorie needs this transplant through no fault of her own as she is if anything a victim in this situation. The principle of voluntary responsibility would argue that John has through his actions caused his illness and thus created his need for this limited resource. Not only that but in doing so, he has put Marjorie at risk by creating competition for a resource that she needs. Therefore, John should relinquish his claim to the resources, the liver transplant.  

This might be seen to reflect some natural intuition in this situation. But is this really fair? 

The ethicist J McMahan likens this scenario to that of killing in self-defence. He argues that the key determinate in the right to kill in self-defence is the moral responsibility of the individual threatening you. Thus, though he recognises in this situation John is not directly attacking Marjorie, he is morally responsible for his actions that have created a direct threat to her life. McMahan would argue that by creating this risk to Marjorie’s life through his choices, John must pay the cost of his actions and is morally required to save her by relinquishing his claim to the organ.  

On this argument it seems right to prioritise patients who are not morally responsible for their need for an organ over those who are responsible. In making certain choices they have threatened the life of someone else and so have diminished their claim to be treated relative to the other individual. This is not to say that they shouldn’t be treated, but in situations where there are limited resources priority must be given to those who are not responsible for their need.  

This can be seen as an application of the principles of Luck Egalitarianism. Luck Egalitarianism is built around the idea of equal opportunity, so that any inequalities that exist between individuals are only due to their own choices. It aims to eliminate the brute luck element in life which causes individuals to exist unequally due to factors beyond their control such as race, the wealth of the family they are born into, the opportunities available to them, or the level of nurturing they receive as a child. These factors can mean that individuals start life unequally, which is unfair. Dworkin proposed that people should be provided an equal starting point, therefore the only inequalities they should experience should come as a result of their own choices for which they can be held accountable. Therefore, everyone should be provided the same right to healthcare in the first place, and then in making choices that damage their health individuals waive their right to equal access to healthcare. Personal responsibility can then be seen as the cost of free choice and its consequences are the cost of being autonomous adults.  

So far this seems to be an argument related to fairness. Surely then this principle should be applied fairly to the whole of healthcare, and to all decisions that create a demand on limited healthcare resources? Any choices to put oneself at risk should deprioritise you relative to individuals who haven’t take such risks. Therefore, one’s choice to drink should be seen in regards to healthcare as the same as one’s choice to climb a mountain, or go over the speed limit, or indeed to become pregnant (provided there was some choice to engage in sex knowing the risk of this action).  

That is not to say the weight of the decisions is the same. For instance, an injury caused by a single moments recklessness in a car has had less chance to be stopped than years of heavy drinking. However, in both situations the individual has made a choice to prioritise something over their health and so resources should arguably, based on this principle, go to individuals who have not put themselves at risk. 

If this principle is applied, as it should be in an argument about fairness, then an operation for a liver transplant needed due to ARESLD could only go ahead if there were enough surgeons to perform all the operations that were not needed as the result of lifestyle choices. Funding for gastric bands and weight loss surgery could only be provided once all genetic disease had been cured. This principle must be applied completely or not at all. Otherwise you are prioritising based on social decisions, not moral ones, of reprehensible behaviour, and creating inequality in trying to provide equal and fair access to healthcare resources.  

A study by Ubel highlighted that actually we are more likely to prioritise based on social reprehensible choices than simple personal responsibility. The study asked individuals to decide who to give a heart transplant to out of a range of patients; some were IV drug users, some smokers, some ate high fat diets and some had a healthy lifestyle. His study found that people assigned a lower priority to the individuals with the most socially reprehensible lifestyle, regardless of whether they had a better prognosis or their lifestyle was the cause of their illness. IV drug users received significantly fewer organs than any other patient irrespective of all other factors. Yet the most common justification for their decision was that patients who caused their own illness should not receive equal priority. It would seem then that many people believe individuals are just less worthy of scarce resources, rather than it being due to the fact that they caused their own illness. 

If people are unwilling to apply the principle of personal responsibility in all situations then surely it is morally wrong and unfair to apply it only in situations where society judges the decisions reprehensible.  

However, if one is willing to accept the wholesale application of the principle of voluntary responsibility then there would need to be some way of determining the degree of responsibility for ill-health. For one to be fully responsible for their choice they must be aware of full effects of said choice, be free from undue influence and have a full range of options for the choice they are making. It seems reasonable to dispute that this is the case with a lot of lifestyle decisions. Health education in the UK is out of date and has one of the lowest spending priorities despite it being an effective tool for combatting illness. Therefore, the current way we provide individuals with information on the risks of certain lifestyle choices is failing to connect with the individuals it is aiming to educate. If we are to deprioritise individuals for poor health choices, there must be fair provision for these individuals to be educated or made aware of the risks they take when making certain lifestyle choices. It would be the duty of the government limiting access to healthcare based on lifestyle choices to ensure that the risks would be fairly advertised and the information on the risks the individuals are taking to be publicly and readily available. 

It could be argued that actually the opposite occurs and the government actively allows for the promotion of these risky lifestyle choices through advertising. For example, it has been shown that children see as many as 12 advertisements for junk food within a single hour television viewing. This level of advertising, and thus promotion for lifestyle choices that have a links to ill health in later life, would indicate that instead of proper education on the risk of certain choices there is encouragement to make these risky lifestyle choices from an early age. Responsibility should therefore not be placed wholly with the individuals making the choices.  

The ability to make healthy choices can also be limited. Health inequalities seem based in structural inequalities, meaning that people from lower socioeconomic backgrounds have a general lower level of health. A study found that individuals born to lower socioeconomic backgrounds had a higher incidence of poor health habits later in life, suggesting that it is not free choice that individuals exercise when making certain lifestyle decisions, but rather a product of their upbringing. While this does not mean that it is impossible for individuals from lower socioeconomic backgrounds to make good health decisions, they are subject to different perceptions of health habits and have different restraints and reinforcements leading them to make choices that are not wholly free, and so they should not be placed with the full burden of responsibility for these decisions.  

Luck egalitarianism, to be fair, would seek to rectify these problems, and personal responsibility is a luck egalitarian principle. However, it cannot be applied in one respect and not in another. Every aspect of society would have to shift to luck egalitarianism for this to be fair.  

It seems clear that personal responsibility is not a fair or morally sound way on which to distribute the NHS’ limited budget. The fair way to do so must be decided by our wise new government. Yet one thing is clear regardless of whatever way they choose, the NHS needs more money than they can give it.  

Kit Stanford

Look After Yourself  

The most important element to ensuring that you make the most out of your placement is looking after yourself. As a medical student it is easy to feel overwhelmed by the various emotional challenges that are commonplace during clinical placements, such as confronting patients’ illness and death, attempting challenging new skills and developing professionally. It is helpful to allocate time within the week to relax and perhaps attend a few society events. You could even start a new hobby.   

It can be useful to speak to friends and family for support. Additionally, talking to doctors can prove to be valuable as they are best placed to give you advice on how they have dealt with the stresses of medical school.  

Having a good regime for stress relief is essential. It can support you in benefiting from placements by increasing your concentration, capacity to make decisions and ability to establish strong professional relationships. 

Devise a plan 

Before placement, devise a plan outlining what you wish to learn for the day. You can take objectives from exam specifications to ensure that you are targeting your learning. Sharing that plan with your supervisor can facilitate you meeting your objectives as they can often point you in the direction of patients that have particular signs or offer you teaching if they have time. Whilst on placement you can identify doctors that have undertaken specialist training and can often arrange to sit in on their clinics.  

Clinical placements are a great opportunity to put into practice what you have learnt. Use your time to practice history taking, examinations and clinical skills. Getting feedback from peers or a clinical supervisor is a great way to learn how to improve. Aim to learn at least one new piece of knowledge, be it practical or medical theory, per day as this can help to breakdown the workload.  

Volunteer  

It is common for medical students to refrain from performing clinical skills, such as histories and examinations, due to fears that they may be incorrect. Such opportunities are a great learning experience as they are quite similar to OSCE scenarios. Additionally, you can receive feedback on your performance to help you improve in the future. Taking advantage of these opportunities helps you to build your confidence in a clinical setting.    

Attend Junior Doctor Teaching   

Often there is opportunity for medical students attending clinical placements to attend junior doctor teaching. The teaching often centres around topics that are relevant to the medical school curriculum and prove to be useful in providing a clinical context to the medical knowledge.  

This is also a great way to make friends with the junior doctors! They are the ones who have most recently finished medical school and so they are familiar with your experiences. They can offer you teaching on medical concepts but also on things beyond the curriculum, such as career decisions. Additionally, there is a chance to gain a mentor, be offered research opportunities (such as audits) and start to form your network.   

Reflect  

Reflect on what you have learnt during your clinical placements at regular intervals. At medical school you learn clinical knowledge but also the professional skills that shape you into the doctor that you become. Reflection helps you to make the most out of your everyday experiences, learning what actions were successful and perhaps occasionally what actions were not, in order to guide your future practice to shape you into becoming the best doctor you can be. Reflection can also be a useful tool in helping you to devise daily plans!  

Finally, enjoy your clinical years – they are a wonderful learning journey and are truly the highlight of medical school. Make sure that you seize every opportunity and put into practice all of the knowledge that you have learnt!  

Good luck for all of your placements!  

Amaal Maqsood-Shah

Right or Wrong?

On a recent placement I was lucky enough to spend an afternoon in a fertility clinic. Whilst there the consultant asked me whether I knew the conditions required for a patient to gain access to Assisted Reproductive Technologies (ARTs), the group of treatments that IVF belongs to. I managed to remember something about the period of time patients had been trying for but fell short of any further answers.  

Following some further quizzing and a fair quantity of leading questions I had managed to connect the dots and explain most of the medical constraints. The questions then changed in nature and I was made aware of various social conditions that can prevent individuals being allowed access to ARTs. These conditions seemed to focus on the welfare of the child that would be created as a result of the ART access. If ARTs are meant to help provide equal access to individuals’ reproductive rights (should one accept there are such rights), then these constraints surely create a further inequality, as there is no regulation on the prospective parents’ social situation in those who can conceive without assistance.  

Could these constraints be ethically impermissible?  

Firstly, what are the actual conditions one must meet to gain access to ARTs? The Human Fertilisation and Embryology Authority (HFEA) which governs policy on ARTs in the UK states that women should not be provided access to Hormone Replacement Therapies (HRTs) unless the welfare of the future child, or any other child affected by the birth, has been taken into account. It states that the service provider must consider factors likely to cause a significant risk of harm or neglect to the child, which include previous convictions relating to children, discord in the family environment, mental or physical conditions, substance abuse, medical history that suggests the child will be at risk of a serious medical condition or a refusal to provide any of the above information. The centre can refuse to provide access to ARTs should it be concerned about any of the above factors.  

In abstract this seems reasonable, until you consider it in the context of the limitations placed on parents who are able to conceive without ARTs; none.  

The United Nations (UN) enshrines the right to “marry and found a family,” in its Declaration of Human Rights. This can be seen as a positive right to have children. If this is so then by limiting access to ARTs it can be seen that governments are preventing some individuals from accessing their human rights in this respect, and so create an inequality between those who need ARTs to conceive and those who do not. The question then is, can this be justified? 

The arguments for this restriction are based in the consideration of the welfare of the future child. It is argued that the right to procreate is under what is termed an internal constraint; this means that unless someone fulfils certain criteria when performing an action, they do not actually use their right.  

One useful example to consider is driving. We all have a right to drive, provided we meet the internal constraint of having a valid driving license. If we drive without a license then we are not truly exercising our right and so can be punished.  

In the case of having a child, it is argued that the internal constraint is that the child resulting from the exercise of the right to have a child must have a reasonable prospect of a minimally decent life. What does this mean? It means that if the child born does not have a reasonable chance at having what it considered the fundamental level of quality of life, then the parents have not truly exercised their right to have a child.  

Obviously this is problematic as the child is alive, and short of force sterilising individuals who society judges not able to meet this internal constraint, which comes with so many issues that I feel it isn’t even worth entertaining, there isn’t much one can do for parents who can conceive without ARTs. The child can however be removed from the parents after being born.  

So how does one decide to define a minimally decent life? One argument is that simply existence is enough to qualify as a minimally decent life, as existing is better than not existing. This is a thorny ethical issue and one I don’t think I could possibly fairly tackle, so instead perhaps it is better to consider it another way. 

Let’s say it is better to exist than not exist. Therefore, the only constraint on the right to have children is that you will actually have a child. This seems a fairly low threshold. In this scenario it is possible that for whatever reason a parent could therefore exercise their right to have a child, and that child not have a reasonable prospect of exercising the same rights that their parent used to conceive them – a right to individual liberty and free choice. Thus, in exercising their right to liberty in choosing to have a child they prevent another person from exercising their rights. This is morally wrong as it contravenes each individual’s right to autonomy, and so this cannot be the true internal constraint. 

This does highlight something though; the child must have a reasonable prospect of being able to exercise its rights. Which rights though? Given we are looking to the UN for the right to have children, it makes sense to look here again. The answer that seems to make the most sense to me can be found in the United Nations Convention on the Rights of the Child (UNCRC). Here the UN outlines the rights of the child, including rights to be protected from “being hurt and mistreated, physically or mentally” and to have all decisions relating to them made in their “best interest.” 

If we take this then we could say that the internal constraint on exercising an individual’s right to have a child is that the child must have a reasonable chance of exercising its rights enshrined in the UNCRC. I think this seems fair.  

Back to IVF. So, we can’t stop parents who don’t need ARTS from having a child without meeting these conditions, but we do take the child into care when these rights aren’t met. Sadly, this may be after some lasting damage, emotional or physical, has been done to the child. Surely if we have a chance to prevent this then we should act? 

By placing social considerations of access to IVF and other ARTs we are protecting the rights of the future children, stopping them suffering possible harm before intervention, and preventing an extra pressure being placed on an already stretched and underfunded care system.  

Whilst it might seem unjust on the parents, it is if anything fairer on the children, by helping give all children as equal a start in life as it is possible to in this world. Parents should be supported in every way possible to provide their child with access to these rights, but in some cases, this is not enough. Ultimately, we must act to protect the rights of vulnerable groups, like children, who cannot protect themselves, and by placing these social constraints upon access to IVF this is one way we can. 

Kit Stanford

Vulnerable people should self-isolate for the foreseeable future, stay indoors, limit contact etc. etc. but what if you don’t have a safe place to do that, what if you’re one of Britain’s thousands of homeless? Approximately 10,000 people sleep rough in the UK, with a further 320,000 described as ‘hidden homeless’, sofa-surfing or living in temporary, unstable accommodation.  Statistics demonstrate that the homeless population are 3x as likely to have a chronic health condition, particularly respiratory problems like COPD or Asthma, things we know don’t sit favourably with fighting Covid-19. Equally they are more likely to be malnourished and the continuous exposure to the elements is associated with a reduced immune system, making contraction of the virus more likely.  

Current advice surrounding hostels is that they may remain open unless directed otherwise by Public Health England, but it is clear to see how easily the virus could run rampant in such an environment. But whilst hostels are currently able to remain open, other services which facilitate large group gatherings, such as soup kitchens, are being forced to close.  For those able to remain open, many which rely on an elderly volunteer force, have seen staffing levels drop as self-isolation begins. St George’s Crypt, a sanctuary for those facing homelessness in Leeds, has announced that it has had to withdraw its lunch time service, which provided a hot meal free of charge to hundreds of people each day, but also a guaranteed friendly face, social interaction and the chance get warm and dry.  

Equally consideration must be made to ensure those experiencing symptoms are encouraged and feel welcomed to seek help. The idea of repurposing empty offices or utilising empty hotel rooms to provide a clean, warm and safe place for those needing sanctuary feels like a positive one.  

At the time of writing it was announced £3.2 million emergency funding will be provided for local authorities to assist the homeless community with accommodation and vital support to safely self-isolate. There are also reports of a trial which saw 300 rooms made available to individuals already known to services and that London’s Mayor was putting in plans to block-book rooms for the next 12 weeks. A beacon of hope for some of our most vulnerable citizens.  

Florence Kinder

A Medical Ethics workshop for Sixth Form students thinking about applying to medicine, one student lingered at the end. Expecting the usual questions about directions to the station or finding good work experience, I was a little taken aback when the student came straight out with, ‘Does doctors’ mental health not matter?’  

‘Of course, it does!’ I instinctively replied, ‘…but what made you think it doesn’t?’ ‘Well, it’s just something I was thinking, say my patient dies because they refuse the treatment I tried to give, how do I live with myself knowing I’m responsible for their death?’ 

A very astute thought for a 16-year-old and perhaps something we don’t consider often enough. Patient autonomy is so embedded in all that we do, and rightly so, but perhaps we fail to consider the impact that accepting a patient’s choice, one which may not be in their best interests, has upon our wellbeing.  

I’m sure we’ve all met patients who we wished we could ‘fix’, if only we could get them to stop drinking, stop smoking, attend their follow up appointment. You’ve spent half your afternoon with ‘Bed 21’, patiently explaining why smoking is harmful, how it’s making their COPD worse, talking through how we can help them cut down – it’s all feeling positive. They agree with you, they’re ready to take the first step, you’ve ‘succeeded’. You leave for the day feeling like you’ve achieved something and then you come back to the ward the next day, ‘Where’s ‘Bed 21’ you say?’, ‘they’ve gone for a cigarette’… and as quickly as that optimism arrived yesterday, it’s snatched away. You should have known you weren’t going to be any different to before, why did you waste your time? Who were you to think you could change 30 years of behaviour in an afternoon? 

My SSP working with the homeless community challenged me in coping with the desire to ‘fix’, helping settle the idea that this need not be our only goal. One patient I met there has always stuck with me, let’s call him John. John had recently been released from prison and found himself back on the streets. He was in his early 40s but had a troubled past which had unfortunately led to years of drug abuse, leaving him with health issues so severe he was now terminally ill. When I met him, he openly admitted to still battling drug addiction and turning to crime to support this. He had so many issues and it was clear we couldn’t address all of them. I wanted to help as best I could – if we could just have long enough maybe we could convince him to change his lifestyle and set up all the support there was to offer. Yet equally we could not force him to accept our help as his right to autonomy was paramount, yet it was key to do all that we could to make healthcare as accessible as possible for him, to treat him with empathy and kindness and without judgment.   

I think of him often, I suspect he’s no longer with us and I question if there was more we could have done; probably along his pathway, yes, yes there was more we could and should have done, but I seek comfort in knowing that the afternoon I spent with him, he experienced kindness and empathy. He came to see us, unable to walk, but he left delighted with a pair of crutches. I hope he felt a positive experience of healthcare, I suspect he probably did. 

So, going back to that question, ‘How can we maintain our mental wellbeing in difficult cases, navigate the vitally important patient autonomy alongside our desire to do good for our patients?’. First, I think we acknowledge it’s hard. Our very motivation to be doctors likely stems from our desire to help and to care but I’ve come to see that to do that doesn’t mean we have to compromise our patients’ values. We must view our pursuits in the context of these values and measure our positive impact alongside these. We don’t all have to be heroes or ‘fix’ everyone we meet. But equally, being a ‘hero’ doesn’t always mean saving a life, sometimes it means enabling someone to live their life in line with their values. It’s okay to be upset by people you meet, people you can’t ‘save’.

Talk to someone, you’re almost certainly not alone. Remember to make your actions about what you can do and what your patient wants – let that be the measure of your success.  

Florence Kinder

If you need support during this time, please find links to the University of Leeds, and Leeds University Union support pages below:

https://students.leeds.ac.uk/info/100001/counselling_and_wellbeing

Walking through the doors of the general practice surgery triggers emotions that I would not expect when on medical student placement: fear, nervousness and excitement!

Today marks the fifth week that I have been on my GP rotation. Over the course of these weeks the Coronavirus pandemic has evolved. The nationwide attitude is reflected by patients and staff here; from irony and cynicism to genuine fear. The waiting room is remarkably quiet, there are only two patients picking at their nails anxiously; a startling contrast to the usual hustle and bustle of this buzzing practice. I try to enter Room 3 but am immediately sent to get personal protective equipment: a mask and apron. I was expecting to have to wear such items when on my elective in countries with tuberculosis and haemorrhagic fever, not sitting in a general practice in West Yorkshire!

After the first patient leaves, there are no more, only phone triage consultations; the doctor calls patients and decides whether they need to come into the practice or if they can be managed from home. A mother is told to bring her 5-year old with suspected tonsillitis into the practice. Young children are going to have to be seen by a doctor and so it seems wasteful to even have this telephone conversation. The doctor explains that calling allows better organisation of patient appointment times. Those with long-term respiratory conditions who would be extremely vulnerable to a coronavirus infection should be brought in together at a separate time to those who are likely to be carrying it.

Next, the doctor phones a patient who is newly depressed. The doctor asks screening questions about thoughts of suicide and self-harm. This is difficult enough over the phone but this GP surgery is currently going under reconstruction so there is the added complication of a drill in the background. It is so difficult for the doctor to sound empathetic and caring whilst shouting down the phone.

A patient is called who has coronavirus like symptoms, whose husband tested negative for the virus. The doctor asks about cough, shortness of breath and fevers. The patient has wheeze like symptoms so the doctor explains she will have to see her. Despite her husband’s negative test result for Covid-19, this patient may be infected. It seems counterintuitive to bring her in as she may infect others, but the doctor needs to examine her and decide the best treatment option for her.

There are patients taking disease-modifying antirheumatic drugs (DMARDs) and chemotherapy who have to come to appointments for reviews and blood tests. These patients are immunocompromised and a Covid-19 infection could be fatal. There are no guidelines about how to manage these patients. Similarly, if patients need an X-Ray for a respiratory condition they will be sent into hospital; their risk of infection will be massively increased and it is those with lung problems who would be worst affected by Covid-19.

The doctor exudes frustration with the lack of information and guidance. There have been no meetings with the Clinical Commissioning Group or local Public Health England. This practice is trying to take a sensible approach but are essentially improvising. It is striking how the staff at the practice and across the NHS are selflessly risking their own health for the majority and are remaining calm in the face of the unknown.

Because of the coronavirus pandemic, I am now signed off my GP rotation and cannot help feeling like I should be doing more to help. Perhaps medical students could be trained to phone the patients and triage their appointments, a document could be created screening for red flag symptoms for different medical conditions. Or perhaps a service could be set up where the public can call medical students for reassurance, if they still feel anxious after reading about Coronavirus online. As I walk out of the practice I realise that my experience of GP was definitely extraordinary and was absolutely fantastic. But I can’t help feeling that sending me home to do nothing is not the best use of resources.

Rosie Solomon