Category: Current Affairs

Shruti Chawla, Intercalating

No, this isn’t a cry for help. 

Recently, I was recommended “The Hard Thing About Hard Things” by Ben Horowitz – a big guy in tech (Wikipedia is your best friend here).

After reading an interesting anecdote on pg 58 in which a consultant let a 35-year-old with heart disease walk out of his clinic, proclaiming him a “dead man”, then reading Horowitz compare this to selling his platform, I had a slight revelation. 

Parallels can be drawn between being a CEO and being a medic. 

Let’s start with page 20 – a section titled “euphoria and terror”, really set the mood for the rest of the book. It gave me flashbacks to the first block of placement on Kidney and Liver Transplant. The confluence of these emotions covered those six weeks of my life, euphoric when I closed a laparotomy , yet terrified when my consultant asked me what the inguinal triangle was. Euphoric when I got to assist during a HOBS crash call, yet terrified when a man screamed at me during my first cannulation. 

On a more thoughtful note, Horowitz describes sacrificing his personal life on page 27. His lack of presence within his family life during crunch situations is a feeling a medic knows all too well. I think we all come into this career with our eyes wide open, yet missing birthdays, knowing that one of us will get the Christmas Day rota and having to cancel plans at very short notice is something that none of us will be doing with a smile on our face. I mean, even having a reading week during my intercalation felt like the biggest reward. I digress, there is no need for this unpleasant reminder. 

 A bit of a structural rant here….

Page 35 – “Needs always trump wants in mergers and acquisitions” – the same can be said for clinical commissioning. 

Clinical commissioning is the process of deciding what service provisions an area gets. It’s a multifaceted process in which certain things are considered: the needs of the population (e.g the chronic condition management, population characteristics and key areas of health promotion). This means depending on your area, you may not be eligible for certain types of treatment. Adopting a more altruistic mindset, the needs of the population outweigh the wants of the certain individuals. If we discuss any ethical theory here, we may find ourselves thinking about healthcare as a negative right; there is no obligation of service provision to an individual. The recent merger of NHS Health Education and NHS Digital into NHS England was a visionary (!) change, aimed to “reduce duplication” and use national data more effectively for processes such as commissioning. This structural reshuffle is nothing but a stark reminder that our holistic approach is prevalent at a micro-level, but is reduced to numbers from a governing perspective. 

Jumping to page 65 – Horowitz described a “fair” way to lay employees off. That’s a task I never want to be endowed with. Continuing with the tenuous links – there is a major comment to be made about fair treatment for employees within medicine. The word “fair” is loaded, and there’s a lot to unpack here. A major issue to highlight is the need for pay restoration for Junior Doctors. Since 2008, Jr Drs have had a 26% pay cut, yet the department of health and social care refuse to engage in this conversation, leading to the 72 hr walkout on March 13^th. The 77% turnout and 98% support for the walkout comes with the aim to reform review processes so that pay can be recommended independently and fairly to safeguard both the recruitment and retention of junior doctors. The GMC estimates 4% (approximately 5000) doctors permanently leave the NHS every year – be that for private organisations – where there’s the promise of free coffee or to a completely different country. Is it the lack of flexible working, staying on call until later stages of employment or the lack of mentoring that has caused this? Food for thought. 

To be transparent, I’ve only got halfway through the book, yet the excitement to write the chaotic thoughts that it brought out of me was too much not to submit and article this month. 

Perhaps there’s a part two in the works?

I think if anything, this highlights that every work sector deals with the same fundamental issues, however, it seems the barriers in a government owned organisation shackle us tighter than in other fields. It’s time to look elsewhere for the answers to our problems… widen the horizons from the medic mindset and explore different models of work, whether this be from the tech sector or the trading floor.

Katie Webb, Year 3

A recent court decision has stated that the public have no legal right to camp on Dartmoor. What does this mean and how has it come about?

The 1985 Dartmoor Commons Act was assumed to give legal provision for people to wild camp on Dartmoor (Dartmoor Commons Act, 1985). Wild camping is camping outside of a designated campsite and is typically done by hikers on multi day hikes. The act gives the public the right of access for the purpose of “open air recreation.” It was widely accepted that wild camping would come under this.

However, Alexander Darwall, a wealthy hedge fund manager who owns 4000 acres of Dartmoor challenged this interpretation in the High Court. His lawyers argued that the access rights did not extend to people sleeping in a tent. The Dartmoor National Park Authority (DNPA) tried to defend the right to wild camp, by stating that it was not on the list of explicitly banned activities, and that plenty of other types of allowed recreation, such as star-gazing, would require the use of a tent. However, the High Court judge found in Darwall’s favour and this ruling banned wild camping across the whole of Dartmoor (Horton, 2023).

Currently the only place anyone can legally wild camp is Scotland, as the 2003 Land Reform Act guarantees this right, with guidance set out in the Scottish Outdoor Access Code (Land Reform (Scotland) Act, 2003). However, the rest of the UK does not provide the public with the same access rights. In fact, the Right to Roam campaign, an organisation advocating for greater access to nature, found that 92% of England and Wales is off limits to the public even to walk across, let alone camp (Right to Roam, no date). 

Previously, Dartmoor provided a small oasis of greater access, allowing countless people to spend magical nights under the stars. The well-regarded Ten Tors Challenge, an organised event where 4000 young people summit ten tors in a 35, 45 or 55 mile route across two days, has wild camping as an integral aspect. 

Following the court decision, the DNPA hastily negotiated an agreement with landowners to give the public assumed consent to camp on some of their land (DNPA, 2023). This involves the public being able to wild camp on certain (but considerably smaller) areas on Dartmoor, in exchange for a fee, likely paid by the already stretched finances of DNPA. While the DNPA deserves commendation for attempting to find a solution, it is crucial to note that a permissive agreement to wild camp, rather than the previously assumed right, and could be retracted by landowners at a later date. In short, it is far more limited than the right the public was assumed to previously have.

There was a public show of support for the right to wild camp following the ruling, with the issue gaining attention in national newspapers. The Right to Roam organised a peaceful protest walk and spiritual ceremony on Stall moor on Saturday 21^st January, which was attended by approximately 3000 people (Stallard and Marshall, 2023).

The DNPA has also recently announced that they will be seeking permission to appeal the ruling, on the basis that the judge’s decision may be flawed as it was based on a very narrow definition of recreation (Horton, 2023). While the appeal may give supporters of wild camping hope, the subjective and somewhat ambiguous current bylaws highlight the need for access rights to be enshrined in national acts of parliament if we want these rights to be extended and safeguarded. 

Local Leeds North MP, Alex Sobel, was an early Labour voice on the matter, promising that Labour would expand the right to roam (Sobel, 2023). This was followed up with Labour’s shadow Environment secretary, Jim McMahon to state that there needed to be “a rethink” of access to land and waterways, as “access to nature is a matter of social justice.” He went on to declare that if Labour came to office, they would pass a right to roam law, as well as enshrine the right to wild camp on Dartmoor if the DNPA’s appeal is unsuccessful (Horton, 2023). 

It now feels that we are at somewhat of a crossroads. On one hand, the recent court ruling feels a regressive step that is reducing our access to nature. On the other, this may provide the anger needed to galvanise a nation to demand better access rights and change the way we think about laws of land ownership.

References:

Dartmoor Commons Act 1985. (c.37). [Online]. London: The Stationary Office. [Accessed 28/01/23). Available from: https://www.dartmoorcommonerscouncil.org.uk/data/uploads/254.pdf

Dartmoor National Park Authority, 2023. Agreement reached following wild camping discussions. News Release. [Online]. [Accessed 24/01/23]. Available from: https://us12.campaign-archive.com/?u=21b2c661e1dffa9d75479d410&id=7ef3a3e074

Horton, H., 2023. Right to wild camp in England lost in Dartmoor court case. The Guardian. [Online]. 13^th January. [Accessed 14/01/23]. Available from: https://www.theguardian.com/environment/2023/jan/13/dartmoor-estate-landowner-alexander-darwall-court-case-right-to-camp

Horton, H., 2023. Dartmoor park launches attempt to appeal against wild camping ruling. The Guardian. [Online]. 27^th January. [Accessed 28/01/23]. Available from: https://www.theguardian.com/environment/2023/jan/27/dartmoor-national-park-wild-camping-seeks-permission-appeal

Horton, H., 2023. Labur government would pass right to roam act and reverse Dartmoor ban. The Guardian. [Online]. 27^th January. [Accessed 28/01/23]. Available from: https://www.theguardian.com/environment/2023/jan/27/labour-government-would-pass-right-to-roam-act-and-reverse-dartmoor-ban

Land Reform (Scotland) Act 2003 asp 2. (c. 1). [Online]. [Accessed 28/01/23]. Available from: https://www.legislation.gov.uk/asp/2003/2/pdfs/asp_20030002_en.pdf

Right to Roam, no date. The context. [Online]. [Accessed 28/01/23]. Available from: https://www.righttoroam.org.uk/#:~:text=In%202000%2C%20the%20Countryside%20%26%20Rights,coastlines)%20without%20fear%20of%20trespassing.

Sobel, A., 2023. Our National Parks should be open to all and access to Dartmoor is integral to that. Labour will expand the […]. [Twitter]. 13^th January. [Accessed 28^th January]. Available from: https://twitter.com/alexsobel/status/1613861455992074247
Stallard, E., and Marshall, C., 2023. Dartmoor protesters march over right to wild camp. BBC News. [Online]. 21^st January. [Accessed 28/01/23]. Available from: https://www.bbc.co.uk/news/science-environment-64270310

Elizabeth Ratcliffe, Year 3

Leeds graduate, David Henry Lewis, is best remembered as the Kiwi adventurer who sailed the world, and yet his 2002 obituary hints at his other life as a doctor who was integral in the establishment of the NHS. Lewis was born in England but raised in New Zealand and Rarotonga; he was educated in a Polynesian school and firmly identified as a New Zealander. Described as “short, sturdy and tough” Lewis was well-suited to skiing and mountaineering but committed to a medical career instead and he arrived in Leeds in 1938 to complete his education. He also served as a medical officer in a paratroop regiment during World War Two. 

Lewis’ sailing career started in 1960, when the breakdown of his first marriage (he was an unashamed lifelong womaniser) reignited the ‘adventurer bug’ in him and he competed in the first solo trans-Atlantic race and came third. He briefly returned to medicine in the UK, however for Lewis, an unusual doctor with a sometimes-bizarre bedside manner (he was known to examine patients only in his swimming trunks) it was unsurprising that his NHS career was short-lived. In 1964 he took his second wife and two young daughters and completed the first circumnavigation of the globe in a multihull ‘Rehu Moana’. He then sought to learn traditional Polynesian navigation techniques from Micronesian sailors – responding to their questions of why in his mild but tenacious manner: “My name is David Lewis, I come from the village of London in the island of England, and I have come to sit at the feet of your wise men and learn how to find my way across the sea”. But even that adventure wasn’t enough, Lewis went on to capsize alone in the Antarctic, establish the Oceanic Research Foundation, extinguish an onboard fire and survive a crew mutiny. 

Alongside Lewis’ sailing celebrity, in his brief career as a doctor he played an important part in the foundation of the NHS. Although the National Health Service Act of 1946 pledged to provide a family doctor for the entire population, Aneurin Bevin had failed to persuade GPs that universal healthcare was important enough to sacrifice their independent (and often very lucrative) private practices. Therefore, the foundation and 1948 introduction of the NHS was reliant on support from a few key GPs whose action forced those resistant to comply. Approximately ninety percent of patients had signed up to those doctors willing to enter the scheme within the first month, leaving behind a crumbling system of private healthcare. David Henry Lewis was one of the few doctors willing to risk the security of their careers on the NHS. Lewis’ support was unsurprising given his political beliefs: he was a communist who vehemently opposed political systems with bureaucracy that failed the poor (Putt, 2002). Although Lewis’ legacy is not one of individual medical innovation or genius, the NHS was the result of a social revolution and brave systemic change that introduced the first universal healthcare system in the world. And the gamble Lewis took paid off, the 1948 mortality index showed a twenty percent decline compared to 1938 (which had the lowest standardised mortality of any year pre-WW2) and a drastic improvement in public health was seen; the NHS altered medical practice immeasurably and imbedded itself in the sociocultural psyche of the UK. 

Described by fellow adventurer Dick Smith as a “wonderfully fantastic scallywag” Lewis recorded his adventures in 12 successful books and shared his love for the ocean and traditional navigation with thousands. He sailed well into his eighties, even after losing his eyesight, and after he died in 2002 his ashes were scattered in his beloved Pacific ocean. Although Lewis is well remembered as a sailor, adventurer and anthropologist, his contribution to the pioneering work of the infant NHS should not be forgotten as its impact is immeasurable. 

Sailing well into his eighties, even after losing his eyesight, Lewis is only well remembered as a sailor, adventurer, and anthropologist despite his contribution to the pioneering work of an infant NHS being possibly just as, if not more, impactful.

References:

Putt, C. 2002. The sailor who set out to see it all. [Online]. [Accessed 13 January 2023]. Available from: https://www.smh.com.au/national/the-sailor-who-set-out-to-see-it-all-20021116-gdftrz.html 

Rivett, G. 2019. 1948-1957: Establishing the National Health Service. [Online]. [Accessed 13 January 2023]. Available from: https://www.nuffieldtrust.org.uk/chapter/1948-1957-establishing-the-national-health-service 

Thompson, M. 2017. The NHS and the public: a historical perspective. [Online]. [Accessed 13 January 2023]. Available from: https://www.kingsfund.org.uk/blog/2017/10/nhs-and-public-historical-perspective 

Ministry of Health. 1950. Public Health in 1948: Remarkable Statistics: the first months of the Nation Health Service. [Online]. Ministry of Health. [Accessed 13 January 2023]. Available from: https://cdm21047.contentdm.oclc.org/digital/collection/tav/id/1116 

Holly Dobbing, Year 3

Vanity. A word that often springs to mind when cosmetic procedures are considered. People assume she wanted breast implants to impress someone. People suspect he wanted a nose job to feel more attractive. People guess they wanted a face-lift to look younger. 

In this article I will explore the other side tocosmetic procedures. The hidden side. The side that people often fail to consider. The side where cosmetic procedures are driven not by vanity or pride or conceit, but by desperation and insecurity and fear. I propose a question: are cosmetic procedures truly cosmetic if they have such an intrinsic link to patients’ mental health and have a direct impact on their psychological well being? 

Surgery to alter appearance, from nose-jobs to boob-jobs and everything in between, is still surrounded by so much stigma. I know if someone states they have had cosmetic surgery, certain ideas and stereotypes enter our minds. I believe many people continue to view cosmetic surgery with a hidden condescension towards patients who have undergone these procedures. In fact, you need to look no further than magazines and tabloids that ‘out’ celebrities who have had cosmetic surgery, as though it were some sort of shameful secret. 

Let’s also consider procedures such as breast reduction surgery. Breast reduction surgery is often undertaken to help patients who are unhappy with the weight, shape or size of their breasts (NHS, 2022). Often, patients have to pay for this surgery privately because it is viewed as cosmetic if the sole purpose of surgery is to alter appearance. Rarely, the NHS fund the surgery, but only if the patient meets stringent criteria and is experiencing various other side effects due to having very large breasts, such as backache, shoulder or neck pain, or rashes and skin infections underneath the breasts (NHS, 2022). Whilst they do acknowledge mental health issues and depression due to appearance is a significant health reason to want this surgery, this alone is not enough for a referral (NHS 2022). I was also told by a GP whilst I was on placement that even if the patients meet the criteria for referral, they are often rejected anyway. According to the NHS website, breast reduction surgery costs £6,500, however this is likely far more when consultations, pre-operative assessments, medications and after-care are factored in (NHS, 2019). This is a huge financial burden to people who are potentially already struggling with their mental health due to a reduced self-image and significant insecurities. This further illustrates the systemic prejudice we take against people who want these procedures.

Another ‘cosmetic’ issue I want to discuss is that of purchasing wigs. From male-pattern baldness, to alopecia, chemotherapy and an endless list of conditions that may cause baldness, patients in England are expected to buy wigs either from the NHS or private retailers. The NHS fund wigs for a number of specific conditions, as long as a consultant dermatologist requests it, so patients can buy them for the cost of a normal prescription. However, these wigs are standard wigs, with limited choice of colours and styles, and a limited standard of quality. I appreciate with the fundamental funding problems that underpin the functioning of the NHS, we must limit the number, quality or cost contribution made for each wig, however it still feels as though we do not acknowledge that these wigs may be the only thing that helps that patient feel confident enough to still leave the house every day. Physical health and mental health should be of equal importance to us as they often have equally significant effects on the patient’s wellbeing. Allowing the systemic prejudice of aesthetics and cosmetics to impact the mental health of our patients is unacceptable.

But why do we think this way when we take such liberal views on other topics? Is it a strange cultural phenomenon? Perhaps we cling to the idea that physical beauty is something one must be born with. However, beauty is not skin deep, and nor is the impact that cosmetic procedures have on the lives of the patients remotely superficial. Evidence shows that cosmetic surgery has a significant effect on self-confidence and self-image (Motakef et al., 2014). Likely, this is because the surgery addresses deeper personal and psychological issues, rather than purely aesthetics. Therefore, if we stop viewing cosmetics as purely aesthetic procedures, and acknowledge the impact these insecurities may have on our patients’ wellbeing, we may be able to treat patients in a more holistic and understanding way. I believe cosmetic surgery is not a vain venture – it is a huge step for many people towards a happier and healthier life.

References:

Motakef, Saba M.D.; Motakef, Sahar M.A.; Chung, Michael T. M.D.; Ingargiola, Michael J. M.D.; Rodriguez-Feliz, Jose M.D.. The Cosmetic Surgery Stigma: An American Cultural Phenomenon?. Plastic and Reconstructive Surgery 134(5):p 854e-855e, November 2014. | DOI: 10.1097/PRS.0000000000000604

NHS. Breast Reduction (female). 2019. Online. Accessed https://www.nhs.uk/conditions/cosmetic-procedures/cosmetic-surgery/breast-reduction-female/ 31^st January 2023.

NHS. Breast Reduction on the NHS. 2022. Online. Accessed https://www.nhs.uk/conditions/breast-reduction-on-the-nhs/ 31^st January 2023.

NHS. Advice and pathway for the supply of NHS funded Wigs. 2020. Online. Accessed https://www.kirkleesccg.nhs.uk/resources/individual-funding-requests/advice-and-pathway-for-the-supply-of-nhs-funded-wigs/ 31^st January 2023. 

Holly Dobbing, year 3

According to the Department of Health and Social Care (on the UK government website), surrogacy is ‘when a woman carries a baby for someone who is unable to conceive or carry a child themselves’ (Department of Health and Social Care, 2021). Surrogacy is often seen as a ‘treatment’ for couples who are unable to conceive, or as an alternative to adoption; actually, it is much more than this. Surrogacy brings a wealth of complex ethical issues, largely relating to autonomy: the surrogate mother’s right to choose.

On signing the contract, the surrogate mother signs over her rights to the control of her own body over to the commissioning couple (Dodds and Jones, 1989). The mother agrees not to smoke, drink or take drugs for the entirety of her pregnancy, as well as to commit herself to any and all medical appointments, including abiding by all decisions of the doctors regarding treatment (Dodds and Jones, 1989). She also must undergo amniocentesis (testing of the amniotic fluid in the womb (NHS, 2022)) and is obliged to abort the foetus if the commissioning couple desire her to do so given the results of the test (Dodds and Jones, 1989). This illustrates the complete powerlessness the surrogate mother has in making any autonomous decisions with regards to her pregnancy. 

Furthermore, the surrogate mother must agree to give up the child prior to insemination (Dodds and Jones, 1989). This means she must agree to this before she even experiences pregnancy and the deep emotional attachment she may develop with the unborn child. How can a woman give fully informed consent when she does not yet know how she will feel about such an act? Therefore, is it ethical to legally hold her to a contract she signed without informed consent? 

In addition, surrogate mothers are of a lower socioeconomic class in comparison to the commissioning couple (Dodds and Jones, 1989). This means women may turn to surrogacy to provide for themselves and/or their other children when they would not otherwise do so. This also opens a doorway for financial coercion and exploitation of surrogate mothers. 

One solution could be to implement a board of people to counsel and discuss with the potential surrogate mother her options prior to signing of the contract. They could also assess her motivations and the key influences on her decision-making. This may mitigate against exploitation of the potential surrogate and ensure that her decision is as fully informed as possible. This would reduce the risk of surrogate mothers being unduly influenced and coerced into a decision they are not comfortable with. 

Alternatively, surrogate contracts could include an escape clause, to allow the surrogate mother more autonomy over the outcome of the pregnancy. This would allow surrogate mothers the freedom to abort the foetus if they felt necessary, or to keep the child if they felt giving the child up would cause them significant harm, with no repercussions from the commissioning couple. This would give surrogate mothers far greater autonomy to choose what is best for them and their health and wellbeing without fear of being sued. However, given the child may be genetically related to one or both of the commissioning couple (Dodds and Jones, 1989), this calls into question the likelihood of a custody case in which the commissioning parents may sue the surrogate mother for custody of the child. This further generates trauma and suffering for those involved, including the child. 

In one particular article investigating the ethics of surrogacy, Dodds and Jones conclude that in the current cultural, economic and social situation, regardless of any solutions or changes implemented, the only ethical outcome is for surrogacy contracts to be illegal (Dodds and Jones, 1989). They argue that surrogacy contracts have little regard to the child, and commodify both the women and children involved (Dodds and Jones, 1989). However others, such as Kim Kardashian who reportedly had two of her four children via surrogate, say it’s the ‘best thing’ (Worldwide Surrogacy Specialists, 2018). What do you think? Is surrogacy a violation of ethics, or an altruistic act of bringing life into the world? 

References:

2018. Celebrity Surrogacy: Kim Kardashian. Worldwide Surrogacy Specialists LLC [Online]. Available from: https://www.worldwidesurrogacy.org/blog/celebrity-surrogacy-kim-kardashian [Accessed 28th December 2022].

2021. The surrogacy pathway: surrogacy and the legal process for intended parents and surrogates in England and Wales [Online]. Department of Health and Social Care. Available: https://www.gov.uk/government/publications/having-a-child-through-surrogacy/the-surrogacy-pathway-surrogacy-and-the-legal-process-for-intended-parents-and-surrogates-in-england-and-wales#:~:text=Surrogacy%20is%20when%20a%20woman,or%20carry%20a%20child%20themselves. [Accessed 28th December 2022].

DODDS, S. & JONES, K. 1989. Surrogacy and autonomy. Bioethics, 3, 1-17.NHS. 2022. Amniocentesis [Online]. Available: https://www.nhs.uk/conditions/amniocentesis/ [Accessed 28th December 2022].