Should unhealthy people be refused emergency organ transplant due to their lifestyle choices? Alice Hewett

Should unhealthy people be refused emergency organ transplant due to their lifestyle choices?

Alice Hewett Lower Sixth

The NHS only has access to a finite number vessel in which the organ will be actually of organs available for transplant in times functioning to rectify one’s livelihood; of need, so it must be questioned whether this is why much of the argument is these valuable resources should only surrounding the relative health of one’s be offered to patients who are arguably body. ‘deserving’ of a A highlighted transplant donation (‘deserving’, here may be referring to one who has kept his or her body in suitable [W]e can’t control a person’s actions after the case in the media was that of George Best, a late footballer. In 2000, his acute liver damage health and hasn’t got a detrimental habit that transplant. due to suspected years of alcohol abuse was led them into needing noted as significant, a transplant). However, under the law that and in 2002 a transplant was performed will come into effect in Spring 2020, we at King’s College Hospital in London (as are now transitioning into an ‘opt-out’ he required admission to hospital, we can donation system (it will be presumed that safely say here that Best was ‘unhealthy’). you wish to donate), in the hope of raising Nigel Heaton (the head surgeon of the the number of organs readily available for aforementioned transplant) told The donation*. With this new law, potentially Guardian newspaper that people who are ‘undeserving’ patients may be in a position likely to re-engage in the activities that to receive a transplant, leading us to this lead them to need a transplant in the first question why those of ‘ill-health’ are worthy place should be strictly screened. In the of receiving life-changing treatment. case of George Best, he did, in fact, reA key element to the integral debate of the fact that we can’t control a person’s whether the ‘unhealthy’ should receive actions after the transplant; thus maybe donations is the specific definition of a loop of transplants could be entered, “unhealthy”. ‘Health’ is defined in the potentially compromising those who are Oxford dictionary as “the condition of a arguably in better ‘health’. This scheme person’s body or mind”; the issue of “mind” may present an issue, is a poor state of mental health a salient factor that should be considered in the face of a donation crisis? If so, perhaps you are a believer of the unhealthy being rejected, would the fact that if someone had schizophrenia (for example) influence the decision made of donating a valuable organ to them rather than to a person of a sound mind but in a similar body condition? In terms of donation, the condition of somebody’s body is what most people consider primarily in terms of health; and as for transplants, it’s the engage in his drinking habit, highlighting

would give an unhealthy person an opportunity, but a second appeal may be considered more seriously, making the affair seem less ludicrous. And one may be inclined to trust the words of such an endowed medical professional, though an NHS medical director (James Neuberger) argued that: “We’re transplanting humans not angels.” This statement touches on the ethical reasoning for organ transplants being available for all, regardless of ‘health’. Purposeful use of the word “angel”, perchance, may focus the attention of the transplant away from the decisions of the donee and towards the aid being offered to a “human” in need. Especially, in this case, we must always remember that because somebody doesn’t live by the means that a healthy person does, it does not entitle them to be completely disregarded from the national healthcare service, and implicitly, society (which George Best was a famous member of).

Since most organ donations being received in the UK are commissioned by the NHS, we must ruminate on the policies that are being adhered to. One of the seven guiding principles for the NHS states: “The NHS provides a comprehensive service, available

George Best

to all”, without specification of lifestyle choices. Consequently, it could then be argued that the refusal to treat a patient with a nocuous habit would be directly contradicting a pivotal decorum in one of the elementary commitments of the NHS. Now let us consider the specific name of the NHS: “National” - a whole nation, “Healthcare” - the provision of medical care to a community, “Service” - the act of helping or doing work for somebody. Within the name of the NHS, the treatment of those in need is guaranteed. In our selfishness, we must not forget that the unhealthy are more than entitled to receiving sufficient treatment, in exactly the same way those of good health are. So maybe the fact that a UK citizen’s taxpaying contributes to the work of the NHS is all that should be taken into account when seeking treatment; including that it could be seen that they are paying additionally for their problem with the taxation in its price. So with this in mind, a further slight from society in the refusal of treatment is incomprehensibly unjust.

Conversely, we may reflect on the utilitarian argument: on acting for “the greatest good for the greatest number.” What may be inferred from this is that by sacrificing a donation for one who has allegedly compromised their own wellbeing may not be administering the greatest benefit to the majority of the population. The prospect of a person in good health receiving a transplant appears more feasibly beneficial to the unified population versus an individual who may very well recommence that destructive habit which landed them in his or her initial predicament. A point of discussion that may relate to this idea is the theme of ‘priority’. If the direct refusal of a transplant for an unhealthy person results in this person’s death is this really an act for the greater good? On the other hand, Linking to this point, in ‘The Nursing if we were to lower respectfully his or her Times’, the argument of “autonomy” is priority in the donor list, an opportunity used; this Greek-derived word is defined as of a replenished lifestyle still may be a ‘the right or condition of self-government’. viable hope for them. In this way, it may be Looking at this example we could infer that better seen as a greater act for the whole there are no rules surrounding prolonged Liability in Organ Donation body (seeing as excessive alcohol intake or smoking those with liver damage from drinking still (for example), hence a restriction on the belong to the population). This compromise grounds of potential future healthcare (as also suggested by Nigel Heaton) would vulnerability could be seen as a breach of not only be beneficial for those who are rights. So to punish somebody for acting ‘unhealthy’ but also those who we may extremely within their own consider higherright should be avoided at all costs, especially by such an essential pillar in British Within the name of the NHS, the priority ‘healthy’ cases, for instance, a youth. society. This argument links treatment of to the previously mentioned promises of the NHS, as we infer from it that as long those in need is guaranteed. This approach could be coupled with an idea as a person is ‘ordinarily proposed by Jeff [a] resident’ in the UK, healthcare can be McMahan in Justice and Liability in Organ received; regardless of ‘bad health’ (that is Donation, a social research experiment. To related to one’s own repeated detrimental adduce one of his ideas, he reflected on the lifestyle choices), reinforcing the rights of concept of “moral liability”. In particular, the ‘unhealthy’. the moral liability of the unhealthy Person A endangering Person B (who, as far as

we can see has made minimal choices to implicate his or her own health) by competing against Person B for a chance of receiving a vital donation due to Person A’s conscious decisions. This theory has a somewhat conservative ground and is widely supported by members of society. However, problems have been detected in its proposal. In particular, problematic areas were highlighted by Daniel Wikler in his paper “Personal and Social Responsibility for Health”, in which some considerable flaws are brought up:

For example, if the NHS has a budget (for one area) of, say, £20,000, this money would then be prioritized for those who are dangerously ill through no fault of their own. Consequently, a pregnant woman may be deprioritized as she was seemingly aware of the dangers of pregnancy before the decision to carry a child. This proposal has some extensively vast implications. A further point Wikler made in his findings was the adversity in calculating to what extent one is accountable for his or her ill-health. There is no ironclad method in place for determining the accountability of people for their actions, and so forth here is the opposing argument against McMahan: with no clear way of fairly determining accountability who are we to act God and decide whether or not a person is worthy of a new shot at what may very well be a new life. Thus, McMahan’s theory could be seen to be incorrect, devaluing the opinion of those who support the theory. Amidst some of the slightly drawn-out philosophical arguments for and against

Dame Clare Marx organ transplantation (for people of illone’s worthiness of donation, allowing health by lifestyle choice), one thing is subsequent decisions to be made regarding being made increasingly apparent: the the entire life of a patient, with minimal urgent escalation in the number of obesityinput from the patient themself. related hospital visits. In August last year, the NHS said (in ‘Good Morning Britain’) A radically opposing view to that of that “the number Michael Buerk is that of of obesityNICE or surgical Dame Clare Marx (the related hospital admissions has increased by experts do not recommend refusal president of the Royal College of Surgeons, from 2014-2017), who explains 15% and cost of treatment that “many patients are the service £16.1 million”. This is an extortionate (including organ transplants). willing to engage and use their resolve to improve their overall health, but sum of money, it can be very difficult and many may argue, all for a cause that to lose weight”. In this interview with may have many effective treatment methods The Guardian, she further discusses why available; in contrast to something like NICE (National Institute for Health and AIDS, let us say. In fact, the journalist Care Excellence) or surgical experts do not Michael Buerk even went as far as to recommend refusal of treatment (including directly address the obese collective (in this organ transplants). With years of specific case), stating that they are “weak, not ill” experience in this sector of healthcare, in an interview with The Times, under the we may surmise that this opinion has headline “Let Fat People Die to Save NHS been molded after witnessing and acting Money”. While there may be people who upon an exhaustive list of both ‘healthy’ agree with this statement, we must consider and ‘unhealthy’ patients. Her humane that despite the fact that (if the obesity view suggests conversations and actions in this example is entirely preventable) between doctor and patient in a slightly it could be seen as a conscious choice to more forgiving environment than that overeat, very few people actually wish to envisioned by Michael Buerk (who is, in remain obese. So, if they’re wishing for the fact, a journalist and not a highly acclaimed circumstances to change, is that an entirely surgeon). conscious decision to remain obese on their behalf? This concept may also be applicable In conclusion, it is a comprehensive and to other ‘unhealthy’ lifestyle choices, such complicated list which encumbers the NHS as smoking or drug abuse. In this way, into the prevailing predicament, and there we revisit the ‘accountability-for-healthare many further arguments and theories scale’, in which undefined rules define for and against organ transplantation for the unhealthy which may (or may not) influence any decisions being made by the health sector. Regrettably, this is an ongoing debate that I see has no easy resolution that would satisfy all toward the near future. Although I am sure many current compromises and decisions are being made by those who have control over such matters (hopefully not journalists), there has been no blanket rule as of yet. Hopefully, those of you with a conscience may realize that a lot more reflection is necessary for deeming a patient unworthy of a new life; even if they’re one kilo over the weight limit.

*Alternatively, you can inform the NHS with your objection to this and you won’t donate. This is hoped to alleviate some part of the problems in the current shortage. In this way, more people should be helped by transplant, hopefully making this argument less critical.

Natural disaster = economic destruction? This was written for the Bank of England blog competition

Freddie Anderson Lower Sixth

The aftermath of Storm Desmond

The effects of natural disaster can be Preparation for such events is imperative, incredibly debilitating for a country, not only in places prone to weather and its economy especially. The damage disasters like the Philippines. In the UK in caused to a country’s infrastructure by, for 2015, Storm Desmond caused an estimated example, a typhoon, can £500 million in damages be huge. A study from The Intergovernmental Storm Desmond across Cumbria due to heavy flooding and this Panel on Climate Change caused an is just one example. In (IPCC) suggests with strong scientific evidence that global warming will estimated £500 million in order to combat these events in the short term, governments continue to increase in damages across must incorporate better the 21st century, causing a rise in sea level and an increase in the number Cumbria due to heavy flooding. warning and defence systems and protocols, for example phased-array and severity of tropical radar technology, which cyclones, to give just one example. Another is used by the military. This can be used study carried out by the Asian Development by meteorologists to detect the intensity Bank on the effect of natural disaster on of storms much faster than the regular the Philippines shows the possible damage caused by such events on an economy. The Philippines are especially prone to typhoons and floods and the intensity of these events is increasing due to climate change. The study shows that spending by families on medicine, education, transport, communication and high nutrient food all decrease by around 25% to 30% following a natural disaster, suggesting a large decrease in standard of living. In terms of economy, many roads, factories, telecommunications and power networks are lost to these disasters, which can lead to negative growth and higher unemployment, sending a country into recession. doppler radar systems used to detect possible weather events.

In the long term the prevention, or at least deceleration, of climate change is a must. In order to do this, governments must look to move towards a carbon neutral economy and society. This will require heavy subsidisation of renewable energy resources and movement away from nonrenewable fossil fuels such as gas and oil. Costa Rica is one of the fastest moving countries towards decarbonisation; their government is working to make the use of fossil fuels obsolete. They are incentivising the consumption of more clean energy goods such as electric cars; they are working on better land management and planting forests. Referring to fossil fuels, the Minister of Environment for Costa Rica said this: ‘We plan to phase them out through new policies and incentives so that eventually, down the road, they will be useless.’

These weather-related disasters will not stop increasing in severity without serious intervention. The idea of ‘creative destruction’ will soon no longer be viable, because soon there will be no time for long term rebuilding of infrastructure. This is not a problem that can be passed into an uncertain future; something must be done now, otherwise there will be no economy, and no planet left to save.

Is the NHS heading into a snowstorm?

Snowflake generation is used to describe millennials who are deemed less resilient over sensitive and overstressed. This, if true, can both have two direct complications onto the NHS from both

the future workforce of the NHS and the future patients. Is the NHS forecast for a snowstorm of snowflake like adults racked with stress related illness?

Firstly despite the fact young adults are interested in discussing politics increasingly (since access to mainstream media spikes more discussion ) are we often more concerned about cultural appropriation of Halloween costumes than the politics of how taxes should be collected and how the NHS should be funded? If so, does the NHS even have a future at all? Would it become so run down and inefficient that privatisation is the only option?

And secondly, more focused throughout, that if this snowflake generation can deal with stress of daily life in a healthy way and if not may result in daunting pressure on the NHS from a rise in stress related ailments. While still the average ratio of successful medicine applications is 1:9 places at universities an executive from the NHS has said that people have an ‘unrealistic expectation of their employer (the NHS)’. Surely those who make it through the rigorous selection process would have a full understanding of the hours and sacrifice it takes to be an NHS staff member. There are concerns that the future workforce is not prepared for a life time dedication of

Elizabeth Church

Lower Sixth Lower Sixth

stressful work and therefore only catalyses the problem of an NHS on the edge. Waiting times in A&E are rising perhaps showing this correlation of too stressed staff proportional to more stress related illness. Of course there is no denial that over worked staff are becoming a crisis (This Is Going to Hurt by Adam Kay is a brilliant reflection of this). Is the issue just going to snowball due to soon to be working millennial adults being unable to deal with pressure, stress and overtime?

Are sick leaves only going to increase with more attention to mental health? Perhaps in the next ten years taking the odd ‘overstressed day’ off will be common and millennials crippling under workrelated stress catastrophes. Already stats have shown NHS vacancies increase by 9.4% from March 2017 to 2018, which undoubtedly strains the NHS who spent £805 million on bank staff between April and June 2018. Sick days are often thought as for when you are physically ill, yet mental illness such as high stress validates sick leave as well. It is right that mental sickness is deemed valid but I think there are certain grey areas, one that need to be further researched and refunded as to what validates mentally being unfit to work. This is something that can only improve with time and funding into mental health awareness yet much like a pain tolerance, mental wellbeing is incredibly individual hence challenging to diagnose.

An example of mental health awareness came when Time magazine published an article this summer on the Dutch concept of Nilsen of where you simply do nothing. While concepts are aimed to help Improve mental health studies have shown that these prolonged times of doing nothing only build up stress for after. Much like mediation this is probably a skill which needs to be practised so that trying to relax is not stressful, which of course sounds counter intuitive. There are even scientific literatures suggests that warn Nilsen can lead the mind to wander and have negative psychological impacts such as PTSD. Often participants studied during and after Nilsen had increased heart rate and trouble falling asleep. What adds to the difficulties of reducing stress is that there are what some deem as ‘wrong’ and ‘right’ ways to relax. As a generational goal stress cannot start to take over our lives as its effects are so damaging to the cyclical nature of an

already stressed NHS. Many critics in the Oxford Press see the snowflake generation as ‘whining rather than acting’ and ‘finding constant cause for offence and victimisation’. While the potentially derogatory word is used and may be a large stereotype it cannot be ignored that stress levels in this generation are massively increasing. Surveys such as on Forth have shown that in a sample of

2,000 people in the UK, 85% of which say and observations, I think there is just a they experience stress on a regular basis, mind-set shift as to victimising those who then a further 54% saying work hard. There are they are concerned about the health implications. While it is of course good [H]umans are physically many, many causes and correlations as to why stress is rising beyond people recognise the health implications of stress, do they really know all the health implications not designed to cope with long term high the healthy amount and why people are starting to suffer more. This does not mean that everyone resultant from it? Is it possible for the future intensity stress. will instantly ‘melt’ under pressure but perhaps (and CEOs and entrepreneurs maybe permanently ) we of our country to be ridden with illness will start to see the corrosive aftermath and disease due to an inability to cope with of stress soon to come. Now we only can stress? prepare for its effects.

A major question is why (or if) stress levels have increased for this snowflake generation, is it merely a widespread lack of motivation, is it due to social media influence, change in diets? The possibilities are unlimited and vary per person. What is often missed however is that stress is contagious. A stressed colleague is almost inevitably affecting those around therefore stress levels can increase exponentially in a workplace. Regardless , a study by Aviva found 72% of 16-24 year olds find the term ‘snowflake’ is unfairly applied perhaps leading me to believe most people are unaware of quite how big the problem has escalated and what it means for businesses such as the NHS. The likelihood is that if you are stressed so are other people which is both comforting and unsettling at the same time. To show the concern imagine if you book a GP appointment then you may think nothing of it yet if the 7.85 million 15-24-year olds in the UK all book a GP appointment then that is a very long waiting time. While I think there is a stress epidemic in the UK, I do not believe that there is a sudden inability to cope with typical work, money, relationship stresses (they have always existed). From reading After recognising that these snowflakes are stressed, how soon will a snowstorm be hitting hospitals? Stress is evolutionary and in some manageable ways useful and causes a waterfall of holistic effects. Hormones such as adrenalin and glucocorticoids are released instantly causing increased heart rate. This happens in most animals yet the metabolisms of animals are not affected by these hormones as dramatically as they are in humans. Blood pressure will automatically increase with prolonged periods of high heart rate which is great for suppling blood to muscles needed to run away from predators but not so great for digestion, growth, reproduction, concentration and sleep problems. It seems that humans are physically not designed to cope with long term high intensity stress.

An angiogram, essentially an X-ray to look at the heart’s coronary arteries, on the NHS costs £1,300 and that is before stents may be needing to be placed, further check-ups or surgeries etc. We have all heard of a typical hardworking business man who is one minute in the office the next in theatre with a quadruple bypass surgery. Imagine more and more of these major operations in addition to many more minor ones such as angiograms and the economic effect of those. Stress-related illnesses are not overnight killers, part of the NHS long term plan is to reduce those with cardiovascular disease in the UK as it is estimated to be the cause of a quarter of all deaths in the UK. Stress is sometimes a missed risk factor while poor diet, lack of exercise and smoking stand on top, yet surely stress only worsens these problems. The NHS spends around £7 billion on CVD a year a figure which is likely to increase on top of the rising £25,000 a minute spent on treating diabetes in England and Wales from poor diet (a very common side effect of stress). Both CVD and diabetes have stress as a serious risk factor. No matter how much money is put into the NHS it is

unsustainable if there will be a tundra of to 10 minute longer breaks, the 56% more more over stressed and unhealthy adults to sick days, the cost of treating NHS staff come. with preventable An estimated 4 /10 CVD are misdiagnosed or the NHS does not have the capability smoking related diseases and the loss in productivity of underdiagnosed, and even the NHS website has admitted that ‘four in ten people treated to withstand the storm of predicted rise in health the workers. While simply helping people to quit smoking is hard enough it may for hypertension do not have their blood pressure implications. be even harder to look more closely at the controlled to target. root of the problem Partly this is because these conditions are which is often stress. How is the NHS usually silent with no symptoms indicating supposed to help those who are stressed if there is a problem or that treatment isn’t the foundations are already uneasy? working. And partly, it is because today’s GP consultations are complex and time If you are stressed, you may: pressured.’ NHS staff are crumbling under • feel overwhelmed increased pressure already. This does not • have racing thoughts or difficulty lay an idyllic path for the doctors of the concentrating future. • be irritable Health risks also increase from high • feel constantly worried, anxious or alcohol intake and increased smoking. scared Smoking for many is an unhealthy way of • feel a lack of self-confidence dealing with stress, and it is not even that • have trouble sleeping or feel tired all people are unaware of the deadly effects the time of smoking. Out of the 1.2 million NHS • avoid things or people you are having staff an estimated 73,000 smoke. The problems with Independent published an article on the • be eating more or less than usual estimated effects of this showing some • drink or smoke more than usual alarming results such as the smoking breaks, although discouraged in the NHS, The solution to the problem is to cost the NHS around £200 million. This find healthy ways to cope with stress figure comes from the more regular and up management not just try to cut around the problems such as cutting out smoking areas. Legislative actions are already the first step into developing an embedded work life social standard. Currently Gov.uk has said 48 hours is a ‘normal’ work week, yet full time doctors are often surpassing this due to failure in efficient hospital systems. ‘Every mind matters’ is the slogan used by the NHS to help with stress management and become more educated in mental health to hope to stop the problems before they intensify. At the current rate the NHS does not have the capability to withstand the storm of predicted rise in health implications. Collectively people need to begin to recognise the problem of their own mental wellbeing before it requires medical attention. Stress management is vital not only for the health and happiness of you personally but also the function of the National Health Service and the UK. If these so called ‘Snowflakes’ become sick with stress the country will be buried deep in snow with no NHS to help dig them out.