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BLACK BAG Journal ofthe Medical Faculty of Bristol

U

vercity

SPRING T988 Editor Elizabethc'ordor Assistant

Edito6

Michael Forsrer

Andriw Piotrowicz Business

Matragq

Tracey Gillies

C.rtoo[e

Bob Baker

Typesettirg YorkHou6eTtpographic Pritrted

All

by

GPS Pritrtets

eofltributio,ls ote v,vlcoma ahd should be s.nt to

Edito\ Blach Bag, Dotthin HoLte' Bistol Roral htfimary, Bisol2, The

Editorial Contents Medical Admissiong

by Dr. Jonathan Mus$ave ..,..,...........,....' 2 Revieiol Spot ....,..,.,.,....,.........'..'....'....... 5 Liveg ia Our Tired Halds

by Dave Burgnerand John dePury .......'...' 6 Malrwatcher Competitioa Time

it appe3rs tha! no newsprper publication can be co$idered complcte vtithout devoting al least half of its pages to medicsl matters of one kind or anothe!. In this edilion we heve included a couple of issues recently hiShlightedr th€ excessive hours So far thrs yesr,

...........'....,....'....'.........

9

Explodng Ethice

by JulianHughes

........,...........'..........'.. l0

Comments

by Dr Gabriel I-aszlo

Nigel Leste!

I$aac Nyamekye ...............'.........'..,....'.' 14 Children at Risk

by Mark Herbert ....'....'....""""""""""' 16 Impressiors of Poland

by Andrew Piouowicz Developnertal Screeniag of House Officerc

by Dr. Juliao Shield .....'.........,..'....'..""' 20

rvorked by iunior docron, end the hody debarcd

D.vid

Alton Bill. Many of you must hold 8!ron8 views on these subiects, so pleas€ s€nd us your comments! Also discuss€d arc the methods employed in the seleclion of Bristol medical students,aid th€ need for the iruoducrion of an ethics course into the curriculum.

On a lighler nok, Msnvratcher hrs been keeping a vcry clo6e eye on recent happenings, and we continue our s€riea on rcvision exercises for lourth years. We

hope thet you will fitld this spot as us€ful tis thc last.

Fitraly, there is only one more edition for this academic year, so if you are interested in helping next yer!, atrd would like to 6nd out how this notorious and highly controversial periodicel is nurturcd, do get in

touch!

MEDICAL ADMISSIONS When faced with over one tlousand hopefitl applications tfuough U.C.C.A. each year, how does the Medical Admissions Committee go about making is selections? IIere, Dr. Jonathan Musgrae explains.

As on all controveNial subjects, each ofus has at some

time felt that we could make a much better job of selection than the members of Lhe Medical Admissioos Committee. As one of them, therefore, I welcome this opportunity to explain how we go about it.

Procedures vary g,idely from school to school. At some the Dean is clos€ly involved- At Bristol we are unique in having a tripartite Fafllty of Medicirc

divided into Schools of Medicin€, Dentistry and Veterinary Medicbe. As a resdr $e Deatr of Medicitr€ is a very busy person atrd coDteDt to leave selectiotr to the Medical. Dental and Veterinary Ad.nissions Commitlee.

The Medical Adrnissions Committee, chaired by th€ Clinical Dean, comprises 14 nembers (8 dinical ad 6 pre-clinical), of whom the Pre-C:linical Dean and the Clinical Deans at Southmead and Frenchay are exomcio members. We meet at 9,00 a.m. each altemate Vedn€sday thmughout th€ AutwllIl and Spring Teims to discuss UCCA forms. We spend a iflher s€vm whole days 3 belore Christmas;4 alrelTards inrerviewiDg about 550 applicatrts. Becaus€ of the aumb€r of applicatioff we receive - 1,230 in 198G87 - we are

further sub-divided into pain conprising one clinical and one pre-clinical member, whose iob ii is to read and discuss their forhighdy quota of applicatioos.

On each interview day we are t€amed with a different member. Thus tle UCCA form of esch successfi. applicant will have been squtiDised by at l€ast four members of the AdmissioDs Committee and, in many

cases, discussed by rhe whole CommitteeApplicams are inrerviewed if rhey bave at leasr 5 or 6 gade A pass€s at O level, 3 grade B passes at A leyel, an Upper Second class horcurs degr€e or other qualfic-a-

tions of a compamble standard. Their inrerests and achievements atrd a coddetrtial reference are also talen itrto consideratiotr. It may seem udair to parents ard teachers of late developers that admissioo to medicine should depend on so matry high O level grades, but, as Professor Peter Richards of St Mary's has wrirren, "academic achrevemmr srill carries rhe

greatest weight in selecting candidares fron rheir UCCA form. The seat ma,ority ofapplica scall€d to interview are acadenically strong, and it is thetr rbat their p€nonal characteristics decide on the ourcome."t Applicants with rather morc Bs than As at O level rc€d not abatrdon hope. If they ar€ Feparcd to defer applying until their A l€vel grad€s are klown succ€ss m:y be within their grasp if drcy have achieved at least BBB. What I have wyitten so far applies mainly to young applicants stil aft€trding schools in tle UK- Altlolrgh, quite righdy, they folm th€ largest group, ir should

not be forgotten tbat tie itrt ke of 128 in October 1987 also i.trcluded 7 eraduates, 7 former prcmedical studetrts, and ll oveNeas students who 6nd it dilfcult to utrdertake their training ir their home country.

The admission of a few graduates and premeds, we feel, hebs to widen even furrher the educational backgrourd from which our students are drawn. over the years we have aalnitted, among otlers, hospital laboratory t€chdciaN, physiotherapists, nurs€s, deDtists, Eercbatrt banleG, utr 'enity atrd polycchnic lectulers, a speech therapist, a Falklatrds War veteran, a polic€mrn, a solicitor, a polyglot interpreter, a \0RAC major, a RAF education ofncer, a fumiture salesman, a balet daicer, an airlirc pilot, a nun and sevenl priests.

Betseen them they h"ve gaiDed an impressive range of drstirocdons, pries and int€rcalated degr€es. Such people cenainly make small group teaching very much more stimulating. They also do much to foster cohesion aDd boost morale among the younger members of their y€ar. Bristols medical admissions policy is far from

Conu-ary ro popular b€Iief we do trol reslrict our choice to applicatrts who pur Brisrol 6rsr. Our rask is ro attr'act the b€st aod nor inftequendy we offer a place ro

someotre who has placed us low otr bis or her list.

Ne€dl€ss to say any@e who has placed us 6fth and who rcally wishes Io go to, say, Edinburgh is ulikely to be lured away. Nevertheless some priority should be give[ to aoyoDe who bas itrdicar€d a $rorg prefercNe for Bristol. For this reason we do try to see those who place us flst, or second to Oxbddge, oo one of the

eady interview dats. N€xt year UCCA pmpos€s to simplify matters by insEuctitrg applicqtrts to indicate deir 6rsr choice rith an asterisk. leaving the renainilg four utr]:anked. Itr due course ranking may be dropped altogcther. It will be interesting to see how thes€ chsnges affed both caodidates atrd sel€cton e.like.

This brirys us to the interview its€lf. Bristol us€d not to interview. Why hold rhem? How should the be cotrducted? How lory should they be? Should irtervi€wem rceive any forhal tlaidtrg?

Is it realistic or d€simble to aim for unifomiry of conte$ ald epproach? Vhar qualities are being sought?

Seven of the 29 UK m€dical schools do not usually ifterview promising applicatrrs. They believe that gr€ater obiectivity catr be achieved by applying a

F€determined raroking syst€m to each applicadoD. It can be argued tbat rhis procedue is no fairer ro each candialat€ than €xposue to humatr s€lectors all roo

of their falibiliry atrd of rheir obltation to ignorc their owtr prciudices. I can appreciate bodr argumetrts. I owe my PhD to a Cambddge colege f,,hich awarded me a Colege Ressrch Studentship without an itrtereiew in themid-60s-anidealistic age because it too had res€rvations about theml Today I share rhe aware

maiority view that too much is at stake ro admit people to a very long strd expensiv€ - f100,000 - course erithout lookiry at th€ object of so large ao irvestdent Inv;ting pronising appucar s lo aa irterview also gives rh€m an opportutrity to see a pa4icular school fo! themselv€s aDd discuss it with the group of students who show them mund.r If itrtervi€ws are to be held it is only right that dose who conduc! thern should think carcfi.rlly about, for i$taDce, rvho should be invited ad for how lotrg.

There is no shortage of applicants who, on paper at least, s€etr well qualified to attact our s€rious aft€trtion. There is also a limit to the number of days rhar ir r

is reasomble to take aheady busy selectors away from their trormal duti€s. To date we have r€sisted rhe

temptation to restrid tbe number of p€ople interviewed because of the difficulty of agreeing upon criteria for narrowing the shordist even fufther.

Our iftefliew load is high - for hr:mane reasons it is aot easy to acbieve aI we should like in the time available. illost i$ewiewees arc yourg and we \pish to attract Ether thatr repel. How€ver selecrors of mtratns to lol1g professional cowses ar€ responsible ro botb the University snd rhe profession in quesrion.

In my opiniotr, htefliews should be long enough ro enable both panies to: (i) exchange stress-reducing and

civilities; and (n) to d;scuss mough contentious ropical issues for the iftervi€w€rs ro iudge rhe ability of each caddidate to presenr a clhereot case and stand up against gende but plobiry 6re.

What qualities at€ w€ s€eking itr applicarts? We will alr€ady bave notd or the UCCA form: ability to cope academicafly; rcsearch into qles of course available;

commitmmt (discussioDs with docto$; perhaps even some work experience); outside iftercsrs and achieveDents; abiliry lo get on well wirh people (part-rime iob); a charitable disposition (volu ary work); and a srnighdorward personality assessment (Conidential

statem t). It is u[ealisdc to draw up dgid lists ofthe qualities r€quir€d of lie ideal futurc doctor, €specially when he or she may be ody iust 17. They will include tho6€ tpotr which oth€I authorities have laid such sress:

Plz.zlft'. EXPREAA 31 BERKELEY SQUARE

(oPP. GEORGES BOOKSHOP) CLIFTON, BRISTOL. TELEPHONE 260300 OPEN EVERY DAY 1 i.3O A.M. TO MIDNIGHT FOR FiNE PIZZAS

(i) "commimrcnt, persevsuce, detsmination, idtiative, oiginality, and conc€m for others";4 (n) 'the ability ro comrtunicate verbally and in writitg' a wi[_ ingness to accept rcsponsibility, pstieDce and common_ sense";s and (iii) "a sens€ of wel b€ing, responsibility, self-cotrtol, toleraffe, achievement, Durturance' aflliadon, atrd defererce".6 It is si$ficant that boti Westall (s€e above) end Richards stress tle ability to communicate: "most medical posls require the ability to commuoicate with ar to care for people and the training itself cenainly requires the ability to communicate."T I agree $uillingness to commu-nicate is atr im€parabl€ part of'commilmenl'. \vi$ l-hal in mind I pay particular attention ro any relevant comments itr the Cotfidential statemenr. Each of us is familirr with such comments as: "she is taciturD rath€r than shy and does not put herself forward"; or "X has no dimculty in communicating orally, but would not .egrrlarly do so voluntarily". On the other hand, how could snyone fail to be impressed

by Y, "a quiet girl who nevenheless communicates wcll with people and has an easy pleasant mannei'; or Z, "a warm, friendly, confidmt person who commun; cares fluendy and relates very ersily to others"?

The wise selector mus! of course leam to tak€ a balanced view of heads' reports. On the one hand, he

or

she should give due weight

to the opinion of

someone who hss been able to folm an assessment ofan

applicant over a longer period. Oo the other hand,

account has to be taken of personality dashes, and of the seemingty udair advalrtaeE of those fortunate

pupils

over-€trdoer'ed

with ple:sitrg

quafities.

Moreover many applicants, allegedly shy and diffident in class, chafter away happily at iDterview. All of us too have to be otr our glard agai.nst ov€rlooking a kiDdly thinking intoven h a crowd of noisy extrovens.

Much more could be l,ritrm, Welcohe chatrges of artitude duitrg the past twenty yea$ have contributed to the increased intake of vtomen. Today they s€em to have an easier passage to medical school. The 1986-87

figures reveal that, anroog tb€ ordinary applicants al least: (i) we received fewer spplications ftom women (383 to 401)i (ii) more of them received offers (104 to 68); and (iii) started $e cou$e 169 to 411. There is no evidence that they ar€ bett€r qualified academically:

"Bristol analysed their 1982 candidates' A levels and found no siglifca[t difference of academic performance betq,een the sexes."3 The ssme is uue six years leter. There is however one imponant dilfereDce: girls are more socirlly assued at l7y, than boys and handle the fireside chat part of ary ioterviev much more competendy. "Many of the subdeans said how much easier and ftore pleesant it was to interview girls."g Perhaps, in aD attempt to be fairer to their less assured classmates, we should pay rather morc ettention to A's thoughtful attitudes to buming issues of the day and a litde less to bubbly B's experiences as a budding waitressl Readers' views oD the matter would tr very welcome.

l.

S.. Richeds (1987).

S* T.blc I i! Haeki$ (1983).

3. For funhd di*u$io! of de <lifi.rins vi.ws on th. v.lu. of iltcNi.v5 w Hleki$ (1983) dd tb. R.pon ot tb. C.ncnl

2.

3k3,b

36o*

Mdiql

Council confcEncc on tbc S.l.ction of M.dical Studdts bcld on 22nd Februsy 1979.

4. Richa& (19E7).

5.

7.

8.

9.

w.lron (1985) Richsds (19E7).

Hawkirr (1983).

Hawkins (1983).

AclnowletEents ncniew of lttedical ft5tslologt, 13/E Wllldn t OorE !9 witls 5p6dncolyid trE<Icd slrrdsdr n'5 bi€d odlliorj ol lh s lodft€ i6* p|q,1ci6 o dEb€, LplodolE lmmry ol phlsloloqy 636t!E4s 6aap.g€. ltat .2135

nnEblosl:

ashdycuide

Mobtl

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bio.lsniihY ond fid€olor bblo€r/

rdoi€d D rEd.re,,rE k:lBl dllq n tu<,6 try (lo@6i. bbctsifiy, ad th€ nbl4ld dd cdl blikrgy c, hol]]rlre a3a+3619-2 720Fo!s 1'!7 a2adl

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ttuftry €l ol

\4fir6 io plo4b ghcFb6

*letior. Vodd lvledrcin u,Jue 11,1983).

Rjclatd,P. 1987 . lanitg M.lliitu 198a. 4th edn. Ijldor: British Hawkins, R. 1981. Soutrding our studflr

Mcdical Affirtiorof fut@ docto6: disos Waltotr, H.J, 1987, PeMr.lity sion parer- Joumal of rhe Royal ssiety of lledicitr€ 8r, 27_30.

Ilarpet's Blochemishy, 21/E R.

Refererc€s Gcmml Mediel Coucil- 1979. ReFn of rhe Crnf..cra on the Seleciion oflvtcdisl Studmc h.ld on Februdy 22, 1979,

2iE

Wlllo|n t GononC A Cdrlcdrio sftr.t 4*re rq 116/r, <, Me 83(+7aaa-O zaFoC€. l9t? lt/UO

I should like to thatrk Dr Coles, Dr Schofield, Dr Kelly end Mr Jooes for their very h€lpfii suggestions.

HP2 4RG, Ensland

Vesr,ll, v.G. 1987, It@ b othn edn. r-trdon: Chapm dd Hall

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M.dnal Scrool 2ttd

REVISION SPOT

II

Welcome back to the page devoted entirely to ttre luckless fourttr yean who are being drawn towards the high speed circular saw of Part I Finals. Our spot on alaesthetics seemed to generare sufficieut interest, we felt, to justi& auother feature on a different subject. Tha[k you to rle second years who sent ln answeas.

This time we are considering two subjecrs: Surgery and Psychiatry. Ve thought ir mighr be useful ro send a question flom a recent palrr in each subiect to local emineDt cliniciats, so that those revising can get a feel for a "model answer", Unfomrnately, due to clerical error, the two questions were rruddled up and sent to the wrong p€ople- Nevertleless, you may find the replies to be of some use:

Psychiatry. Aug 1987.

Surgery. Aug 1987.

Narne

Narne

15 year old girl is broughr ro you by her parents with a story suggestive of anorexia nervosa. Oudine your management.

A 65 yerr old matr is broueht to the casualty d€pr. scre€ming in agony, clurching his abdomeD. puls€ 150.

B.P 2510, aad blood gushitrg froE €very ori6ce. you

A

Or,s

susp€ct ruptuied aortic aneurysm. Oudine your

tt€L gowN

Afr?le-@

immediate mrnrgFmenr.

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(trf qW ftr,ur)

O?ztficr.r ro Prs( 0(( *?to S7O? r{rs.rrl{q ruY?fMf

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&cl <,4* e-<st,r- 4., {It Lr r.Bl q.r; ad,- d q^ t.rns o^.} h {^r &t.il* er$v Ers.. .l^,r J^n* . -rL.d:1 i9&ti*4 {^ t

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$\,.t .dL .s$ \ ..&y <r;ru.!a 93e,-a ocirjr draJ5 '!. {!.+ c. rr"{rr/ !-J[ .$ct-.J&rca 11..,-.. . . . (I think that shoutd

be sumcient.

. . . Ed)

LIVES IN OUR TIRED HANDS is apparent that many working practices may be cotrsiderably different in the N H S seems unlikely, howiver, that tle emotive issue of Junior Doctors'hours is one which

ofthe 1990s' will be easily resolved. Hele taoe Burgner and John de Pury ansiderihe case fo! reducing tle workload of Judor

It It

over long hours on duty, atrd the consequent drfficul_

As the chronic underfunding of the NHS and the governm€nCs singular leck of a convincing response to the crisis heve finally surfaced in the media, some

irl leading a "nomal life". These findings are echoed locally; e questionnaire 6urvey of JHDS in the ties

ettention has also been focused on the pressures faced

by NHS staff. As house officers, clinical students, and SHOS we have all seen (or will shordy see) the urgent need for an improvement itl the {'orking conditions of junior hospital doctorc (JHDS), both to stop patients' lives being put at rbk and to limit fie personal toll od the doctors themselves, In other professions (such as airline pilots aDd lrarD drivers), $'here excessive hours may abo €ndanger the lives not only of the professional but also of the people entrusted inro their care, there is a legal maximum of dury hours. This is not the case for JHDS; while airLine pilots are not allowed to work more than a hundftd hours per month, some JHDS arc contra€ted !o work this time in six dals. JHDS work an average of eightv-

five houn per week and may continue to work well over one hundred hours a week. For those of us who choose to remain in hospital medicine these hours

will

rppty for the eleven years posl-regrstrrtion lraining necessary (on average) before a consultant grade is These dangerous and intolerable working conditions

are detrimental to patient carc and to doctors themselves: the sleep deprilation and exhaustion faced by JHDS quickly results in an incr€asing impairment of mental agility, reaction time, shon term memory and other pschological parameters necessary to perform

ir

a busy hospital environment. In one the declining mental performatrce of iunior experiment during a seventy-two hour weekend shift was doctors adequately

l

€quivalent to twenti to thirty yea$ mtural ageing Not surprisingly petients suffer as a result; they ere treated or operated on inaPpropriately or unnecess_

ofdrug) are given, aDd lhere is a higher complication rate following operations and procedures carried out late at night. In short, patients'lives are being put at risk. srily. The wrong drugs (or the wrong

doses

But ir is nor only the patientswho suffer: JHDS have

s suicide rate thrce times the nstional average; they have one of the highest rates of marital discord in the population; and they are some of society'$ heaviest abus€rs of drugs aad alcohol. Morale amongsl JHDS,

with many ofter health service workers, b understandably low. A recent report comrnissioned by the DHSS ftom the Policy Studies Institute (an indep€nas

dent think-tanl) questioned srx hundred iunior doctoft over a two year pedod about their working conditions and hopes for the future.' The findings revealed widesFead pessimism and disenchantment, mainly due ro poor career prospects and frusuaLion

South West rcgion revealed that "many . ' showed cynicism and bitterness about the medical esteblishment and the lack of sympathy with the problems of sheer overwork experienced by iunior doctors "3 The working conditions facing maay JHDs are far from beidg e new problem; indeed it is often suggested that the maiority of JHDS work under what has been described as "a Victorian defnition of professionalism" - th€ system has not changed fundamentally since rhe days of apprenticeships. Attempts to limit the hours worked by JHDS both by the DHSS and by the medical profession itself have usually been, at trest, half-hearted. In 1982 rhe DHSS 'requesred' that all rotas should be reduced lo a 'one in three' or less by August 1983. At the same time district 'hours ofwork' working panies were set up to review rotas and to recommend changes, provided that tiese remained

withh the heal.l authoriti€s' medical personnel budget Most of these working panies, which consisted ofequal numbers of iunior docto$ and consultants rogettrer wirh representatives of NHS managemenl have since stopped me€ting. In spite of alother DHSS circular to the same effect, Do itritiative eith€r fiom the governm€nt or from the Fofession itself has Ied to any real improvement in JHDS'workhg conditions. Yet ihere is a growing body of opinion boih withiD the profession itsel! and within the pubLic at large that legislation should be introduced lo signiicandy reduce doctors'

hours, as has been successfully achieved in New Zealand. Such an apFoach is unpopular with Govern. ment, management and some consultants. why is it rhet these parries are so unwilling to see JHDS' hours reduced?

There are t\x,o broed classes of argument advanced against a reduclion in JHDS' hour6. The first is "the Professional": long hours are iustified as being necess_ ary for training and for gaining experience. Yet 6urely, even apert from the question ofendengering Patients, a 'tired doctor is not in a position to be receptive to ideas and experience. A mole in$idious argumen! insists that rhe introduction of a more norma.l working w€€k would undermine professional commitm€nt and produce "clock watchrng" doctors, as if enthusiasm for patient care, moral€ and professionalism were enhanced rather than debilibted by exhaustion. The introduction of a rational working practice would be dillcult witlout signficanL changes in the medic.al hierarchyr in parLicular, the inEoductron of a more 7%xible practice including cross cover Io lighen the load on luniors in the hard-pressed specialities (such as paediatrics,

sugery or csrdiac care), the inEoduction of a day olf aft€r a night on ce[, heving e Iudior on call tilt 9 p.m. to cov€r a busy period, but off for the rest of the night, strd shift work (which bas akeady beeo successiJly intmduced in Accidelt aod Emergetrcy departmcnrs).

Ircvitsbly, siDce JHDS might work for two or thr€e frms ir a given week, this would lead to borizo$al rather thaa vertical alegiaffes, atrd thus rcduce th€ power of the consultant over hcr or his frm. Not surprishcly tlete is opposition to flexibte, rational work practice i$ som€ of the more senior ratrks of the medical professiotr.

Secondly, there is the argumert over the fnaoctat

consequenc4s of a clurEe in curreBt work prrctice.

JHDS are, on average, paid leis &a[ 50", of their basic rate for ov€r-time worked, so tlat over the cours€ of a week maly house officers will eam less than €2 hour. This guarante€s that ir costs less !o employ orre doctor for eighty houis thaa two for forty hours each.

Furthermore JHDS ar€ forced !o work €xc€ssive hours becaus€ of inadequate stafnng levels and because of

Fr

insufdcient fu-nding for the provision oflocum cover.

The Medical Practitioners Udon (MPU) is a Union for docton and medical srudents which js a pmfessionally independeri s€ction of the Associatior of Scie} tmc, Technical and Managerial staff (ASTMS). It was tbe first Trade Udon for doctoN ev€r to be estabtished.

The MPU has be€n very sctive in publicisiq rhe dang€rously long hou$ which iunior docto$ arc oblised ro work. MPU policy for JHDS is for im.me-

diate lcaislstion ro limit the hou$ of registrars a.trd iutior doctoE to a sratutory seve y-two bour week.

This would be achi€ved by a rc-oryadsatiotr of stalfon the bssis of oexible working practices (as outlined eerlier). Following this itririal change there should b€ a fi[ther phased reductioo to a statutory sirity hour week, over tle next ten years, This \pould requir€ atr incr€ase in the number ofdoctors, the emount dependiDg on the ratio of coDsultants to tLe expsnded junior sts.fr. Utrfortumtely, the Govem$mt's only idtiative iD rlis afte brs be€n to propos€ . reduction in medicsl studedt ntrrnbers; a rnore strongly oppos€d by ttre MPU but, i$erestingly eDougb, trot by the BMA. So, ifyou c.I€ about your own future, that of your patients, and of th€ NHS, and would like to 6nd out morE abour MPUrs bouls caDpaign atrd its otier activities, contacr rhe local MPU studetrt coorditralor, Steve Chuch (tel Bistol 541502) atrd com€ to th€ rcxt Bri$of MPU neeting on the 7th March where the

natioDal MPU s€crEtarywi[ be speakiag. @lease check details with Steve Chuch.) You have nothing to los€ but rhe bags uder your ey€s!

I! Acrol GnEdr Tdsirim. 16th NNdb.r 1987 fi.Ss&, An6. l3ah De@b€r 1987 BMs{d, K..Ny dd Robst!. BMJ tfth Novobcr 1987 Vodd

%' {

7z>

\r, t4" -:

l,/

r(

DID FAR AS Cll'I SEg , LONC' HOTJRS N€V€R ANYON€ ANY HARM '

I

TheArmvoffers medical stutients much more than just E6,376ayear.

If you are a student, male or female, at a British medical school, you could be eligible for a Cadetship with the Royal Army Medical Corps.

You'll need to have passed your second MB or equivalent. And you'll be required to attend an Army selection board.

But you'll get 16,376 to continue your medical studies in the first year. This in creases each year thereafter

When you become Fully Registered, to prepare you for your flrst aPpointment as a Regimental Medical Offrcer, we will send you on an introductory course which lasts about four months.

This course includes training

at

Sand

hurst, training in administration and field medical organisation at the RAMC Tiaining Centre and in the various aspects of Military Medicine at the Royal Army Medical College at Millbark.

Then, it's six years in the Army, starting with the rank of Captain.

By converting to a Regular Commission you can, of course, stay longet until you're 60 if you wish.

As a doctor in the Army your Practice will be much the same as a good civilian one: fully equipped and professionally staffed.

You could be working in a grouP Practice or on your own; though yodll be entirely respon sible for your own patients, be they soldiers or their families,rather like abusy G.P But don't think that, because you're in the Army, your chances for study will be in any way limited.

Thc

Ame ,l Fhds an Equal

Ollan

niE

While still in clinical training, a number of selected cadets may, with the approval of their Dea.n, undertake elective atta.hments

at Military

Medical Units

in

Germany,

Cyprus. Hong Kong. NePal or USA Ard you'll have the same oPportunities as in civilian life for your post-graduate training in General Practice, Community and Occupational Medicine or one of the Hospital Specia.lities.

But a doctor's life in the Army doesn't stop there. As an officer, you'll be able to take advantage of a very wide range of sporting facilities.

You'll almost certainly travel abroad, and your social life will be busy too. Many of those you meet and work with will become lifelong friends.

Finally, should you decide to leave the Army on comPletion of your Short Service engagement we will give you a very useful tax-liee gratuity.

How much depends on the length of your initial Cadetship and the amount spent by the Army on your medical training. Regular and Special Regular Commissions are pensionable.

For further details please contact Major General (Retd.) R. N. Evans CB FFARCS' Dept. 0750, Royal Army Medical College' Millbank, London SWI 4RJ. He'll send you our brochure, 'Doctor in the Armyiarrd arrange ar interview

S nnrncofficer

EnlW^, nd6

the

tt6

of ile Ro@ R.tatia6 Act 1976

MAN\TATCHER Irt

us return with MANwaTcrrR to the contagious festivities Michaelmas rerm past.

tiat

reigtred towards the end of the

The Preclinical Review san' tlose frolicking 6rst y€ars' Lhanffuly less eructatious of late. keetr to captivate expectant audi€Dces. Although in tle Foverbi"l dark with regard to the rules of the oft r€ferred to spon of

cals ofrce suite; surely indisp€nsibl€ for a man cont; luaily "on t-he iob". MANVATCFER sees less merit.

"popping 6lst year cheni€s

Bar. One hopes rec€trt rumours ftat the now blank wall is sootr to be adomed with porrlairs of "key" Galedcals

itr

Stoke Bishop',

M,INWATCrfiR rras mOSt impressed by the aaditional Epicurean Spirit so prominent throughout.

Tbe Clbcial Review proved a much more notorious alfair. As is their wont, some ofthe fourth year Recbabite brisade flomced hither and thither b€aring tidinss of great woe, atrd waming a[ arcutrd that B€elzebub himself brd surely penned the script. With petitioDs circu.ladns, and the Kingsdown air hevy with talt of sabotage and boycott, r4ANwATcrsR found the preceding weeks alnost as €ntertaining as the thoroughly waggish show itsef.

however, in the eflacement of those historic balloons which formerly grac€d the walls in the Dolphin House

cobmittee membe$, past

ard

present, prove

uDfounded.

FiDally, iiANwArcsER congratulaEs

Richard

Bra$oa and his virgin empire on extending their influence to the murky realds of the Medical School roilers- Orc can bllt speculate on the date of mstalladon of a llrther "Mates" machine in tle D.H.B. linen cupboard, whffe it is r€aly Deeded.

As the fifth years b€gEn to retum to fair Bristol, lunchtirhe talk s'as of elective tales of sun, satrd, and parasitic infestation. M€anwhile, wih rheir 6lst day rt work a mere eighty w€eks away, the fourrh years have become predictably impassiorcd about house omcer posrs. With l€vels ofcotrsffvative neuroticism reaching comical new p€aks, the Glenicals' Presidetrt found himself only ooe step shon of being publidy dismember€d by "his peopl€", after the moot€d introduction of a change the dates for iob applicatioos-

in

M-ANwArcrcR will watch avidly, confdent that oui founh year Dob can generale more rumonr, suspicion and paratroia tha[ tbat other 1988 tob lottery, the Americatr Presidential El€ctiotr.

To matteft less painfi . The Victoria Rooms hosted this year's Careers Fait. With muted admirEtion we

listmed to that rernarkabl€ female surgeon and mus€d on tales of her apparent ability to conceive at will, atrd then give birfi between theatre sessions. Heart felr sympathies are extend€d to the lone vmereoloSist who stoically mamed aII unvisited statrd, while droves of drooling lech€m queued to ogl€ the ever-scfai eaiden adornins the Deighboudtrg Rh€umatology display.

MrlNwarcnnR congxatulates those responsible for the recent acqrisition of the sumptuous rcw s€tdes in the Medical school common room. Now perhapG thos€ garrulous frst y€ars cao confle to coffee breaks their discussioDs of matErs ug€trt. Fr€e from such tawdry talk as to whether Daddy will buy o$e a fat in Clifto&

or jusr Redlaad, Iie library ca! bop€fuly regaitr its previously peacetul air.

I-ookijrg ah€ad, the futule of D.H.B. catr be viewed with optimism. Presidmt "Boss Man" Sperm Jones has appareDtly persuaded his subs€rvient midoDs of the exp€dieDcy of r.dical measures $rch as the Purchas€ of a telephone arsweriDg macbine for the Galeni-

Competition Time Folowiry the overwh€lmiry respons€ to our lasl competitioo, Brart Ad8 now offers eveo more e.rLicing prizes. As {,ell as a botde of bubbly and a tour of the

Bla.k Bag offrce suite, the lucky \rrinner of dfs editiotr's competitio! wil also receive a rare copy of the recip€ for that most volatile of dishes, the "Black Bag Yindaloo". All you bave to do is:

l.

Provide a suitable message to be taped for the new Gal€Dicals' answerpboDe (20 words maximum. please).

2. SuggEst ways of giyitrg D.H.B. a radical new look, to ssil her smoothly into the 190s.

A{swe.s to the Editor, Dolphin House bar.

EXPLORING ETHICS At present, tle Curriculum Comnittee is seliously considering the introduction ofan ethics course to the studeff timetable - Julitn Hughes explains how such a course could benefit us all, and shou.ld not be taken lightly.

I Medical ethics is essential. ffir is superfcial it is a geat loss. Some polemic here may serve a purpos€.

2 There has been a quier rcvolution in fie feld of medical etlfcs. Bristol, chiefly by rhe activities of the Bri$ol Medical Group, has not been backwards in $ese ms[ers: the B.M.G. is holding a conlerence ir the ne.ar future on m€dical erhics.r Anyone knowitrg abour this conlerence who has nor, ar least, given ir serious coDsideration probably shorld not qualifyl 3 Just receDdy I came across a perfecdy ordinary,

with reality,

everyday, medic:.l dil€mma. A man was admitred very

But how in the face of a "stotrg, genuine, and varying views" could tlere possibly be a cons€nsus?

ill

with

extensive pleuEl eflirsions, s€condary to knovrn cancer of the lung. It was clear rhat he would shordy die. He was trot oyerdy in pain nor disrressed.

Little was to be dore, but the iunior doctor rais€d the quesLion of morphiDe. The trurses were encouraging.

Now the point is not whether you rhink this is righr orrFrong not here at atly mte - bur rhar in the absence of bdicarors for morphine rhe only possible pu rpose in giving n was to eod rtre parient's life. lr was nor ,usr a forseeable consequence: ir was fte iftentiotr. Alld knowinglv. witb premedirarion, to kill aD iDnocenr human beirog is, I thiDk, muder4 Nov,/, of course, ].ou may obiecr that under these circumstances it did nor amount to murder. But ttre point is (herc) that ir mighr well have be€n murder.

This decision, was withort doubr, the most importalr de(i.ion ro be made by that iunior docror rhar evedng.

It was a decision for which ihe doctor, in five years of mining, had received tro proper pr€pararioD. 5 Medical erhics is uavoidable. But discussions ltr medical etlics are often supertrcial. We may srare our views and listen to the opposing vie*s of others: this sort of civilised exchange is mexnr to be b€rcficial. No doubt there is some betrefrr in ir- Being able ro accept

if

a process as suffici€trt, however, is only possible we hold the belief that ethical views are subt'ective, rhat

such

is, melely maners of taste.

I prefer btackcurre jam with its udque sharpness aDd becars€ I love the fe€l of blackcuFanrs bursting between my tongue and patate. You prefer ttre mushy sensation and swe€hess of strawberry iam. WelI, bur arc ethical beliefs iust like ,iar? Would thousaDds of

citiens lobby parliament to baa the mushing of

son ofconsensus has es€rged according

people die for their belieG or lan8lish in concentraiion

camps?)

The deputy editor of the BMJ rccently wmte: "Abortion is : conplex medical :trd moral issue and many doctors hold stmng, geouirc, and varying views on

should

ir.

. . TwetrtyyearsaiiertheAboltiollAcr

not ihe

profession have reached a

For all sides believe their views to be rru?: Lhis is nor l.ike stmwbenies v€nus blackcurrenrs. And it is unconfortable to cor$ider, ifone hankeN after cons€nsus, that iforc side is speakitrg the tmth, rhe orher side is damtrably lying.

7 There is a way to avoid unpl€a$nhess and rlar is ro plump for 'situation dhics'. Sir Douglas Black, whose eminence iD medicirc is itrdispurable, has beetr a stesdfast advocare of 'sifi.lation erhics' for some time. Its main tenet he has stated in t\e Jounal ofMednal Ethiu (lME) is 'every case has to bc considered on its merits'.r The problem with rhis view is that it leads to

cotrtadiction which retrders

it

nodsensical. For

instarce, although Sir Dougirs is against absolutes and

pr€-ordaiftd rules he giyes plenry ofexamples of rules which he applies (e.g. 'I wor d not mys€lf abet suicide') and even ofabsolutes (e.g. 'I believe rhar at the end of the roqd rhere are thitrgs which tro docaor should do).4 Even in 'situatiotr ethics' it is a narural incliDation to achieve consistercy as a gerequisite of ratioMlity. Of cou6e 'every case has to b€ considered on its merits'. bur tbsr do€s not preclude rhe operarion of rules or absolutes. wlat is rhe altematiye bur molat anarchy?

8 A G.P. frieod ofmiae, oow workiDg towards a higrher degree, was very €rcit€d $sr be hed fitraly alier years ofpractice beetr taqht medical ethics. He said he had rcver previously heard of the difference berweetr utilitarial and deonrological er]ics. I am sure ir is a good Lhing to know rhe disrircrion. But nedicii elhics is nor ,rrr, like leaming a ftw vocabulary so tiar ou.r exprcs,

sio! of oul prejudices sornds more erudite. Nobody

sligtrdy rotten stra$berries?

6 This, then, is one say itr which medical €thics is

would sugg€st, for instarce, rhat leaming that rrar sori

superfcial. Medical ethics is predicrably abour 'real

dermatology.

9 I am makiry the poitrt that medical erhics is essential,

problems'. To prevaricate atrd insisr rhar we set aside real problems to discNs obiectivity in erhics seems

t0

a

to ehich ethiel beliefs are tust beliefs. (But don't

of

rash

is 'maculo-papular' is ail thar there is

ro

'academic'- by which we mean 'servitrg no rudl

unavoidable, bua ftay be superfcial. Say tbat I go to a lecture oo physiology aDd larer have a discussioD in a

purpos€'. In the medical wodd, rhar, which has ro deal

tutorial gmup

o! phFiotogy ad 6naly a(end a half

day confercnce on aspects of ph]siology. Does thar equip ne to etrter a hospiral and unde$tatrd rhere all the rcal phsiology? We[ ir might do, but actualy yorr have to go drough two years ofphysiologjr l€ctures and tutodals before you are allowed into the hospiral. lrith less

or perhaps no erposure, bow€ver. you calr go hto a

hospital atrd decide to kill someone Fith morphine.

10 Medical ethics, not mere 'matters of eriquette' (s€e last Blach Bas\, is a deep subject. For what is irs r timate aim but to iCetrtiS actions which are righr or wrong? And the performrnce (or avoidasce) or $rch actions will establish our goodness or badness. We may

t[en, by reflectiog oo what is a distincdy good or bad humatr act atrd to do tiat we may have to have ro begin,

it js ao be a good human being. The question, 'what sort of creatures are we?' leads to the realms of philosophy of mind and of religion. ANwers to such questions may involve thought about the nature of language which distitrguish€s humaDs ad char"cterises or circur$cribes our utrderstatrding or the wodd. A[ of this before we have el.etr aplxoach€d the specfic questions of, say, whether to tamper wiih the embryo. ff Ethics is also a higlly practical affair. For we cannot comider what

udenak€ the busin€ss oftrying to underscand *hat it is to be a good human being, what it is to Aourish as a human being, wilbour ar fte same riEe developing our capacities. Pady we develop precis€ly that capacity of bunan dourishitrC whicb we s€ek to €lucidare, agaitr stressing that this study, by its mture, musr b€ deep.

Of course, we can act as good human beings without studyiry efiics, but that our activities arc good acrio$ camot be uncridcally takeo for gatrled. The point here is that this critical evaluatiotr, if profouDd alld nor superfrcial,

{'ill

itself de€pen us.

12 Slot erhics ioro rle course, then, bet*eeD alatomy and biochemisrry? Perhaps rhar would do more barm than good. No, the real change is radical. A degae€ cours€ for iBtaDce, i! which rbe preclinical sciences w€te rehitded down to essetrrials, wirhout rhe plerhora ofinformatioa soon forgotten a]ld not required again, inregat€d with a course iD lie srudy of rtre wider aspects of hJmaoity. Such a study must be philoso-

phicxl but mieh include historical, social, potiricrl, teligious and even economic aspects. And would it Dor

be que€r

if

students coaiDg ro be doctors were nor

intercsted atrd commifted ro rhis study?

For our study ofhuma! beings: we seek ro und€rstand, to work \rith, to affect, ro change hman b€iqs and we ourselves are humatr. Hence we begin and end wirh utrderstatrditra and krcwledge of ours€lves.

Philomphers are fond of quoting Eliot q'hose words seem opposite h€re roo: 'Ve sbrll not ceas€ from exploratiotr Atrd the end ofall our €xplorilg 'Will be to arrive vrhere we sta{ed Atrd ktrow the place for the 6rst time."

T.S. F.Ltor, L;ttla C'idins

I B.M,G. Dr

Su€

2

B,lLt

3

J.M.E.

olB

on

D.diel edics Friday 28th Mdch. Apply to

Doeliry ai Ceylse HsI

sln.

l3lh Feboaly

1988 1984, 10: 179-182

4 J-M.E, 1984,

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COMMENTS Black Bag etcovages written comment on published articles and other contentious issuc's. Here we print some readers' views on points raised in the last edition-

Beneficial Aspects of Smoking Francis Roe's humorous articlc (Bla.l Bdg, Autumn 1987) should not be taken too seriously. He is probably fed up with his self-appointed position as lhe only toxicologist in Britein who is supposed not !o be to egainst tob.cco. As I am watcbcd continuou$ly by the

ASHr, HECI, OOMPAPA+ and $cverrl other orgaDisations, I am obliaed to offer a brief counter-

Hands Up All Those Who Have Heard Of The Dawson Report "That thz hospnah

haoe

fallcn on

ail

dqs * hnoun to

'Dawson R€port', 1920, para, 82

agEnts of

bla$t, I shall probably be elimineted if I fail to reach the

Editor's deedline.

Careful readers E'ill have rctic€d that the article contains a nusber of subde pieces of gamesmanship.

L The Thatcher-Kitrtrock ploy (use of statistics as a dog uses a lamp-post - for conveni€Dce rether than

i[umiration).

2. The Redgrave gambit (use ofthe word middle class as a

3.

rerm of abuse).

The Ilwis Carm endgrme (illustraling your neaning with a melmuous but totally incomple-

hensible piece of doggerel)Roe 6nds much Dastier things ilan tobacco iD his toxicological woodshed. He is agai$t nuclear waste and uncontoled asb€stos. Ve could add acid rain, rive$ of mercuy, fr€on ihe strEtosph€re. Being dighdy less against tobacc,o is not the same as being

Dr

h

for it.

You can stil obtaitr Dany drugs that rot your liver atrd zap your finger Dails. 'Opren' was banned not iust because it sometim€s did those things but b€caus€ its purveyors rcfus€d to admir ia time tlat it might, Th€re pmbably is a place for a herbal s€dative with mildly addictive prcperti€s which caus€s catanh, emphysema, lung cancer, coronary discase, stomach ulcers and grangrene as wel ss respiEtory silnetrts in other people. If the m.nufactuers of thfu remedy will not keep the date sheet in front ofprospective buyers, the dishonest end inscnsitive health education lobby has to do this for them.

Dt. Gabrbl Laszlo 1 Acrjon on

Smkinr dd Helth

Hc.trh Eduetion Coucil (!ow Autbdiry) + Orsuietio! for Mcdi6 fo. thc PeF.tio! ol Abelut ly Purc

t

rwilliam Ree$-Mogg writirg to the Indz?endnt ('lues, 9th Feb. 1988) on the daqer of clich6s and simplisric imagery distorrirg the complexity of ruth, makes alr

importsnt but uoderemphasised poitrt: "The trurh about Lhe National Health Service is thar i( is oversEetched ald sholr of money. The lie is thar all thar is needed to rcstore the service is for rhe Treasury lo provid€ amther billion poutrds, or two bilion pounds, to top up th€ fi]ndhg." In the same papcr, rhat day's 'health crisis' stories are as folows: "Clhic offen hospital cssh itr NHS pay M deal", "Chariry cash helps recruil extra nurs€s". Gsh, cash, cash . . .

In l9l9 Sir Beruatrd Dawson, later Lord Dawson of PenII, became chairman ofrhe Consuftative Council on M€dicql and Alied Sereices. This body was set the task ofpmducing a repon (although the evennul documetrt

to be an interim repon) under the following terms of rcfermce: "To consider atrd nake recommenilations as to the scheine or schemes requisite for the systemised Fovision ofsuch forms of medical atrd allid s€rvices as should, in rhe opinioD of was only htetrded

lhe CouDcil, be available for the inhabiranis of a given

a&a." Without becoming bogged down in hisrorical detail. ir is enough ro say ltut this was a visionary document that has remained in0uential (Thoug! ir was, at the time of publicatioD, quiedy shelved.)

It remains infuetrtial bccause it was controv€Isiali

"Preventiv€ atd cuativc medicine cannot be separated on any souad principlc, atd in any scherne of medicd services must be brought together i! close co-

ordination." The celtrel fcatue was the concept of the 'Primary Heslth Gntre', insritutions "equipped for services of curstive aDd preveltiva medicine to be conducted by the Seneral practitioncrc of lhat district, in coniuoction with an efrcietrt Du$ing service and with the aid of visiti[g cotrsultatrts aDd sp€cielists." It envisaged the burdeD of the ho6pitals b€iDg ersed by effectively co-ordiMted communiry health servicesi "Domiciliary nursing is an €sseorial pan of a health seIvice." Th€ documeDt psys scatrt allention to questions of fundinS bur how irs proposals frmly rooted itr ideology and redical rhinkirg.

So, iD our pr€sent clinat€ of cash crisis and cash

clich6s, why mmtioD a documenr bom of an

14

age

Is the "Scheme" working? dedicated to creating a land 6t for heroes? The poliiical climate may have changed atrd th€ report's empbasis on such ideas as 'pbysical cultue' msy s€€m ourmoded itr the extleme urder pr€sat improv€d stendards of living, but it do€s still addr€ss the complexity oftruth.

Everywbele itr the curretrt debate we s€€ the simplistic images. We see p€ople taking sides. We read emotive and seltiDeDtal argumedt. We hear clich€s. '!?e await the decisions e govemment bas€d on ahe balancing of books.

The visions of the Da\[6on Report may have hed little impact on the realitie6 of the National Hcelth Selvice thet succe€ded it twenty-eigh! yeers leter, bui ils attempt to widen understanding of service and stendards in a heahh system can still be appreciat€d.

Will this bold exaFple ever be followed? Or will the debare remain centered on babies with holes itr the heen and budgets wilh holes ell over the place? Hands up all fiose rvho bav€ heard of the Dawso! Repon?

Nisel Lestzr

When applying for prercgistratio! house jobs lasr year, I presum€d, rather naively, that fair play ]pould be universsl itr the "Bristol Scheme". Sadly however, this was trot to be. C,otrtact betwe€n studeDts and consult3trts was often made prior to interviews, and quite oftetr utrfair or even chauvinistic tectics were employed to obtain posirions.

These practices appeer to be a perennial (perianal?!

-

Ed.) problem. A fe{, years rgo this nratter

was

discussed by the Galenicals committee in some detail,

atrd ,fter reference to the Staff Student Liahon Committ€€, d€a$, consultrnts, and students all crpress€d abhorrmce of thes€ plactices, They suSg€sted tha! Grlenicals should write to ell B stol consultatrt$ end that they should deter students from approaching them. Many agrced on peper and yet jt app€5rs now that practices are worse tlan eve!.

At the very last, ifconsuhalts do decide to allocate their jobs prior to i[telvi€w, it should be made krcwn, so that students do Dot waste one of fteir three appl! catiotrs otr s iob tbar has alresdy been given away.

Many found this particutady frustrsting lasr year.

In its present folm I fe€l that the scheme does not hav€ a place to play itr the s€arch for a job, simply becaus€ it doesn't wo!k. It should b€ scrapped, thus slowi$g individuals to apply for iobs wh€n and where they like. Whilst this should mtke litde differ€nce to for iobs, it will at least drcse whicb Lhe $heme imposes remove the molal obligatiotr otr the rest of lls, and allow everyone to plry the giame!

It s€€ms thar itr tbe r€al world "scbemes" do not exisl, but urderhatrd d€alings and nepotism desrly do.

already

frKfis*r

@,@ l5

CHILDREN AT RISK On l3th and l4th February, the London Medical Group held a conference to discuss rhe many hazards children face in the different societies of today. Here, M arh H erbett, secrerary of the B.M.G. repons on one of the most controversial issues covered.

The 25th I-ondon M€dical croup Conference focused on many asp€cts of 'Cbildrm at Risk'; from children under extreme stress in war zones to those living in acute poverty in developiog countries, to children abused by their parenrs in our modem 'developed'

valued adult, but otr some outdated estimat€ of its capacity to survive if ir were ro be exp€ ed suddenly itrtQ the outside world. A double standard €xish. For i$taDce, a child who6e life could be termitrated at t$enty-four we€ks may have the potential to live, and

societyPossibly, one special form of abuse b the premeditated termination ofthe Me ofa foetus, and because of lhis subiecr's populariry in the rccent media, wirh the David Ahon Bill. ir shall b€ discussed here, ulcorporating some of th€ views of the conference speake$,

yet legally not have the riglt. However, the same ch-ild who is bom prcmanrely can be help€d to survive with the aid of neonatal htetrsive care.

such as Professor David Morley, ryendy Savage, Genld Hughes, Srephcn Wolkind and Dora Black.

A straight-forwerd inrroduction is ro ask "does the unborn child have .igh(s, and if so how are these modined so as not to encroach upon those of the mother, the family, or even the communiry?"

It would seen rhat the foetus does indeed have some rights. It is a living senrient being, thar holds rhe value of one dey becoming aD aduft. The baby in-urero does

not, though, hrve lhe same claims es the adult. For exehple, ahhough often beirg Siven the right to life and health care, it cleerly cannot be allowed to marry.

However, when does the developing child acquire the privilege of righls, and do€s ir procure more as ir gets older? The answers lie in deciding v,hich things have rights; iusr human beings, any living sentienr being, any living orgrnism, or nonliving material obiects? Mayb€ the liae crn be drawn ar living things whi.h respond to stimuli. For example, the butterfly has a right to live. and a morher mighr stop a six yesr old boy from rearing off its win8s. However, does rhe human embryo shortly aft€r cotrception have tie same ability to respondl Thus, does it have a claim on life greater or lesser lhan rhe burrerfly. The argument is

clearly more complex than this- The €mbryo has grearer value because of its porenrial ro become

Ideally, teminalion of pr9gtrstrcy only occurs wheo the dsk to the mother's physical or menral self if the

prcgnancy werc allowed to continue arc greater than if it were stopped, or trcause th€ foetus is so severely rnslformed thar it can oDly lmk forward to a demonstrebly awful life. The crse of the 6ve year old who is quadraplegic, has a proFessive kyphosis, suffers from ftcurrent chesr iDfections, is cortically blind, and knows no life outside a hospital bed may be clear cut. antenrtrl diagnosis could have predicred the quality of this child's life possibly ir would heve been kinder to have ended ihc moiher's pregnancy end ler the baby die. Many suspecied Down Syndrome fo€tuses reech !hi$ end. Corfict exists though, because ir is etgued !ha! th€se Down Synd&rte children can ofrm have very happy and fulflled lives.

Maternal rights musr bc considered in rcleiion ro rhose of the fo€tus. Ce! the pregnancy be allowed ro conlhue if it is goirg lo ruin th€ already $tablished lifc of the motber or her femily? !?hat is the impact of a severely handica$,ed child being boln into a fami.ly

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where the mothct is alteady sEess€d ard ove!burdened looking efte! he! orher cNldren? Is the foetus to be p€rmitted lo live despire hersh economic snd €motioDal deprivation thar may subsequently befall the other children?

a a

human being.

Presumably though, society presenrly assumes that the glowing foctus is nor worrhy of life unril it reaches rweoly-eigbr weeks ofgesrariooal ag€. ar wHch pomt ir is protected by law from anifcial abonion.

Twenty-eight weeks has b€etr chosen as the lowerlimit of the age acquisirion of the righ. lo live be€ause that is, although ourdared, an estimaE of the foerus' abilly al a cenain developmmlai srage ro survive ex. urero. Vi$our rhis ability, rhe lrw do€s not permit il to claim a right to life ilr-urerc. The limir is farcical, nor being Mscd on fte foerus'senlienr qualiLies, oreven ils level of consciousn€ss, nor irs pot€trtial ro be a useful

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The dilemma's of ethics in 'Children at Risk' are matry. Above, I have oudined some of those morat problems that we face conc€rning the foetus, whose right to life, health care, and so on, must be carefully evaluated, so that it can be decided whether these dshts ar€ being violated, and wh€ther the chnd inutero is being abused. A peDultimate thought is "what is the burden of these foetal rights on rhe communily?"

Can we afford up to f100,000 per child for neonatal btensive care, or is ii wrong to even conremplare the child's value and tuture in lerms of money?

V'hat of boderlirc cases in prenatal diasnosis? If the unbom child is recognised as having Turner Syndrome when its chromosomes are studied to exclude Dovvn Slndrome. is $erc case for termitration? If the chitd is going to be infertile, a bit shorter than average, and with a webbed neck are these suffcient grounds to take away this developing baby's right to life?

Foetal child abuse was only one of the several areas ofthe violarion ofrighrs considercd in the 25rh L.M.c. conference, and it is as well to pua rhe discussion of children's moral rights inro perspective. 700lo of rhe world's children live h developing counrries and ofren suffer fiom social depdvarion - receiving only 6010 of the total resouces for heafth care and llol0 fo{ education. Is it corect ro be conremplating the rigrhts of rhe foerus when milions of children die per year ftom lack of availability of food, of oral rehydmrion fluids, or of simple vaccines and ofier health care measurs?

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IMPRESSIONS OF POLAND The clinical attachments offer a valuable opportunity to sample medicine in a variety of settings and even cultures. Here, Andreto Piotrowicz, who has recendy returned from an Obstetrics and Gynaecology attachment in Poland, describes how the Poles cope with their declining health service and crippling economic crisis.

Hardship and austerity have always tended to fost€r a \ense of humour, and nowbere, ir seems is rhis more true than in Polad. At a time when one year was drawing to a close and the next could only promise yet another round of price increases, the Poles were urged !o draw confort from the fact that 1988 would, at least be an average year. Although worse than 1987, it would still be better than '89.

This little gem of wisdom, supplied by a T.V. presenter who, I believe, sdll has his iob, went down well and was often repeated. Few Poles could havc conveyed berler rhe currenr climare of pessimism hangiry over the country, and even to th€ least observant western visitor it is inrnediately obvious that Poland has indeed fallen upon hard times. People do not need to be asked before telling you about the twenty year long waiting list for flat, that the price of a car h equivalent tofive yea$'wages or how much time is wasted searching and queuing for life\ bare necessi-

This situation is trot unique to Poland and neither are the resulting widespread coruption and flourishing blackmarket. No oner however, s€ems mole able in applvmg their talmrs in $ese 6elds ro s€eitg themselves through times of crises than the Poles, a fact which must reassure them far morc than do their witty T-V. presenters.

At no time was this crisis more apparena to me rhan while working in a major hospirai spccialisine in Obstetdcs and Cynaecology. This hospital, despite its impressive array of ultrasound machinesr possessed only one cardiorocograph, acquired by an enterprising Obstetrician fortunate enough to have colleagres in rhe West. Rubber glov€s and catheters, along with orher items considered to be disposable over hete, werc painstakingly rcsterilised and a steady supply of many essential drugs was only possible thanks to rhe benevolence of Western charities. The lifespan, however, of medical equipment is limited, a6 must be rhe resources

ties,let alone its little luxuries.

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of charirable o.gatrisatiotrs, and it is dot difficult to envisage the coDs€quences ofa Daive aod shon-sight€d

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Sovemmenr policy wb.ich regards iDvesrmeDt in rle nation's heahh as wastefii and ecotromicslly uffewardiry. This poticy also go€s far ia explaining why doctors are paid less than trvo thirds the wege of an unskilled manual lebourer, and who, es a result, must

supplement their income by doing extra tetes or demanding unoffrcial !,eymeDts from their patients who in exchange receive swift and pain free Eeatment in s hospital bed. I! such e system, where heshh care wolke$ are so hampered and frustrated by poor working conditions and in whom quslities such as

skill, dedication and professionalism are so undeavalued, the human face of medicine is 6rs! to suffet, followed inevitably by declining standerds of care.

This has rcsulted in claims stating thar health cere would be far betrer offin privatehands, a response ther is both predictable and imnically familiar.

Yet, despite all of rhes€ shorlcomings, Poles can at least claim thar nowhere else behind lhe iron currain does lile seem tess dgid and flee liom tXe conslramts ol party dogma. Streets arc no longer liraered wift red stars or slogans, religion can be practiced freely without recrininations and the press callies anicles

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opeDly debating controversial issues. Poles also 6nd it relatively easy to travel to th€ wesr, and although their lack ofmoney and dubious financial practices have not made them popular guests, it srill rates mor€ high.ly in

their affections than any socialist neighbour. Not surpdsingly, therefore, any cuftural imports come fie same direction. Cinemas show lhe latesr U.K. and U.S. flm releases, aDd a significalr amount ofT.V. air time is devoted to pop videos, game shows and hard-

sellirg advertisiry.

As a result of being fed a diet of travel tales and sell imposed western values Poles have a concept of the west to which they relate very well and regard themselves, slightly ideslisticatly as potenrial equals of ery westem EuropeaD natio!, prevented from achievilg this much sought afte! parity as much by low wsges and atr ircotrvenible currency es by their political

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This form of altemative communism is, in one sense step forwcrd. Ttre adoption, however, ofsuch liberal and democratic relucs is ofdoubtful signficance to the country's rEal Ploblefn. Yet, it is this $ystem of values whicb continuG to b€coEe hore end more progressive a

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