Ethical Dilemma of the week. A fifteen year old girl asks for the contraceptive pill.

You are a GP and you see Millie, a fifteen year old who comes alone. She tells you that she would like to go on the pill. What issues does this raise? How would you handle this scenario? Answer

contraceptive-pill 

Millie should be asked why she wants to go on the pill. The pill is often used for other conditions, such as to regulate and control periods and treat acne but it is likely that she is requesting it because she wishes it to be used as a contraceptive.

Using the  4  ethical pillar framework [see P74-79 Medical School Interviews – The Knowledge ]

What does the law say? [Justice]

Millie is fifteen; younger than the age of consent [16yrs]. Her parents are almost certainly her legal guardians. If she is having sex with a man over the age of 18 that man can be accused for child abuse as she is still legally a child. However see the Fraser Ruling below on contraceptive prescribing.

Beneficence – A doctor should always act in the patient’s best interests.

Sex before the age of consent is common in this country and the rate of teenage pregnancies and sexually transmitted diseases in the UK is higher than in any other European country. Millie has shown that she can be responsible by seeing her doctor. It is important for the doctor to establish a good relationship with Millie, to be someone she feels she can trust. Millie is more likely to take the doctor’s advice regarding protecting herself against sexually transmitted disease by using condoms if she feels that she is not misunderstood and patronised. If Millie is going to have sex anyway it would be in her best interest that the risk of pregnancy and sexually transmitted diseases is minimised.

Maleficence [Harm]

There is no evidence that prescribing contraception increases teenage sexual intercourse levels – however this is contentious. Evidence exists to show that good contraceptive access decreases teenage pregnancies. The side effects of the pill are usually minor and serious side effects rare in most girls but risk factors need to be screened for by the doctor.

Autonomy

Under the Gillick Ruling and Fraser Rules if Millie can demonstrate that she understands the risks of sex at such a young age and the risks of treatment with the pill then she has competence and therefore autonomy.  The Fraser rules [see below] state that the doctor should question Millie to see if she has full understanding and try and persuade her to involve her parents. However if she is adamant that she does not want them to know then she has the right to confidentiality. If the doctor feels that there is a strong likelihood of sex occurring any way then he should prescribe her contraception.

Fraser Ruling and Gillick Competence

Mrs Gillick took her Health Authority to court because they were supplying contraceptives to under 16yr olds without informing parents. She had 5 daughters and felt that she had a right to know if they were being prescribed anything.

The case went to the House of Lords. The judges, chaired by Lord Fraser, ruled that if a child was competent and had autonomy then their confidentiality was to be respected [i.e. their parents did not need to be informed] if they fully understood all the risks. The doctor should try to persuade the child to talk to her parents but if the child insisted she did not want to, they did not need to be informed. In the case of contraception the doctor had to feel that there was a strong likelihood of sex occurring anyway. The doctor should always consider the possibility of sexual abuse [which should be always reported].

This case led to the term Fraser Rules and Gillick competence.

A child is ‘Gillick Competent’ if he/she is mature enough to have understanding of what is involved – there is no arbitrary age limit.

 These rules apply to all medical procedures not just contraception and abortions. A ‘Gillick competent’ child can give consent to have a procedure against the wishes of her/his parents and has the right to confidentiality.  (see earlier ethical scenario on  The Jehovah Witness Boy)

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Under Pressure

A and E images 2

Ambulances  waiting outside A and Es which are full of patients waiting to be found beds on already full wards

It has not been a month since Jeremy Hunt and Theresa May rejected comments by the British Red cross that the UK was facing a ‘Humanitarian Crisis’ in health and social care. The Government cut back funds to councils who pay for social care for elderly/frail patients discharged from hospital.  As a result there are delays in discharging patients who are sometimes disparagingly referred to as bed blockers. Bed occupancy is now about 90% on average. A safe level is thought to be 85% .

A nursing home bed costs  between £800 – £1100 a week; an acute hospital bed three times that amount but it comes from the NHS budget.  Hunt and May announced that foreigners should be charged for using the NHS and GPs should open 7 days a week. However scapegoating GPs and foreigners will not make ‘beds appear’. Seriously ill patients still need to be admitted.

 

Extract taken from ‘The Secret Doctor’ Blog  BMA

There were no beds.

I was in resus at 9pm with a young person who had been intubated and ventilated to keep him alive following an overdose. We’d been told the closest bed was forty miles away, but the sister on critical care phoned around the local units and eventually negotiated a bed somewhat closer.

The parents waited anxiously to be told where our NHS could manage to fit their son in, their son who had almost lost his life completely in the last hour. I watched the relief on their faces when they were finally told we only had to move him ten miles away.

Meanwhile, we had been alerted to another critical patient less than ten minutes out, so the daytime registrar, who had already finished his shift, stayed to do the transfer. Nobody else would be free.

I scanned down the line of resus bays and they were all full. I shot the A&E consultant a concerned look and he assured me they were moving one out. The health care assistant was just packing them up, so I helped her push the trolley around to major injuries.

We negotiated past the row of patients in the corridor. ‘Cubicle 10,’ the coordinator shouted, but when we got there is was already occupied. They were all occupied.

‘I’ll sort it out’ the coordinator assured me, so I hurried back around to resus.

The next patient was post cardiac arrest, but he had been shocked and stabilised, so we intubated him and got him ready for an urgent coronary angioplasty. That angioplasty would save his life, but when I handed him over to the anaesthetist I knew I would still have no bed for him when he came out the other side.

I moved on to the next resus bay; an elderly man was on 100 per cent oxygen and hypoxic. His family sat around him and he struggled still to breathe despite non-invasive ventilation assistance that had been started as a temporary holding measure. I was there to assess whether he stood to benefit from admission to intensive care. They tell you this assessment is always done independently, that it should not be tainted by capacity problems.

Question 1: Do they need admission?

Question 2: How can I facilitate it?

I believed that entirely, but the reality… there were no beds.

The consultant came and it was decided the patient would not benefit from escalation to intensive care.

I agreed it was the right decision for the patient but I was also genuinely relieved this was the decision, that he didn’t also need a bed I didn’t have.

The second patient returned from angioplasty and stayed in the theatre recovery area all night. An on-call anaesthetist took herself away from emergency theatres to stay with him.

Morning time came and there was still no bed, so we transferred him to another hospital too.

Pass the parcel… pass the patient, but this was not a game and I didn’t enjoy it.

The next evening I arrived for night shift number two. ‘I’m sorry,’ the charge nurse said, ‘the day SpR is in resus with an intubated patient and I just have no bed for him, I think you’re going to be there all night’.

And so it continued.

The drunk consultant scenario.

 

 

why-be-a-doctor

You are a junior doctor and your consultant [your boss, the head of your team] arrives for the morning ward round smelling of alcohol. You confront him and he confides in you that he was drinking because he was upset because his wife left him the day before and asks you not to tell anyone. How would you handle this situation?

It is important to consider this scenario from the view point of all involved.

Your consultant’s point of view: He is going through a difficult period in his personal life and now by coming to work in this fashion he is jeopardising is career and standing in the hospital. However it is much better that he takes sick leave, the stress as well as the drinking would make it hard to concentrate and mistakes which in medicine can have terrible consequences are almost bound to happen. He should not feel that it is a weakness to seek help, we are all vulnerable and there are services such as occupational health, BMA counselling services that are available free of charge to doctors. It is important that he has insight and does not worsen his situation by trying to ‘soldier on.’

The hospital/NHS point of view:  The hospital has a reputation to protect and will be sued for any mistakes made. If the consultant is off hand or rude this may lead to complaints. It certainly cannot have its staff coming to work intoxicated. However the consultant is a very skilled, experienced member of its workforce and has given many years of loyal service so be treated with empathy and compassion. He should be encouraged to use the counselling services available and given time off work but it should be made clear that coming to work in this manner is unacceptable.

The patient’s point of view: – the most important. Patients have the right to be treated safely and courteously by attentive staff  that have their full wits about them. Medicine has the potential to cause serious harm as well as good.

Your view point: As a junior doctor your consultant is your team leader, mentor and teacher. He will also be the person who will give you a reference for future jobs. It is therefore important to still treat him with respect and courtesy. He as a person going through a difficult time deserves sympathy and empathy. However you have a duty to your patients and patient care and safety trumps all – ‘make the patient your first concern.’ It would be going against the GMC rules and probably hospital policy if you tried to cover up, even if no one came to harm. It may be the first time you have seen him like this but other occasions may have occurred and there may be a repeating pattern.

You should ensure that your consultant stops working, that he goes home [by taxi, does not drive]. That all patients he has seen have their notes reviewed, that you inform the relevant authority and seek help with that day’s work.

Abortion.

trump-abortion

President Trump signing papers restricting abortion.Where  are the women?

The topic of abortion has been in the news this week. It is the 50th anniversary of the Abortion Act  in the UK and President Trump bought in legislation a few days ago to  stop Government funds going to any organisation that provides counselling for abortion. This would stop funds going to most NGO s all over the world that are involved in women’s health and provide contraception, pregnancy and obstetric services and HIV aid for women. Changes in the funding of US health care agencies such as Planned Parenthood will also make obtaining contraception and legal abortion harder in the USA, particularly for the poor.

The  Rebuplicans won both houses of Congress and Trump has said that he would nominate ‘pro-life justices’ [there are likely to be as many as three vacancies] to the Supreme Court. Even one pro-life justice appointment may change the present balance and lead to the over throw of  the court’s landmark 1972 Roe v Wade decision that established a woman’s right to an abortion in the US.

We know that bans on abortion do not work.  Paradoxically countries that have strict bans on abortion tend to have the highest abortion rates because of widespread illegal abortions and often poorer access to contraception.  Western Europe has the world’s lowest abortion rates despite having better access to abortion. In countries with bans, women who can afford to pay still manage to find doctors willing to carry out abortions, usually for large sums of money and the poor resort to dangerous ‘back street’ abortions. When the Steel Bill that established the Abortion Act in the UK was bought in, the number one cause of maternal mortality [women dying in pregnancy] was illegal abortions.

abortion

Abortion is a very emotional subject. It is the only procedure that a doctor can opt out off in the UK. When taking about abortion remember that your personal beliefs should not affect your treatment of a patient. Even if you disagree with a patient who requests an abortion the GMC makes it clear that patient should be treated with consideration and empathy. It may be reasonable to ask her to consider other options if she does not seem completely sure  but she has the freedom to make her own mind up and there should not result in any significant delay.The patient should be quickly referred to a colleague who is willing to help her.

The Abortion Act 1967 [UK] makes abortion legal if the following criteria are agreed by 2 doctors.

1 If the pregnancy has not  reached 24 weeks  and there is  greater physical or mental risk of harm to the mother or her existing children and family by continuing the pregnancy.

2. At any stage if there is serious risk to the health of the mother

3. At any stage if the foetus is likely to be born with severe physical or mental abnormalities.

Pregnancy and delivery are more dangerous than a termination so reason number one suggests that provided the pregnancy has not gone far there is effectively abortion on demand. However late terminations, beyond 12 weeks are rare. 90% are before 12 weeks in the UK.

The major organs are formed by 12 weeks. We think that the foetus may begin to feel pain at 20 weeks when the nervous system begins to mature. When recognisably human life truly begins is very controversial.

President Trump. His first few days.

make-america-kind-again

100,000 of us went on the anti Trump rally on Saturday in London!

Obamacare

One of President Donald Trump’s first actions was an executive order aimed at trying to roll  back Obamacare. Obamacare resulted in healthcare for 20 million Americans who had been previously uninsured and without access to healthcare. About 200 million Americans are also possibly going to lose benefits because  many  benefited indirectly by forcing their insurance companies to cover them for all conditions and the Trump administration has announced that  1 trillion dollars will be wiped off the Medicare [the scheme for the elderly] and Medicaid budget.

As yet there has been no disclosure about what may replace it. Tax hikes on the very wealthy [those that earn over $250,000] which were used to pay for it will be abolished. The  Obamacare pushed up ‘skinny’ premiums; those for fit, males without preexisting illnesses. It effectively involved significant transfers — from the rich to the poor, the healthy to the sick, the young to the old. As a result some people lost out and resented higher premiums. However universal health care is considered normal in all other health care systems in developed nations and such transfers are part of these systems. I would consider this an essential part of a civilised society

Vaccination

Donals Trump tweeted

‘Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good and changes – AUTISM. Many such cases!’

Donald Trump has appointed Robert Kennedy Jr, a prominent vaccine conspiracy theorist, to chair a commission on “vaccination safety and scientific integrity”.

As a doctor I know how devastatingly  effective an easy it is is to sow seeds  of doubt in anxious parents’ minds. NO link between Autism and vaccination has ever been found. I doubt whether Donald Trump could even be bothered to read  [certainly not understand] the results of a Cochrane review of trials. Vaccines have been said to have saved as many lives as antibiotics. Some of the most feared diseases such as smallpox, measles, whooping cough, diptheria, tetanus, polio, meningitis [- I could go on and on] have been stopped in their tracks by vaccinations. Vaccinations are even more important now that we have increasing antibiotic resistance!

Planned Parenthood

It is rumoured that Trump plans to defund Planned Parenthood on the anniversary of Roe v Wade  [the controversial Supreme court judgement that made abortion legal in the USA ]. Millions of mostly low-income people who rely on Planned Parenthood for essential health care such as birth control, cancer screenings, STI testing and treatment, well woman examinations and more would no longer have access  And people who already face  barriers to getting care, especially people of colour and people in rural communities, would face additional hurdles. At present Planned Parenthood relies on the Government for 40% of its funding, the rest comes from donations. This is a further attack on women, particularly poor women. It is impossible to plan careers, independent lives without control of your fertility.

Trump’s appointments  Tom Price, Trump’s chosen health minister avoided straight answers when asked about the cuts to Medicaid and Medicare.He bought shares in the tobacco industry and then bought in a bill a week later to stop measures that would negatively affect the tobacco industry. Since being chosen he  bought shares in a hip replacement company 6 days before he bought in a bill that would strongly benefit the company.https://www.youtube.com/watch?v=UY33w3dNU04https://www.youtube.com/watch?v=epxst1Uo8YAhttps://www.youtube.com/watch?v=UY33w3dNU04

girls-just-wanna-have-fun

It is worse than I feared. President Trump is a disaster for all of us who want to improve the health and lives of people around the world. He is racist, misogynistic and has no sense of public duty [boasts that  he pays no taxes.] Within the first couple of days he has introduced changes that have increased the wealth of the super rich and made it so much worse for the needy in society. He has not backed down on his racist rhetoric His team has justified a register of Muslims because a register of Japanese existed during WW2. They  For this reason I joined the Women’s March on Saturday and marched with 100,000 women and men against Trump and what he stands for. [I recommend  watching Ashley Judd’s brilliant speech https://www.youtube.com/watch?v=EXSN-HHowhc ] Does marching have any effect? I agree that Trump will not listen but others might. A few months ago the right wing Polish majority government were about to bring in the most stringent anti abortion laws ever [abortion were not to be allowed even in cases of rape or when the mother’s life was in jeopardy] 6 million women marched – and the law abandoned.  A lot of us are angry. We can’t  take achievements in racism and sexism for granted. Last week the Russian Government repealed laws against domestic violence in order to make violence within the home legal again. Sexism also blights the lives of men [ I recommend http://www.channel4.com/programmes/grayson-perry-allman  http://www.heforshe.org/en]  and stops men having deep more meaningful, loving relationships with women and  deprives them of close involvement in the lives of children.men-of-quality-do-not-fear-equality

There is a lot to do. Trump is the result of a selfish ‘me first’ attitude that is becoming more prevalent in our world. I refuse to allow him and R wing politicians in Europe represent us.  Anger is often viewed negatively but it is a useful emotion if channeled correctly; it gets you up off the ground and energises you but it is just the start of action.  I have since increased  my donations to certain charities I support. I even thought about donating to Planned Parenthood – donating money to the health care system of one of the richest countries of the world – how crazy is that ! I also plan to increase my political involvement. Please do the same -make sure you voice is heard – write,’like’ you tube videos and  posts so they go viral, just get out there, physically or on the internet. Be counted!

Evidenced based medicine rests on shaky ground according to BMJ.

drug trials

Research published today in the BMJ showed that when scientists have financial ties  to a company that make a drug the results of trials are more likely to show the drug to be effective. This is particularly worrying because 58% of ‘principal investigators’ had financial links to the drug company. EBP [evidenced base practice] or EBM [evidenced based medicine] involves looking at trials to decide what are the most effective treatments. It is therefore worrying to think that decisions may be made on such skewed data.

The recent scandal regarding Tamiflu is a very costly example. The Government spent £500 million stockpiling Tamiflu [a treatment for flu] in order to be prepared for a Bird-flu epidemic. Yet as far as we know Tamiflu may be no better than a paracetamol at reducing symptoms. Roche the company who makes it refuses to make information available to doctors from the Cochrane centre. The Cochrane centre was set up by Archie Cochrane who served as a doctor in World War 2 and wrote that he believed that much accepted medical practice had no evidence to support their use. He went further and stated that ‘I was afraid that I shortened the lives of some of my friends by their use.’ He promoted evidence based medicine and set up the Cochrane Library of systematic reviews. It has now become the International Cochrane collaboration and involves over 100 countries [see my book  Medical School Interviews The Knowledge P69 -71 for further information on Cochrane and Evidence Based Medicine]. Researchers looked at the published trials and began to spot discrepancies. Roche seemed unable to answer the simplest questions, such as how many trials had been conducted. Regulators and agencies around the world appeared to have different information on the same drug. One trial was only published ten years after it was completed. The names of those conducting trials seemed to change arbitrarily. There were also concerns about the design of the trials. Some summaries said patients received a dummy placebo sugar pill, when in fact those pills contained an active ingredient. Other research was done on specially selected patients who would be more likely to recover from flu when given Tamiflu than other patients who were given a placebo. But this is no isolated case. Overall, about half of all clinical trials never get published. What’s more, trials with positive results are twice as likely to be shared as trials with negative ones.

The same is true of trials of other treatments such as certain surgical treatments – for example does removing lymph nodes as well as a melanoma reduce the recurrence of melanoma cancer? Lymph node removal can lead to significant swelling of the arms and may not be beneficial. The Halstead operation for breast cancer was one of the great medical scandals.  Halsted developed the radical mastectomy in the 1890s; this procedure removed the breast, skin, nipple, areola, pectoral muscles, and all the axillary lymph nodes on the same side. Even more radical procedures were sometimes used, removing part of the breastbone and ribs to get the internal mammary nodes. These operations would lead to permanent pain, swelling and disfigurement. Trials began to show that recurrence rates were no greater for more limited operations. More was not better! Despite this most surgeons in the USA continued to use the Halstead operation till 1985. Informed consent relies on a patient receiving accurate information and freely making a decision based on that information. If trial information is partially withheld we do not have that information! It is known that about half of all trials are never published These are often the smaller trials with negative outcomes for a drug that a company wishes to promote. A funnel plot can indicate bias. Most results in a systematic review of multiple trials show a normal distribution. However in a funnel plot showing bias the smaller negative trials ‘are missing’

funnel-plot

funnel-plot-2

Many of you will be having medical school interviews in the next few weeks. A common question asked is ‘What would you do to save money in the NHS?’ Well, ensuring all treatments funded by the NHS were evidenced based and preventing over treatment would save money and prevent iatrogenic harm [harm caused by medicine] – a win-win situation!

The BMJ is campaigning and calls on ethics committees, funders [such as the NHS] and institutions not to give approval or host trials or fund subsequent drugs unless all trials are published in full and good time. It is also asking for public support so join in and sign the petition at alltrials.net!

Today is blue Monday. Stress and resilience [important topics at interview.]

stress-pencil-croppedToday is ‘Blue Monday’ supposedly the most depressing day in the year – originally thought to be the 3rd Monday in January. It was probably first suggested by Cliff Arnail. His equation has six factors:  debt (d), time since Christmas (T), weather (W), low motivational levels (M), the feeling of a need to take action (Na) and time since failing our new year’s resolutions (Q).

blue monday equation

Although I am not sure how scientific this all is it certainly seems to fit in what we see as GPs and counsellors seem to be busiest and booked up in January.

Of course stress is not limited to just one day a year. It is just that it seems to peak about now. Christmas often brings us face to face with realities of family life [divorce lawyers have their busiest month], credit card bills start arriving and the optimism of the New Year and new year resolutions start fading.

For students, January often means mid-year exams.  Students have left the cosiness of home where they have usually been looked after and return to essay deadlines, exams, doing their own cooking and cleaning etc. First years have got over the excitement of starting University and second and third years have the pressure of knowing that all marks contribute to their degree grades. The short days and the darkness make it hard to get up in the morning and to motivate yourself. Some people do suffer from SAD, seasonal affective disorder where a lack of light can lead to depression.

Stress, anxiety and depression are very common anyway. A new report published a couple of days ago by ICM claims that 55% of interviewees said that stress caused by their employment has an adverse effect on their mental health and day to day life. As a GP 1 in 4 of my consultations are about stress, anxiety and depression. That is far more than any other condition, including all respiratory infections such as ear, throat and chest infections combined!

Medical Schools repeatedly remind interviewers that students and doctors who fail and cause concern do so, not because they are not clever but usually because of stress and a lack of ‘emotional resilience’. The medical course is long, intensive, full of exams and students and doctors constantly see distressing events. Empathy is important but it is always important to keep a professional distance and take care of yourself.  Therefore many candidates if not most, will be asked questions on how they cope with stress or how do they think that they would manage a heavy workload and extra curricular activities.

By now you should have evolved ways of learning, dealing with exams,managing your workload  and developed ways of relaxing. To avoid feeling overwhelmed some people make lists, it is important to prioritise tasks,delegate or even cross off tasks further down your list.  It is difficult but sometimes necessary to be assertive and to speak to people who have unrealistic expectations; for example a teacher who seems to ‘forget’ that you have other subjects apart from hers. Managing time effectively, (using travelling time to read the student BMJ or this blog for example!) is important. Demonstrating self discipline e.g. by getting up early before school for rowing practice would be worth mentioning. It is alsoimportant to have ways to unwind. Exercise is a great way of burning off stress hormones and boosting endorphin levels, as is music and singing. True friendships areinvaluable and bring a sense of self worth. And anyone having difficulties should seek help as soon as possible and realise there is no shame attached to this. Macho – ‘I can cope’, ‘soldier on’ attitudes are very much frowned upon.

Goodbye 2016! My Three Most Significant Medical Events

mosquitoes

Zika, the new health threat, is a virus spread by mosquitoes which burst onto the scene in 2016.

It causes only a mild illness and 80% of patients have no symptoms at all but it seems to be associated with disorders of the nervous system, particularly microcephaly in developing foetuses, a condition in which babies are born with small and poorly functioning brains which usually causes mental retardation.

Twenty one countries in the Caribbean, North and South America, including  Florida have been affected and women have been advised not get pregnant in some of these. It has spread on a massive scale in the Americas, where transmission was first detected in Brazil in May 2015. Large numbers of the mosquitoes which carry the virus and a lack of any natural immunity in the population is thought to be helping the infection to spread rapidly.

It was first discovered over 60 yrs ago in Africa but the link between microcephaly and infection was not noticed. This could be because health surveillance is very poor in these countries or because the majority of the population have had an infection in childhood. As a result, by the time girls get pregnant they have already developed resistance to the virus.

junior doctors strike no 2

Junior doctors in England took industrial action for the first time in 40 years.Over 76 per cent of junior doctors voted in the ballot, with 99.4 per cent voting yes. The medical profession overwhelmingly supported their juniors covering their work and joined them on the picket line. The Government declared that changes in the junior doctor contract came about because of statistics that showed increased mortality at the weekend. The Government sought to:

1) Extend “plain time”, the hours in which a trainee doctor receives standard pay, from 7am-7pm Monday to Friday to 7am-10pm every day except Sunday, though he later offered to make it 7pm on a Saturday. This is in order to create the seven day NHS   [normal working for throughout the week] without spending more .

2) To remove the obligation to work to the European Working Time Directive which limits the hours doctors can work. While there is some evidence that patients admitted at the weekend are more likely to die within 30 days, this is a complex issue which is has never been directly linked to junior doctor staff numbers.

Weekend mortality is bound to be greater because only emergency cases are admitted not routine cases. When this is taken to account the ‘weekend effect’ is much diminished and most doctors and experts believe that is is mainly due to a lack of access to investigations such as scans and consultant supervision. Stretching the existing workforce around 7 days may create more gaps during the week days and worsen patient services then.

genetic engineering

On a more positive note 2016 was the year when gene editing started to hold out exciting possiblities. CRISPR-Cas9 is a gene editing technique that uses the Cas9 protein and a strand of RNA to make breaks in strands of DNA.

Then new genetic code is then placed inside the breaks. This can allow the genetic code to be rewritten. It is powerful and reliable, quick and very cheap. CRISPR-Cas 9 “components” can be bought for $30.  Possible applications are numerous, this is why Science Magazine declared the technique its ‘Breakthrough of the Year!’ Researchers at Duke University in the US used CRISPR-Cas9 to delete DNA in mice that was preventing cells from producing a protein essential for muscle function. This causes a human equivalent disease called Duchenne’s Muscular Dystrophy. A virus was used to deliver DNA alterations into the cells of mice.When they injected the therapy directly into the legs of adult mice, it resulted in improved muscle strength. When they injected it into the bloodstream – tests showed improvements in muscles responsible for heart and lung function.

Earlier this year, a group in China announced it was the first to successfully edit the genome of a human embryo. The breakthrough at Sun Yat-sen University in Guangdong showed the errors in DNA that led to a blood disorder, beta thalassaemia, could be corrected in embryos. Gene editing has been used to make mosquitoes resistant to the malaria parasite which they transmit to humans and to make pig organs genetically similar to human organs.

Organ donation. Topical issue of the week – and ethical scenario

organ-transplant-20110418-085820

 

It has now been a year since the new  the new Welsh system came into force , residents are presumed to have consented to organ donation unless they positively opt out.

In June the Welsh government said the scheme had already saved dozens of lives after revealing that in the first six months, of the 60 organs that were transplanted, 32 came from people whose consent had been “deemed”. ie  those who choose to do nothing, if they are 18 or over, have lived in Wales for more than 12 months and die in Wales, they will be regarded as having consented to organ donation. Families still have the right to over rule and refuse but it has led to an increase in the desperately short supply of organs. Many  die whie on the waiting list for an organ.

Ethical scenarios regarding organ donation are common – try this one.

An ex-alcoholic patient [who is a mother of two children], a seven year girl, a 75 yr old war hero and a homosexual man need a liver transplant. Who should have it?

 Answer

A doctor should never be judgemental. As in most complex situations a decision would only be made after consulting with senior doctors, the hospital ethical committee and the hospital legal team and/or your medical defence body. All of these are sources of valuable advice and it is important to share responsibility for any decision with them. Remember doctors work in teams not in isolation.

The case for the ex-alcoholic woman to be given the liver transplant

Some people may say that her illness was self inflicted but that is no reason to discriminate against her. Ex-alcoholics may relapse and start drinking again but many diseases affecting the liver such as auto-immune diseases may also affect a new liver and she should not be denied treatment because of this. Being the only parent to a child is a very important role but it is wrong for a doctor to value one life more than another and positive discrimination may lead to a slippery slope where people in certain important roles, e.g. national leaders, have priority in transplant waiting lists.

The case for the seven year old girl and the war hero.

Some people would say that the war hero has served his country, paid his National Insurance tax and deserves to receive his liver transplant on the NHS. Others would say that he has lived a reasonably long life while the young girl who probably has most of her life ahead of her is more deserving.  The NHS and NICE does sometimes look at QALYs [quality added life years] when deciding to fund certain expensive treatment. If a treatment costs less than £20,000 for each extra year of good health it extends life by, it will be funded. In this scenario the girl would probably benefit by gaining more QALYs than the war hero. However the use of QALYs has been denounced as ageist and it is considered wrong to discriminate because of age.

The case for the homosexual man 

His entitlement is as valid as anyone else – it would be discriminatory and completely unacceptable to think otherwise.

Conclusion

A doctor should never be judgemental and never value any one life above that of another. For this reason transplants and ‘who gets the organ’ problems are decided in this country solely on:

1. clinical urgency [who needs it most],

2. The best match [whose tissue type is most similar and least likely to reject the organ]

3. the length of time they have been on the waiting list.

Organ donation

There is a massive under supply of organs for organ transplant and each year many patients die while waiting for a suitable organ that may have saved their life.

At present there is an ‘opt in’ system in the UK which means that it is important for people to carry donor cards, sign the organ donor register and make their wishes clear to relatives if they wish their organs to be used to help someone if they die.

A few months ago, because of the shortages of organs NHS Blood and Transplant suggested that people who agree to donate their organs when they die could be given priority if they themselves need a transplant. This, however met with a backlash from the Church of England and patients’ groups, who say ‘such a change would mean doctors treating two patients differently – something which would undermine medical ethics.’

 

 

The interviews have started- Sheffield, Oxford and Cambridge

interviews

Sheffield

Before the interview you have the opportunity to go on a tour of the medical school and talk to medical students

The interviews are changing to a MMI style format

Common questions relate to

  • knowledge of and interest in study in Sheffield
  • motivation for Medicine
  • evidence of commitment for caring
  • depth and width of interests (achievements in specific fields)
  • communication skills
  • understanding the nature of Medicine
  • medical work experience.
  • topical issues in the press
  • ethical issues

The Medical School states

‘After your interview the panel will grade you on your performance at the interview. Based upon this grading the Admissions Tutor for Undergraduate Medicine will then make the final decision as to whether you are offered a place on the course, held on a reserve list or rejected.  You will normally be notified of this decision through UCAS within three weeks of the date of your interview.’

Why Sheffield?

Sheffield is a well regarded city with a big University. The Medical School was founded in 1828 and has many prestigious alumni including Hans Kreb – who was Professor of Biochemistry and discovered the Kreb’s cycle. Student accommodation is good and relatively cheap and is close to the Medical School.

It is a systems based integrated course.

Cambridge and Oxford

There are usually 2 interviews [often 3 for Cambridge] which take place at the individual colleges and last about 30 min. Additional written tasks may be given. It is customary to stay overnight at the college and have the interviews on different days.

One interview is usually quite science based with 2 interviewers with questions to do with your subject syllabus that test your ability to make deductions and think aloud in a clear logical fashion and summarise your answer. You score most marks from your working out rather than the answer. Your interviewer will often try to guide you as you answer so make the most of their hints. Interviewers are looking for students who have insight into basic concepts. They may be teaching you in small groups for a number of years and want to make sure that you are a likeable enthusiastic student.

The other interview may be more typical of other medical schools with questions about your Personal Statement and books and articles you mentioned

[more information in my book – Medical School Interviews The Knowledge [P101/102]

Video of a mock interview http://www.emma.cam.ac.uk/admissions/videos/interviews/?showvideo=46
what Cambridge say they are looking for http://www.youtube.com/watch?v=kujK0W-K0qc#t=60
They are famous for ‘out of the box’ challenging questions such as:
Why don’t most herbivores have green fur?
What percentage of the world’s water is in a cow?
Why are there so few large predators?
They are not looking for an answer necessarily, what they are looking for is seeing how you respond to these tricky questions-whether you are able to think logically and how you use the information given to you by the interviewers

Make sure your A level/equivalent knowledge is up to scratch
Why Cambridge/Oxford?

Amongst the top 5 Universities in the world with top research institutions and an amazing history of Nobel prize winners and other alumni.

They are both beautiful University cities. You have small tutor groups and some well endowed colleges give grants for travel and trips abroad. The college system means that you socialise with students doing other courses to a greater extent than in other medical schools.

Oxford is a bigger town than Cambridge. Oxford class sizes are smaller but Cambridge offers more places to study medicine.

Learning is mainly lecture based and there is not much patient contact in the pre-clinical years.