¿Qué Jesús Haría?

Tomorrow I start nights. You'll learn all about them in good time, I'm sure. For the moment though I wanted to do something I've never done before and ask people's opinion on a situation that arose last week.

I'm going to be as brief as I can because I want to go to bed:

I was out drinking. I saw another guy there who I thought was really attractive. I imagined that, were I not in a relationship already, he would be the type of person I'd really fancy. I stood up and realised he was in a wheelchair. I was suddenly no longer attracted to him.

I felt extremely guilty for a moment. It passed.

Do other people think, or know, that they would have felt like this? Is it only natural? Or horribly unfair?

What say ye?

Out of Control

I needed drugs to get going again this morning. I awoke to find I had developed a chemical meningitis of the Stella variety over night (known otherwise in the lay parlance as a Stella head). Thankfully, being a doctor, I have accumulated a handy stash of all the ingredients necessary for a concoction that can restore me to some minimal level of functionality: aspirin, paracetamol, metoclopramide and lansoprazole. Sometimes I add a multivitamin, but I know that this is mere garnish for the chemical goodness that forms the true meat of my panacea.

I droned through the patients histories at the consultant meeting as is required of me then lapsed into an absence while the Neurobeasts clashed horns over who knows best about what should be done. It was only then that I realised what an odd looking bunch they are. A few in particular are visually arresting: there's the sickly pale man with an autistic affect and a malevolent stare; a stern-looking bull dike with a face like a greedy beaver; and some damp squib who looks like a puppet with its strings cut. I tried not to stare too much, especially with my stomach as unsettled as it was.

All the patients were miserable today. I suppose they have good reason: none of them can move from the neck down anymore. Strangely enough this wasn't really the focus for their misery at all. The reason they were so sad is shit. No, I mean it literally was shit; or the lack of it to be more precise. The same process that had deprived their bodies of sensation and power had also deprived their bowels of any automaticity by damaging the autonomic nervous system. The shit wasn't going anywhere. My poor sweeties hadn't had a good poo for over a week, bless 'em. They'll need the works: laxatives galore, daily enemas and possibly a manual evacuation or two. The latter is very much a last resort, predominantly because if it comes to that it's my hand that has to do the evacuating! I'll certainly need some metoclopramide for that one, I tell you.

It's kinda sad how tragic and pittiful we are when our bodies break. Our greatest joy, our dreams and desires, all intimately linked to the production of a well-formed stool. Reduced to reliance on others for everything, we lose all dignity and control. We are left at the tender mercy of others; their whims and their caprices replace our own as the deciding factors in our destiny. Today one of the patients thanked me repeatedly for nothing more than having moved her leg for her. It had become torturously painful in its former position but she had no way of moving it herself. She had asked the nurse to rearrange her but the nurse needed somebody else to lift her safely and there was nobody free; she'd gone to find somebody but got distracted along the way and not yet returned. I found the patient quietly sobbing. After I'd moved her, I said it was no problem, smiled and inwardly thanked the fates that it wasn't me in her place. I knew it wouldn't be long before her new position becomes just as torturous and I sighed as I wondered how long this time would she lie helpless and in agony before somebody was free to move her again.

A Second Opinion from God?

In the last 3 months, I have done many of the everyday things that a 26 year old might do. I have been ice skating, gone dancing, caught a show at the theatre, seen numerous films, worked my arse of, and lazed around on the couch to name but a few. All well and good, you might say. Sharon is the same age as me and previously her life was little different. She probably even had a little more fun: there's a history of cocaine and ecstasy and the hope of a career in the fashion industry. Recently, however, things have been a little different for Sharon. For the last 3 months, she has been in a encephalitic coma. Her only trips have been to the ICU and HDU. Considerably less well and good, I might say! Nobody held much hope for poor Sharon.

Imagine our joy then when she started to improve at the end of last week, culminating in her opening her eyes of Friday! This week, to everybody's amazement, she started to talk. OK, so she's not quite there yet - there are psychiatric and cognitive problems, which may or may not get better, and most of her speech involves telling people to fuck off - but it's a start and she may improve still more.

All the same, we still need to know what has caused this illness, if only because the symptoms were so odd that finding an organism may help us to treat any future victims with this very atypical clinical picture. We have a single lead: an area of infective looking tissue on CT which we could biopsy and culture. Sharon cannot consent to the procedure; she does not currently have the capacity. In the morning, we spoke to her mother who agreed that the biopsy should go ahead all the same and that she would consent to this in place of her daughter (as the law allows).

That was the morning. By the afternoon everything had changed. Sharon's mother had some news. She had gone to the church and spoken with the Elders. The Elders has listened to the story, considered, and pronounced their verdict. Sharon had had no brain infection. God punishes those who live dissolute lives and Sharon had taken drugs. God does not like drugs. His punishment had been severe but he had heard the prayers of Sharon's mother and, being a good and merciful old chap, he had relented. Sharon would recover and all would be well. There was no infection and, ergo, there need be no biopsy. Sharon's mother, a devout Christian, swollowed it whole. She withdrew her consent for the biopsy immediately. Now our last chance to find our what had caused this illness will dissolve away as her body clears the infection.

We could still do it, of course, but we won't. It's not worth the trouble of a court fight. Besides, it's not really fair on her mother. It's not her fault, after all, but the preachers who interfere in areas where they have no expertise. It's bad enough that they profess superiority in the moral arena, let alone in the understanding of medicine. The consultant psychiatrist whose job it is to assess a patient's competency sees this often. He is annoyed but resigned. He knows that people are vulnerable at this time and we cannot always give the exact answers they crave. Preachers like these feed on uncertainty; they've had a market-share in plugging gaps in human understanding since time immemorial - it's their raison d'etre. Yet, the most disgusting fact has little to do with the biopsy. Without a qualm, these finger-pointers have pinned the blame on poor Sharon for an unpredictable illness of which she is an innocent victim. How unfair. How cruel. What bastards!

"Balls like watermelons, I tell ya! Watermelons!"

I am so extraordinarily bored that it hurts. I'm on call, but it's an on-call like none I've ever done before. There is absolutely nothing to do. I'm only looking after about 12 patients, all of which are perfectly stable and require no active input. Yesterday I sat in my office from 8:30am to 8pm with only one foray onto the ward to put in a cannula and write up some paracetamol. Today I have not even done that much. My flatmate, The Pink Psychiatrist, has been doing on-calls like this ever since he defected to the Dark Side, a.k.a. psychiatry. Whenever one was coming up, he'd forever be moaning on about how terrible they were. Being a medic myself, I'm used to being run off my feet on an on-call and coming home exhausted. My standard retort was that he should count himself lucky and shut his bastard gob! Until now, that is. Now I know how torturous it is to be trapped in a place with diddly-squat to do.

I've read the entire Sunday paper plus supplements. I've listened to the radio. I've phoned my family and friends. I've drank so many hot bevrages and been to the toilet so many times that I'm beginning to wonder whether I should just bypass the middle man and throw the tea down the toilet as soon as it's made. I've even dusted off ye olde textbook of Neurofuckedology I found on the office shelf and done some work! All that and still only half way through with sweet fuck all to do. It's like being in prison.

Still, at least the papers were good. There's nothing like a good sex scandal to pass the time. It would seem that Mark Oaten has come a bit of a cropper over his liason with a young renter he met through Gaydar. Of course, the irony of the whole thing is that Gaydar is actually just an on-line meat market where literally hundreds of thousands of people offer themselves up in the hope of a quick shag...oh, sorry, I meant a 'meaningful relationship'. So why was this numbskull paying 80 smackers a pop? Really people that stupid deserve to be caught. And what was he thinking anyway? As if some street urchin that sells his arse for a living is going to have the moral compunction to pass on the opportunity of a tidy little earner just because it involves selling one of his clients down the swany. I can just imagine the kkk-ching! of the dollar signs in his hollow eyes the moment he realised that the baldy old slug with the penchant for football kits was actually a potential leader of the Lib Dems. Still, I can't help feeling a little bit sorry for him: imagine being exposed by a paper with a title as patently preposterous as "The News of the World". I mean as if! Anyway, I'm also rather disappointed in Mr Oaten. Not because of some moral revulsion on my part at his perceived failure as a role model; politicians are hardly the greatest of role models whether they are out shagging homo renters while their wife sits at home alone or not. No, I'm disappointed because of the lack of ridiculously implausible excuse proffered to account for his misdoings, a la Ron Davies' badger spotting or Kevin Spacey's dog walking. It's these aliens-stole-my-homework type excuses that are the punchline to the eternally-great joke that is another's fall from grace. To just admit to it and say you're sorry is to rob the people of their bread and circuses. Bloody Lib Dems: you can always rely on them to get it all wrong!

Chronic Fatigue Syndrome

No, this is not one of those articles in which some doctor - inevitably subsequently described as 'unhelpful' and out-of-date' - dares to suggest that chronic fatigue syndrome is really nothing more than a big pile of made-up poo. Certainly not...I would never suggest such a thing. I would never suggest it because I know that chronic fatigue syndrome exists and I know that because I have it. I am tired right now. I was tired when I woke up. And I'll probably be just as tired when I wake up tomorrow. In fact, I am tired pretty much all of the time.

Is this surprising? Well, not really I suppose. My job is busy, busy, busy. I haven't had any lunch for the past three days, let alone a coffee break. There isn't enough time to do everything I'm supposed to do in my working day so I end up staying late. Last night I left at 8pm when I'm supposed to finish at 5pm. That's nothing too unusual. The hospital managers recently thrust diary cards in our direction to check how many hours we were working. Don't be fooled - this isn't so that they can accurately assess the size of the problem of too-much-work-too-few-people before doing something about it. Oh no. Diary cards exist only to make sure that they are not paying us a penny more than they have to by law. The idea is that we record what hours we work each day and what we were doing and then they pay us a intensity supplement if the job necessitates a lot of out-of-hours work. Except that's not quite how it works. The problem is that everyone works so terribly hard that those cunning foxes in management have had to devise some wily tricks to ensure that people feel obliged to minimise the extent of their voluntary overtime. Take the last set of cards I filled in; they carried the following in bold at the bottom:

"Please note: only the hours that you are required to work should be recorded. If you are consistently required to work out of sheduled hours this must be raised with your consultant and a solution put in place prior to completing these cards. If you stay behind later or arrive earlier than you are scheduled to, this is a voluntary choice and should not be recorded."

Riiiight. So I get what you're saying here. I stay behind at work because I love it so much that I just can't bare for it to end and, besides, I've got absolutely nothing better to do with my time because I have no existence outside of the hospital. Of course, it has nothing to do with the fact that there isn't enough time for one person to do all the work required to look after the patients properly. No, nothing at all. Absolutely nothing to do with that fact that I know very well that if I didn't stay behind then Mrs Smith wouldn't have her CT because nobody would have discussed and ordered it; Mrs Jones wouldn't get any antibiotics because nobody would have wrote them up and put the cannula in; and poor Mr Kent might die because the even-more-ridiculously-outnumbered hospital at night staff wouldn't have got round to considering his lack of urine till the wee hours of the morning. Nope, it's all for the thrill of the medicine that I'm here till late.

My arse.

Essentially the statement above ensures that the only acceptable way to fill in the diary card would have been to copy out my rota verbatim. That way the hospital managers can claim to be reducing hours while doctors work late into the evening on a supposedly voluntary basis. If anybody dares to suggest that they simply couldn't leave or the work would never get done, they are told they should hand over what they cannot do in the day to the night team. Yet, the night team is a pitiful skeleton crew and no decent human being with a conscience would be able to walk out the hospital having left it to those wretched souls to sort out all the left-over shit. If everybody were to do so, the entire system would simply buckle and collapse. But then perhaps that's what it needs. Perhaps we ought to do exactly what they say and hand whatever we can't reasonably fit into our working day over to the night team. Then, maybe once a few people had died because the night staff couldn't cope, something might actually be done to remedy the situation.

The fact is, though, that I know we never will; and what's more horrible still is that They know that too. It's hard to leave innocent people to suffer the consequences of poor policy and, on the whole, doctors are a kindly bunch. And so I'll continue to start early and stay late. And I'll continue to be fatigued. Chronically fatigued. Except, unlike those whinge-bags with the syndrome, nobody will ever give me a nice medical diagnosis and put me out to pasture, where I swear I'd be ever so happy just to chew the grass all day long.

Concrete Boots

I was once a barman. I liked being a barman for numerous reasons, one of which was the fact that you weren't expected to know everything about being a barman from the moment you walked in. There was a nice little intro to the ins and outs of it all: how the till works, how to change a barrel, how to pour the spirits. If somebody asks for a lager top (and there really is no excuse for doing so I must say!) and you give them a pint of lemonade with a splash of Foster's then who gives a fuck! Your concoction goes down the drain, somebody explains how you make it properly and, best of all, nobody's going to get killed over it.

Medicine, alas, is the polar opposite. With medicine you go in at the deep end. As a junior, every six months you will swap jobs. Just when you've finally got to grips with the nuts and bolts of your job, it's time to up sticks and fuck off to a whole new speciality that you know nothing about. Except, this time, there is no nice introduction, no explanation and no instructions. This time, from the moment you walk through the door, you're expected to know it all. It all.

And that's why today I nearly killed somebody.

As you all know I was recently elevated to the exhalted status of an SHO in neurofuckedology. Today a fat young girl rolled up (quite literally some might say) with 'terrible headaches and suspicious eyes'. The latter were suspicious not because they were warily eyeing up anyone who might potentially steal her pork pie, but because the optician had noticed that the nerves at the back that allow us to see were both very swollen. She had papilloedema and see needed an urgent MRI and a needle shoved in her back to see what was going on in her spinal fluid. Problem was she wasn't the only one that needed stuff doing. There was that bird whose spinal cord is rotting away and can barely breathe, the chap who can't walk properly anymore, and this lass who now needs detailed instructions to do what she's always done without a second thought previously. They all needed needles shoved in their back, and before 4pm when the neuropathologist goes home. Then there's that woman who's bleeding from her bowel and needs a telescope test. Plus all the daily crap for the more-stable others. Shit. Where to start? What to do?

No great surprise then that I found myself rushing at 3:30pm to do the lumbar puncture on the fat chick with the weird eyes. "You get the lumbar puncture quick and I'll go see the patient downstairs.", said my reg. In my rush to beat the clock, I completely forgot why I was doing the test in the first place. I forgot her fucked-up eyes suggested raised pressure in her skull. I forgot that if you stick a needle in somebody's back who has raised pressure in their head then the resulting gradient means their brains are sucked down and forced through the hole at the base of the skull. Crushing your brain through the bottom of you skull is known as coning and is, alas, not generally compatible with life. Indeed I forgot all of this as I pierced her leptomeninges and saw with a smile the crystal-clear spinal fluid that I so desired. I remembered all of this in a blood-curdling flash as the fluid shot up the pressure guage and overflowed the top of it. Fuck, high pressure! Oh fuck, the MRI! The M-R-fucking-I! I'd forgotten to check if there were any big masses in her head on the MRI - if there were then she's going to cone for sure. I finished the procedure in a sickly sweat. I must have asked her about 20 times in the few minutes t lasted if she still felt OK. Nobody had told me to check the MRI but I knew that was no excuse. In fact, nobody told me anything about lumbar punctures at all - I was just expected to do them. Yet, if she died, I would be to blame. The law agrees too. It is an established precedent that, from the minute you start any new job, you are expected to know everything about that job. The fact that you are some naif neophyte is no excuse in the cold eyes of the law. According to the Bolam test, the standard of care expected of professionals is judged by comparing with those skilled in the particular speciality in question. However, the experience of individual health professionals may differ significantly: a newly-appointed SHO in a speciality may have no prior experience of that area. Should he then be judged against the highest standard expected of that post or his own qualifications and experience? The law is clear: just as the learner driver has the same level of responsibility as the qualified driver so the newly-appointed SHO has the same level of responsibilty as his more experienced seniors. Now there's the concrete boots in it all for when you fall off the side of the bridge. If you're drowning because nobody bothered to tell you the fence was missing, don't expect the law to pull you out..

The girl did not cone and die, thank the Lord. There were no masses - she probably just has benign intercranial hypertension - but that doesn't make it any less scary. Every day doctors do things that they don't know how to properly because that's just what you do in medicine. It's the same as any other job, once you've made a few mistakes, you quickly learn what and what not to do. Except that it's not the same as any other job. Unlike the bastardised lager top, a mistake in medicine might just end up getting somebody killed, and yourself thrown in jail to boot.

Speaking Freely

You may have noticed that I am a relatively frequent (ab)user of the word 'cunt'. There are at least two reasons for this. I happen to think that swearing is a useful tool in that it adds colour to language by expressing emotion, which is otherwise nigh on impossible to convey. I also happen to think that that good old staple swearword, 'fuck', is on its last legs. In an age when I can read an entire article on the word in my daily newspaper without having to shy away from the old dear sitting next to me on the tube, I can't help but think that somehow it's lost it's magic. Where's that oomf, that zzzing, that kapow!? Cunt, on the otherhand...well...let's just say that cunt is soooooo the new fuck.

You will forgive me, therefore, if I combine two old favourites of mine in the following sentence: Fred Phelps is a cunt! The holy and merciful Fred is also a kind of blogger. His wonderful blog can be found here. Let nobody say Fred doesn't make an effort to keep his blog up to date. Any fag haters out there might wish to review the current list of forth-coming pickets advertised:

1) Funeral of Army Spc. Marcelino R. Corniel
2) Miners Memorial Service
3) Funeral of Marine Cpl. Brett Lundstrom

So, family fun to be had by all there then! I might not be a great fan of war, but can you imagine going to mourn a family member lost in conflict (whether justified or not) and having to deal with Fred and his bunch of dimwit cretins as unwanted guests. What extraordinary wankers to take their grievences with society to a funeral! These people are after one thing and one thing alone: press coverage. They are not even human - let alone religious - in the way they deal with other people's suffering. "They turned America, over to the Fags; they're coming home, in body bags. " writes Phelps. Wordsworth eat your heart out.

It plays on my mind because I am a great believer in free speech and opponent of the limitation of liberty by law. Fred Phelps' incendiary nonsense seems at first glance to be calling out for a banning. It's inaccurate, inhumane, disgusting and hateful. Yet I think it would be a terrible mistake to try and legislate against it. Much like the new religious hatred bill, it would set a very dangerous precedent. In sheilding ideas under the umberella of the law, we protect them from legitimate scrutiny and criticism and provide them with a safe environment in which they might easily grow out of control. It has long been the case that any disagreement with Israel's policies in the occupied territories has been met with cries of antisemitism. This is a patently ludicrous but unfortunately often very effective form of defence. More recently, the chairman of the Commission for Racial Equality, Trevor Philips, was accused of Islamophobia because he had the temerity to appeal to Muslim leaders to reiterate their opposition to terrorism. Religion is only an idea, albeit a very powerful one. It has no special status that demands it must be handled with kidgloves, let alone afforded legal protection. As David Hume was wont to say:

'We may observe, that, in all ages of the world, priests have been enemies to liberty; and it is certain, that this steady conduct of theirs must have been founded on fixed reasons of interest and ambition. Liberty of thinking, and of expressing our thoughts, is always fatal to priestly power, and to those pious frauds, on which it is commonly founded.'

I will not, therefore, be calling for the removal of Freddy's opinions from the Internet. I think he is a good reminder of how far we have come; and how far we have to go. I would prefer instead to call for the removal of any law that suppresses free speech. The separation of state and religion must be maintained at all costs. As an aside, anybody following the recent posts of NHS Blog Doctor will have noted the difficulties that a certain somebody's a-little-too-free speech got them into. I did think it was unfortunate that an opinion could not be stated without recourse to a disciplinary body, especially one as sinister as the Fitness to Practice committee.

Jammy Bastard

Some days the most unlikely things happen.

Today was one such day; for today I passed my Part 2s.

Extraordinary

(Fade out to Dreams by Gabrielle...)

A Beautiful Mind

I have always been a little saddened by the dearth of talent amid the medics. At the beginning of each new job I arrive bright-eyed and bushy-tailed to meet my new co-workers. In the preceding days I've dreamt of Ryan Philippe or Alex Zane look-alikes that I can drool over at our Sodhexo luncheons. The reality is inevitably heartbreaking. The vast majority of doctors are, sadly, minging weirdos.

The Young Professor is one of our registrars. He lives with his mother. I could stop there...but I won't. He wears tweed suits that, combined with his unruly, grey, wavey hair, makes him look far older than he actually is. He flits about the ward like a manic dandy. He speaks with such pressure that he trips over his own words and degenerates into a frustrated stutter. The slightest problem might sent him into a frenzy of twitching and eye-screwing as he reprimands anyone and everybody for their preceived mismanagement. Worst of all, he never, ever leaves the bloody hospital: he's in early; he leaves last; he even came in on Christmas day when he was supposed to be off! Don't get me wrong: he's one of my favourites - the eccentrics always are - but there's no getting away from it; the boy sure is bizarre!

How on Earth I am supposed to climb the career ladder when people like The Young Professor are already clinging on to the higher wrungs? Yesterday my own reg suggested I start a research project and my heart sank. I don't want to stay behind late and work on some pointless research whose only goal is to feather my CV; I want to go out and dance and drink before I'm too old to do so without consistuting a repulsive spectacle. Yet, on the other hand, I do want to progress and I do like neurology so I know I probably should. Sometimes I wish I were a barman or a shop assisstent who never thought about work again as soon as they walked out of the door. Instead, I'm writing this to put off making my presentation for the Grand Round on Friday. At the same, in the back of my mind, there is the ever-present, gnawing guilt that stems from having forgotten to do something for a patient today. It's like you never leave work, like it never stops, like you're always on call. In the words of a great philosopher: I want to break free!

From Social Chasers to Chasing Socials

Today was a good day. The foundations for my unexpected joie de vivre were in fact laid last night during a little jaunt to the cinema to catch the brand-new must-see, Brokeback Mountain. This was a rare pleasure on at least three counts: firstly because it afforded me the opportunity of seeing Dear Jake Gyllenhaal as a needy, closetted gayer begging for man-love, which, strangely enough, is much as I've always imagined him in my dreams; secondly, the man in front of me appeared to have the misfortune of suffering from microcephaly which allowed me to slouch down and still see all of the screen; and, finally, because the whole affair had the undeniable air of an organised Butlin's coach trip right in the middle of London town. From the moment of their arrival it was evident that this film had had a particular appeal for the audience of an alternative persuasion. The marks of the beast were everywhere to be seen: a new-wave haircut or a couple of belt-chains here; a leather Lonsdale satchell or a limp-wrist there. Then, once the whole fandango was over and the tears had been dried, almost the entire cinema promptly got up, swiveled on their Gucci heals, and minced off en masse to That Bar for the first New Week's Eve celebration of the year. The Pink Psychiatrist and I also went along...but only to study the social phenomenology, naturally.

It could have all gone horribly wrong; all that studying of social phenomenology left me feeling a touch fatigued this morning, after all. Thankfully, I was saved by the fact that my job consists of little more than 'chasing' and can therefore be almost entirely conducted from the end of the mess telephone with a sausage roll in one hand and a triple espresso in the other. (I am in the process of finding out the patient's bedside telephone numbers so I will never have to enter the ward again.) 'Chasing stuff' is one of those things that has been invented to take up junior doctors time so that they have something to pay us for. A typical chasing scenario might be as follows. Say I'm a registrar or consultant and I want a CT scan. My junior diligently orders the scan but, because of demand, there is a waiting list for it of, say, on average, three days. Yet, on the wardround the very next day I will feel compelled to ask them to 'chase CT', predominantly because otherwise there would be nothing to write in the plan bit for that day. The junior is then compelled to phone the CT department to ask why the CT scan has not yet been done. It has not been done, of course, because there are other people who have been waiting longer. Simple and sensible. However, by the time the junior has actually got through to switch board, then spoken to the whole department before finding the right person to ask, and finally debated the whole situation for a while to no avail, it is quite possible to have wasted a good hour. It appears to be a prerequisite of seniority in medicine that you hold the delusional believe that a test chased is a test done faster. Only the juniors really know that chasing achieves sweet F A and they're not going to tell because then they'd be out of a job! Besides, there is no end to the things or people that can be chased. Chase CXR. Chase bloods! Chase social services!! Chase next of kin!! Chase old notes!!! Chase neurology review!!! Chase your tail round and round and round and round...

Arbeit Macht Frei!

Yesterday I returned to work after a month of blissful freedom. So traumatic was this transition that I fell ill the night before with a clutch of psychosomatically-induced symptoms, including fever, all-over body pains and an intensely sore throat. Alternatively, this might well have been tonsilitis brought on by suppressing my immune system with as much time on the lash as was humanly possible before starting back. Either way it's work's fault.

I am now officially a SHO in Care of the Neurofucked, albeit a slightly ill one. Since my hallowed instituition is a tertiary centre, everybody is intensely clever. So clever, in fact, that if they hear hooves then they just know it's gotta be a zebra. Being so terribly clever, we only deal with the really big cases. To get through our doors, it's no good just being neurofucked - no, let the plebs in the other hospitals deal with that. Baby, if you wanna hang with the wunderkinder then you gotta get yourself neurodoublefucked, and preferably in a confusing way. We got lapdancers that still groove away in their encephalitic comas; we got stiffmen that shuffle about like mannequins; and we got peeps who went to bed normal and woke up tetraplegic by the dozen. Furrowed brows are very much the order of the day.

Being a tertiary centre, we also only deal with the biggest egos. It ain't no good being a genius if everybody else doesn't know it. The consultant ward-round is the battlefield on which the big beasts of Neurofuckedology lock horns in a grand game of one-up-manship. The SHO reads out the details of some poor neurofucked's case; the beasts comtemplate a moment; then the games begin.

"Well, it's Whipple's encephalitis as sure as I'm the world's expert on it!"

"Really, John! This is as much a case of Whipple's encephalitis as I am a prima ballerina!".

"Oh come on, Thomas, it's obviously tuleraemia! And what's all this nonsense about West Nile Fever anyway".

"Look chaps, I think it's pretty clear here that what we're dealing with is a cocaine-induced vasculitis super-imposed on a rabies encephalitis with an added akinetic-rigid component - I mean what the hell else could it be, you blithering idiots!"

Of course, nothing is actually decided about what to do next, but at least we all know who is the cleverest neurobeast of all by who came up with the most far-out and unlikey diagnosis. Yes...I definately think I'm gonna like this job.

Euthanasia And The Death Penalty

In the previous post I set out the reason's why I am in favour of permitting euthanasia in select circumstances. As well as being in favour of euthansia, I am against the death penalty. It has been pointed out that at first glance this may appear inconsistent and hypocritical. I, however, do not believe that this is inconsistent at all, and this is why...

The death penalty is the most extreme act of revenge that the state is authorised to use in the name of justice. It has been abolished in the majority of democratic countries in Europe and Latin America; it is retained by the U.S., most Asian democracies and nearly all totalitarian regimes. The crimes for which the death penalty may be invoked range from murder, via drug traffiking all the way down to theft. Amnesty International states that, officially, around 3,797 people are were executed in 2004 but, in reality, the number is likely to be far higher. In March 2004 a delegate at the National People's Congress said that "nearly 10,000" people are executed per year in China.

It's supporters argue that it acts as a deterrent and, indeed, one chap pointed out on NHS Blog Doctor's site that 'the UK's homicide rate has trebled since its abolition. Meaning that over 5,000 largely innocent people have been slain who might not have been, had we retained that ultimate deterrent.' Though it is true that murder rates are around three times greater now than during the during the period, it is a logical fallacy of the post hoc ergo propter hoc variety to say that this is due to the abolition of the death penalty. There are any number of reasons why the murder rate may have risen that would be completely unaffected by the possibility of a death sentence: there are more fire arms in circulation; society is less homogenous and riven by more tension; there is a widening gap between the rich and poor; there are better detection and conviction rates for murder. Correlation is not causation. Besides, murder rates are no lower in countries that retain the death penalty than they are in those which have abolished it and, indeed, in the USA, the much-vaunted drop in homocide in the previous ten years was proportionally greater in in those states which do not use the death penalty.

Anyway, the main point really is this. Many oppose the death penalty on the grounds of the sanctity of life. They state that it is always wrong to end life because life is a something scared. The basis of this belief is usually religious or deontological. The latter is best exemplified by Kant who said that every human being should be treated as an end in themselves, as opposed to a means to an end. Every person is a basic good and must be valued as such. It is, therefore, an absolute wrong - ie. it is wrong regardless of the circumstances - to kill any other human being. If this were the basis on which I opposed the death penalty then, yes, it would be incompatible with support of euthanasia; but this is not the reason. I am not religious so the 'gift of God' argument carries little weight with me. Moreover, I don't even believe that it is always wrong to kill somebody. If, for instance, I were on a plane that had been hijacked by a terrorist who was threatening to crash the plane and kill everyone on board, I wouldn't hesitated to try and kill him first with whatever I had to hand. Yet, even he, the terrorist, is an end in himself according to Kant and it is always wrong to kill him regardless of what he does. That's part of the reason that I think Kant is wrong and why I do not think anybody has an absolute right to life.

Instead, the reason that I oppose the death penalty is purely pragmatic. The justice system is not perfect and it never will be. Neither here nor anywhere else in the world can we be assured that there will never be a wrongful conviction. Even the fact the State might remove somebody's freedom by imprisonning them in error is terrifying enough, but at least in that case there is a chance that if new evidence emerges the ruling can be overturned and the person set free. Once you have killed somebody, however, there is nothing that can be done except a posthumous pardon and that is no recompense to the victim, only perhaps to their relatives and even then a pretty poor one. Many of the accused cannot even afford legal representation and end up being represented by court-appointed attorneys whose credentials are sometimes weak. The odds are stacked in favour of the prosecution from the outset. Since 1973, some 122 people in 25 US states have apparently been released from death row with evidence of their innocence. It is the falliability of the justice system that prevents me even considering the death penalty - not the sanctity or right to life - and that is why I think it is perfectly compatible with supporting euthanasia.

Right, that's the end of that... back to away-gays and slugs from now on for me!

What's So Bad About Euthanasia?

I was recently pointed in the direction of another disenchanted doctor’s blog – there does seem to be an awful lot of them, doesn’t there? – that provided some very interesting reading. It seems while I’m jabbering on about away-gays and not calling my friends, other people are pondering far deeper issues surrounding the ethics of the death penalty and euthanasia. There were two main points that interested me. Firstly, is it wrong for doctors to be involved in the business of ending life and, secondly, is it inconsistent to support euthanasia and be against the death penalty?

As regards euthanasia/killing people (the exact terminology matters little), the NHS blog doctor is opposed on the basis, it would seem, that he does not think that medicine should be involved in ending life at all. Medicine may be used to prolong, but not curtail, existence. The Hippocratic Oath is trotted out: presumably for the line stating “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” There is nothing wrong with this point of view and I certainly think, on an issue as difficult as this one, every individual doctor should be allowed to fall on either side of the ethical fence without any reproach or criticism. I myself fall in favour of euthanasia and so I thought I might try and set out why here. I suppose the first thing to say is that I do not think the Hippocratic Oath has any relevance at all. As was pointed out by another blogger, the principle most associated with the Oath – primum non nocere – does not actually form any part of it and many of those exhortations that do are inappropriate today, eg. not taking up the knife, not performing an abortion etc.. I did not swear the Hippocratic oath; I do not feel myself bound in any way, shape or form by such an anachronistic document; and I think it is a little odd that it is apparently still administered to graduates in the US (or so I was told). This frees me from any criticism based on my not observing the Oath’s ban on administering deadly drugs at least. So there.

Firstly I suppose I should set out in what circumstances and in what form I would permit euthanasia. Since the termination of somebody’s life is an irreversible and extreme measure, the circumstances in which it could be used would have to be appropriately grave. The kind of illnesses for which I would permit euthanasia would have to be intractable, imminently terminal (say 6 months or so) and to cause (or be likely to cause in the near future) intolerable suffering. Palliative care must be maximised prior to the patient’s request being considered. The patient must make at least two requests for euthanasia separated by at least two weeks; they must be able to change their mind at any point; they must be assessed by a psychiatrist to exclude any psychopathology or impairment of reason which might jeopardise their competency to make the decision; and most importantly they must be under no external pressure to decide to die. I realise that the last point is a tricky one since it is always extremely difficult to ensure that people are free from coercion and, as people don’t shy away from dumping granny in A&E for Christmas, there is the worry that some might seek a more permanent solution to the annoying old baggage. It is also sometimes said that doctors would themselves be under pressure to push the idea of euthanasia for patients who require expensive and/or constant medical care and because of the pressure to free up limited beds. However, such arguments are in my opinion little more than scaremongering tactics. Surely few people are so morally bankrupt that they would seek to bring about somebody’s death against their wishes – especially for the sake of cost. Besides, those that would, such as dear Dr Shipman and Nurse Allen, will not be stopped by euthanasia remaining criminal any more than they would be protected by its legalisation. The same kind of basis seems to me to form the basis of the slippery slope argument much beloved of the Daily Fascist…er sorry I mean Daily Mail. In a nutshell, it is suggested that once we have accepted ending life in no matter how tightly controlled the circumstances, it’s only a small hop, skip and a jump until before we’re hooking granny up to the potassium chloride because she’s failed to get over her tickly cough in good time. Obviously I parody but the idea is essentially the same: human beings are so devoid of any morality that they would not flinch at ending people’s lives at the drop of a hat. Firstly, the law would make sure the application of euthanasia could not be expanded without vigorous and lengthy debate beforehand, so I very much doubt we’re going to ‘slip’ anywhere in a hurry. Secondly, given the enormous sense of queasiness people feel about accepting euthanasia even in the narrowest of circumstances, it is more likely that the euthanasia – like abortion – would suffer constant attempts to recriminalise rather than liberalise it.

So that’s who I might allow to choose to die; now why I would allow them to choose to die. I suppose the least intellectually rigorous but most important reason for me is that I feel it is right to do so. Most people accept that when an animal is beyond help and its remain life is or is almost certainly going to be predominated by suffering that it is merciful and right to have it destroyed. Human beings are merely animals too, and an unfortunate few experience intractable illnesses which cause them extreme suffering and obliterate their quality of life. In the first example we are imposing our view of what is best on the animal without any moral qualms, whilst in the second the human being would have to actively express a desire to die that is constant over time and then meet very rigorous criteria regarding their condition. Yet despite this, we still would not permit them this release. How then can it possibly be right to allow people to suffer when we would not permit any other animal to do the same? I have my own personal fear of diseases that paralyse the body whilst leaving the mind intact – motor neurone disease is perhaps the exemple par excellance here. Whilst I cannot possibly know what I would really think unless I were actually to be in that situation (which is why I hope this next statement will remain forever hypothetical), I feel very strongly that I would not wish to progress to the point where I was completely reliant on others for everything yet completely sound of mind. Were euthanasia still not available and were I really in this situation, I think it would be intolerable for me and I would have to kill myself. Why should I be criminalised if I had made a competent decision based on all the information and chosen that I did not wish to continue?

Then there is the issue of returning control of their lives to those who want it. Having seen a fair few terminal patients in my nine months of Oncology (yes, I know, it’s not long but it’s still a lot of dying but compus mentus people), I realise two things. Firstly, the vast majority of terminal patients do not wish to speed on their death but instead extend their lives by whatever means possible. I once had a patient with breast cancer complicated by massive lung and brain mets that was adamant that she be resuscitated in the event of an in-hospital arrest. Hence, I cannot imagine that people would be leaping like lemmings into euthanasia without their circumstances being unbearable. Secondly, those that do wish to shorten the dying process usually have a pretty good reason for wanting this. People often talk of pain and how proper use of analgesics should mean nobody has an unpleasant death. In respect to this, I have two things to say. Not all pain is responsive to analgesia, even at doses which essentially render the patient almost comatose. Some pain responds to absolutely nothing – not morphine, not nerve blocks, not antiepileptics, not nothing! Moreover, not all suffering is about physical pain. Mental suffering engendered by the loss of function and independence consequent on illness can be equally as, if not more, distressing than physical suffering and is far more resistant to treatment. Thus, if a patient is sound of mind and makes a well-reasoned request to end their lives, do we not then as doctors merely respect the patient’s autonomy if we choose to help them to do so? Is this not in fact one of our core duties? Until you are actually dead, you are by definition alive: dying is thus just another part of living. We expect and prize the liberty to determine every other aspect of out lives – why not dying?

Phew…I think that will have to do for the moment. I hadn’t quite intended to write so much. I’ll have to finish off explaining why I think support for euthanasia is perfectly compatible with opposition to the death penalty in a subsequent instalment. Goodness, what a cliff-hanger!