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Contents

Medical Admissiong

by Dr. Jonathan Mus$ave ..,..,...........,....' 2

Revieiol Spot ....,..,.,.,....,.........'..'....'....... 5

Liveg ia Our Tired Haldsby Dave Burgnerand John dePury .......'...' 6

MalrwatcherCompetitioa Time ...........'....,....'....'......... 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

BLACK BAGJournal ofthe Medical Faculty of Bristol U vercity

SPRING T988

Editorial

So far thrs yesr, it appe3rs tha! no newsprper publi-cation can be co$idered complcte vtithout devoting alleast half of its pages to medicsl matters of one kind oranothe!. In this edilion we heve included a couple ofissues recently hiShlightedr th€ excessive hoursrvorked by iunior docron, end the hody debarcd D.vidAlton Bill. Many of you must hold 8!ron8 views on

these subiects, so pleas€ s€nd us your comments! Alsodiscuss€d arc the methods employed in the seleclion ofBristol medical students,aid th€ need for the iruoduc-rion of an ethics course into the curriculum.

On a lighler nok, Msnvratcher hrs been keeping avcry clo6e eye on recent happenings, and we continueour s€riea on rcvision exercises for lourth years. Wehope thet you will fitld this spot as us€ful tis thc last.

Fitraly, there is only one more edition for thisacademic year, so if you are interested in helping nextyer!, atrd would like to 6nd out how this notorious andhighly controversial periodicel is nurturcd, do get intouch!

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

As on all controveNial subjects, each ofus has at sometime felt that we could make a much better job ofselection than the members of Lhe Medical AdmissioosCommittee. As one of them, therefore, I welcome thisopportunity to explain how we go about it.

Procedures vary g,idely from school to school. Atsome the Dean is clos€ly involved- At Bristol weare unique in having a tripartite Fafllty of Medicircdivided into Schools of Medicin€, Dentistry and Veter-inary Medicbe. As a resdr $e Deatr of Medicitr€ is avery busy person atrd coDteDt to leave selectiotr to theMedical. Dental and Veterinary Ad.nissions Commitlee.

The Medical Adrnissions Committee, chaired by th€Clinical Dean, comprises 14 nembers (8 dinical ad 6pre-clinical), of whom the Pre-C:linical Dean and theClinical Deans at Southmead and Frenchay are ex-omcio members. We meet at 9,00 a.m. each altemateVedn€sday thmughout th€ AutwllIl and Spring Teimsto discuss UCCA forms. We spend a iflher s€vmwhole days 3 belore Christmas;4 alrelTards inrer-viewiDg about 550 applicatrts. Becaus€ of the aumb€rof applicatioff we receive - 1,230 in 198G87 - we arefurther sub-divided into pain conprising one clinicaland one pre-clinical member, whose iob ii is to readand discuss their forhighdy quota of applicatioos.On each interview day we are t€amed with a differentmember. Thus tle UCCA form of esch successfi.

applicant will have been squtiDised by at l€ast fourmembers of the AdmissioDs Committee and, in manycases, discussed by rhe whole Committee-

Applicams are inrerviewed if rhey bave at leasr 5 or 6gade A pass€s at O level, 3 grade B passes at A leyel, anUpper Second class horcurs degr€e or other qualfic-a-tions of a compamble standard. Their inrerests andachievements atrd a coddetrtial reference are alsotalen itrto consideratiotr. It may seem udair to parentsard teachers of late developers that admissioo tomedicine should depend on so matry high O levelgrades, but, as Professor Peter Richards of St Mary'shas wrirren, "academic achrevemmr srill carries rhegreatest weight in selecting candidares fron rheirUCCA form. The seat ma,ority ofapplica scall€d tointerview are acadenically strong, and it is thetr rbattheir p€nonal characteristics decide on the ourcome."tApplicants with rather morc Bs than As at O level rc€dnot abatrdon hope. If they ar€ Feparcd to defer apply-ing until their A l€vel grad€s are klown succ€ss m:y bewithin their grasp if drcy have achieved at least BBB.

What I have wyitten so far applies mainly to youngapplicants 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 October1987 also i.trcluded 7 eraduates, 7 former prcmedicalstudetrts, and ll oveNeas students who 6nd it dilfcultto utrdertake their training ir their home country.The admission of a few graduates and premeds, wefeel, hebs to widen even furrher the educational back-grourd from which our students are drawn. over theyears we have aalnitted, among otlers, hospital labora-tory 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 baletdaicer, an airlirc pilot, a nun and sevenl priests.Betseen them they h"ve gaiDed an impressive range ofdrstirocdons, pries and int€rcalated degr€es. Suchpeople cenainly make small group teaching very muchmore stimulating. They also do much to foster cohesionaDd boost morale among the younger members of theiry€ar. Bristols medical admissions policy is far from

Conu-ary ro popular b€Iief we do trol reslrict ourchoice to applicatrts who pur Brisrol 6rsr. Our rask is roattr'act the b€st aod nor inftequendy we offer a place rosomeotre who has placed us low otr bis or her list.Ne€dl€ss to say any@e who has placed us 6fth and whorcally wishes Io go to, say, Edinburgh is ulikely to belured away. Nevertheless some priority should begive[ to aoyoDe who bas itrdicar€d a $rorg prefercNefor Bristol. For this reason we do try to see those whoplace us flst, or second to Oxbddge, oo one of theeady interview dats. N€xt year UCCA pmpos€s tosimplify matters by insEuctitrg applicqtrts to indicatedeir 6rsr choice rith an asterisk. leaving the renain-ilg four utr]:anked. Itr due course ranking may bedropped altogcther. It will be interesting to see howthes€ chsnges affed both caodidates atrd sel€ctone.like.

This brirys us to the interview its€lf. Bristol us€dnot to interview. Why hold rhem? How should the becotrducted? How lory should they be? Should irter-vi€wem rceive any forhal tlaidtrg?

Is it realistic or d€simble to aim for unifomiryof conte$ ald epproach? Vhar qualities are beingsought?

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

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

aware of their falibiliry atrd of rheir obltation toignorc their owtr prciudices. I can appreciate bodrargumetrts. I owe my PhD to a Cambddge colege f,,hichawarded me a Colege Ressrch Studentship withoutan itrtereiew in themid-60s-anidealistic age becauseit too had res€rvations about theml Today I share rhemaiority view that too much is at stake ro admit peopleto a very long strd expensiv€ - f100,000 - course erith-out lookiry at th€ object of so large ao irvestdentInv;ting pronising appucar r s lo aa irterview also givesrh€m an opportutrity to see a pa4icular school fo!themselv€s aDd discuss it with the group of studentswho show them mund.r

If itrtervi€ws are to be held it is only right that dosewho conduc! thern should think carcfi.rlly about, fori$taDce, rvho should be invited ad for how lotrg.There is no shortage of applicants who, on paper atleast, s€etr well qualified to attact our s€rious aft€tr-tion. There is also a limit to the number of days rhar iris reasomble to take aheady busy selectors away fromtheir trormal duti€s. To date we have r€sisted rhetemptation to restrid tbe number of p€ople inter-viewed because of the difficulty of agreeing uponcriteria for narrowing the shordist even fufther.

Our iftefliew load is high - for hr:mane reasonsand it is aot easy to acbieve aI we should like in thetime available. illost i$ewiewees arc yourg and we\pish to attract Ether thatr repel. How€ver selecrors ofmtratns to lol1g professional cowses ar€ responsiblero botb the University snd rhe profession in quesrion.In my opiniotr, htefliews should be long enough roenable both panies to: (i) exchange stress-reducingcivilities; and (n) to d;scuss mough contentious ropicalissues for the iftervi€w€rs ro iudge rhe ability of eachcaddidate to presenr a clhereot case and stand upagainst gende but plobiry 6re.

What qualities at€ w€ s€eking itr applicarts? We willalr€ady bave notd or the UCCA form: ability to copeacademicafly; rcsearch into qles of course available;commitmmt (discussioDs with docto$; perhaps evensome work experience); outside iftercsrs and achieve-Dents; abiliry lo get on well wirh people (part-rime

iob); a charitable disposition (volu ary work); and a

srnighdorward personality assessment (Conidentialstatem t). It is u[ealisdc to draw up dgid lists ofthequalities r€quir€d of lie ideal futurc doctor, €speciallywhen he or she may be ody iust 17. They will includetho6€ tpotr which oth€I authorities have laid such sress:

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(i) "commimrcnt, persevsuce, detsmination, idtiat-ive, oiginality, and conc€m for others";4 (n) 'theability 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, responsibi-lity, 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: "mostmedical posls require the ability to commuoicate withar to care for people and the training itself cenainlyrequires the ability to communicate."T I agree $uill-ingness to commu-nicate is atr im€parabl€ part of'com-milmenl'. \vi$ l-hal in mind I pay particular attentionro any relevant comments itr the Cotfidential state-

menr. Each of us is familirr with such comments as:

"she is taciturD rath€r than shy and does not put herselfforward"; or "X has no dimculty in communicatingorally, but would not .egrrlarly do so voluntarily". Onthe other hand, how could snyone fail to be impressed

by Y, "a quiet girl who nevenheless communicateswcll with people and has an easy pleasant mannei'; orZ, "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 ofsomeone who hss been able to folm an assessment ofanapplicant over a longer period. Oo the other hand,

account has to be taken of personality dashes, and ofthe seemingty udair advalrtaeE of those fortunatepupils over-€trdoer'ed with ple:sitrg quafities.

Moreover many applicants, allegedly shy and diffidentin class, chafter away happily at iDterview. All of us too

have to be otr our glard agai.nst ov€rlooking a kiDdlythinking intoven h a crowd of noisy extrovens.

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

figures reveal that, anroog tb€ ordinary applicants alleast: (i) we received fewer spplications ftom women(383 to 401)i (ii) more of them received offers (104 to68); and (iii) started $e cou$e 169 to 411. There is noevidence that they ar€ bett€r qualified academically:"Bristol analysed their 1982 candidates' A levels andfound no siglifca[t difference of academic perform-ance 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 handlethe fireside chat part of ary ioterviev much morecompetendy. "Many of the subdeans said how mucheasier and ftore pleesant it was to interview girls."gPerhaps, in aD attempt to be fairer to their less assured

classmates, we should pay rather morc ettention to A'sthoughtful attitudes to buming issues of the day and a

litde less to bubbly B's experiences as a budding waitresslReaders' views oD the matter would tr very welcome.

l. S.. Richeds (1987).

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

3. For funhd di*u$io! of de <lifi.rins vi.ws on th. v.lu. ofiltcNi.v5 w Hleki$ (1983) dd tb. R.pon ot tb. C.ncnlMdiql Council confcEncc on tbc S.l.ction of M.dical Studdtsbcld on 22nd Februsy 1979.

4. Richa& (19E7).

5. w.lron (1985)

7. Richsds (19E7).8. Hawkirr (1983).9. Hawkins (1983).

AclnowletEents

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

Refererc€s

Gcmml Mediel Coucil- 1979. ReFn of rhe Crnf..cra on theSeleciion oflvtcdisl Studmc h.ld on Februdy 22, 1979,

Hawkins, R. 1981. Soutrding our studflr *letior. Vodd lvledrcint8, 4548 OIo. u,Jue 11,1983).

Rjclatd,P. 1987 . lanitg M.lliitu 198a. 4th edn. Ijldor: BritishMcdical Affirtior-

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

Vesr,ll, v.G. 1987, It@ b othn a Pbc. in M.dnal Scrool 2ttdedn. r-trdon: Chapm dd Hall

3k3,b36o*

ncniew of lttedical ft5tslologt, 13/EWllldn t OorE !9witls 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

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Wlllo|n t GononCA Cdrlcdrio sftr.t 4*re rq 116/r, <, Me Mobtl l'/E83(+7aaa-O zaFoC€. l9t? lt/UO

Ilarpet's Blochemishy, 21/ER. K ttuftry €l ol\4fir6 io plo4b ghcFb6 ot 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]]rlrea3a+3619-2 720Fo!s 1'!7 a2adl

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REVISION SPOT IIWelcome back to the page devoted entirely to ttre luckless fourttr yean who are being drawn towardsthe high speed circular saw of Part I Finals. Our spot on alaesthetics seemed to generare sufficieutinterest, 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 rosend a question flom a recent palrr in each subiect to local emineDt cliniciats, so that those revisingcan get a feel for a "model answer", Unfomrnately, due to clerical error, the two questions wererruddled 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 5.,g E*A 15 year old girl is broughr ro you by her parents witha story suggestive of anorexia nervosa. Oudine yourmanagement.

Or,s tt€L gowN

Afr?le-@ ttr;P-(trf qW ftr,ur)

O?ztficr.r ro Prs(0(( *?to S7O?

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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. yoususp€ct ruptuied aortic aneurysm. Oudine yourimmediate mrnrgFmenr.

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. . . (I think that shoutd be sumcient. . . . Ed)

LIVES IN OUR TIRED HANDSIt is apparent that many working practices may be cotrsiderably different in the N H S ofthe 1990s'

It seems unlikely, howiver, that tle emotive issue of Junior Doctors'hours is one which will be easily

resolved. Hele taoe Burgner and John de Pury ansiderihe case fo! reducing tle workload of Judor

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

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 ofjunior hospital doctorc (JHDS), both to stop patients'

lives being put at rbk and to limit fie personal toll odthe doctors themselves,

In other professions (such as airline pilots aDd lrarD

drivers), $'here excessive hours may abo €ndanger thelives not only of the professional but also of the people

entrusted inro their care, there is a legal maximum ofdury hours. This is not the case for JHDS; while airLine

pilots are not allowed to work more than a hundftdhours per month, some JHDS arc contra€ted !o workthis time in six dals. JHDS work an average of eightv-five houn per week and may continue to work wellover one hundred hours a week. For those of us who

choose to remain in hospital medicine these hours willrppty for the eleven years posl-regrstrrtion lrainingnecessary (on average) before a consultant grade is

These dangerous and intolerable working conditionsare detrimental to patient carc and to doctors them-

selves: the sleep deprilation and exhaustion faced by

JHDS quickly results in an incr€asing impairment ofmental agility, reaction time, shon term memory and

other pschological parameters necessary to performadequately ir a busy hospital environment. In one

experiment the declining mental performatrce of iuniordoctors during a seventy-two hour weekend shift was

€quivalent to twenti to thirty yea$ mtural ageing l

Not surprisingly petients suffer as a result; they ere

treated or operated on inaPpropriately or unnecess_

srily. The wrong drugs (or the wrong doses ofdrug) are

given, aDd lhere is a higher complication rate followingoperations and procedures carried out late at night. Inshort, patients'lives are being put at risk.

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 thepopulation; and they are some of society'$ heaviest

abus€rs of drugs aad alcohol. Morale amongsl JHDS,as with many ofter health service workers, b under-standably low. A recent report comrnissioned by theDHSS ftom the Policy Studies Institute (an indep€n-dent think-tanl) questioned srx hundred iuniordoctoft over a two year pedod about their workingconditions and hopes for the future.' The findingsrevealed widesFead pessimism and disenchantment,mainly due ro poor career prospects and frusuaLion

over long hours on duty, atrd the consequent drfficul_ties irl leading a "nomal life". These findings are

echoed locally; e questionnaire 6urvey of JHDS in the

South West rcgion revealed that "many . ' showedcynicism and bitterness about the medical esteblish-ment and the lack of sympathy with the problems ofsheer overwork experienced by iunior doctors "3

The working conditions facing maay JHDs are farfrom beidg e new problem; indeed it is often suggested

that the maiority of JHDS work under what has beendescribed as "a Victorian defnition of professional-

ism" - th€ system has not changed fundamentally since

rhe days of apprenticeships. Attempts to limit thehours worked by JHDS both by the DHSS and by themedical profession itself have usually been, at trest,

half-hearted. In 1982 rhe DHSS 'requesred' that allrotas should be reduced lo a 'one in three' or less byAugust 1983. At the same time district 'hours ofwork'working panies were set up to review rotas and torecommend changes, provided that tiese remainedwithh the heal.l authoriti€s' medical personnel budgetMost of these working panies, which consisted ofequalnumbers of iunior docto$ and consultants rogettrerwirh representatives of NHS managemenl have since

stopped me€ting. In spite of alother DHSS circular tothe same effect, Do itritiative eith€r fiom the govern-

m€nt or from the Fofession itself has Ied to any real

improvement in JHDS'workhg conditions. Yet ihereis a growing body of opinion boih withiD the profession

itsel! and within the pubLic at large that legislationshould be introduced lo signiicandy reduce doctors'hours, as has been successfully achieved in NewZealand. Such an apFoach is unpopular with Govern.ment, management and some consultants. why is itrhet these parries are so unwilling to see JHDS' hoursreduced?

There are t\x,o broed classes of argument advancedagainst a reduclion in JHDS' hour6. The first is "theProfessional": 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 thatrhe introduction of a more norma.l working w€€k wouldundermine professional commitm€nt and produce

"clock watchrng" doctors, as if enthusiasm for patient

care, moral€ and professionalism were enhanced ratherthan debilibted by exhaustion. The introduction of arational working practice would be dillcult witloutsignficanL changes in the medic.al hierarchyr in par-

Licular, the inEoductron of a more 7%xible practice -including cross cover Io lighen the load on luniors inthe hard-pressed specialities (such as paediatrics,

sugery or csrdiac care), the inEoduction of a day olfaft€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 successiJlyintmduced in Accidelt aod Emergetrcy departmcnrs).Ircvitsbly, siDce JHDS might work for two or thr€efrms ir a given week, this would lead to borizo$alrather thaa vertical alegiaffes, atrd thus rcduce th€power of the consultant over hcr or his frm. Notsurprishcly tlete is opposition to flexibte, rationalwork practice i$ som€ of the more senior ratrks of themedical professiotr.

Secondly, there is the argumert over the fnaoctatconsequenc4s of a clurEe in curreBt work prrctice.

JHDS are, on average, paid leis &a[ 50", of their basicrate for ov€r-time worked, so tlat over the cours€ of aweek maly house officers will eam less than €2 Frhour. This guarante€s that ir costs less !o employ orredoctor for eighty houis thaa two for forty hours each.Furthermore JHDS ar€ forced !o work €xc€ssive hoursbecaus€ of inadequate stafnng levels and because ofinsufdcient fu-nding for the provision oflocum cover.

The Medical Practitioners Udon (MPU) is a Unionfor docton and medical srudents which js a pmfession-ally independeri s€ction of the Associatior of Scie}tmc, Technical and Managerial staff (ASTMS). It wastbe first Trade Udon for doctoN ev€r to be estabtished.The MPU has be€n very sctive in publicisiq rhedang€rously long hou$ which iunior docto$ arcoblised 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 stalfonthe bssis of oexible working practices (as outlinedeerlier). Following this itririal change there should b€ afi[ther phased reductioo to a statutory sirity hourweek, over tle next ten years, This \pould requir€ atr

incr€ase in the number ofdoctors, the emount depend-iDg on the ratio of coDsultants to tLe expsnded juniorsts.fr. Utrfortumtely, the Govem$mt's only idtiativeiD rlis afte brs be€n to propos€ . reduction in medicslstudedt ntrrnbers; a rnore strongly oppos€d by ttreMPU but, i$erestingly eDougb, trot by the BMA.

So, ifyou c.I€ about your own future, that of yourpatients, and of th€ NHS, and would like to 6nd outmorE abour MPUrs bouls caDpaign atrd its otier acti-vities, contacr rhe local MPU studetrt coorditralor,Steve Chuch (tel Bistol 541502) atrd com€ to th€ rcxtBri$of MPU neeting on the 7th March where thenatioDal MPU s€crEtarywi[ be speakiag. @lease checkdetails with Steve Chuch.) You have nothing to los€

but rhe bags uder your ey€s!

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

%'{7z>

\r, -:t4"l,/

r( FAR AS I Cll'I SEg , LONC' HOTJRS N€V€R DID

ANYON€ ANY HARM '

TheArmvoffers medicalstutients 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 requiredto attend an Army selection board.

But you'll get 16,376 to continue yourmedical studies in the first year. This increases 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 fieldmedical organisation at the RAMC Tiain-ing Centre and in the various aspects ofMilitary Medicine at the Royal ArmyMedical College at Millbark.

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

By converting to a Regular Commission

you can, of course, stay longet until you're60 if you wish.

As a doctor in the Army your Practicewill be much the same as a good civilianone: fully equipped and professionally staffed.

You could be working in a grouP Practice oron your own; though yodll be entirely respon

sible for your own patients, be they soldiers

or their families,rather like abusy G.PBut don't think that, because you're in

the Army, your chances for study will be

in any way limited.

While still in clinical training, a numberof selected cadets may, with the approval oftheir Dea.n, undertake elective atta.hmentsat Military Medical Units in Germany,

Cyprus. Hong Kong. NePal or USAArd you'll have the same oPportunities

as in civilian life for your post-graduatetraining in General Practice, Communityand 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 totake advantage of a very wide range ofsporting facilities.

You'll almost certainly travel abroad,

and your social life will be busy too. Many

of those you meet and work with will be-

come 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 amountspent by the Army on your medical train-ing. Regular and Special Regular Commis-

sions 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 inthe Armyiarrd arrange ar interview

S nnrncofficerThc Ame ,l Fhds an Equal Ollan niE EnlW^, nd6 the tt6 of ile Ro@ R.tatia6 Act 1976

MAN\TATCHERIrt us return with MANwaTcrrR to the contagious festivities tiat reigtred towards the end of the

Michaelmas rerm past.

The Preclinical Review san' tlose frolicking 6rst y€ars'

Lhanffuly less eructatious of late. keetr to captivateexpectant audi€Dces. Although in tle Foverbi"l darkwith regard to the rules of the oft r€ferred to spon of"popping 6lst year cheni€s itr Stoke Bishop',M,INWATCrfiR rras mOSt impressed by the aaditionalEpicurean Spirit so prominent throughout.

Tbe Clbcial Review proved a much more notoriousalfair. As is their wont, some ofthe fourth year Recba-bite brisade flomced hither and thither b€aring tidinssof great woe, atrd waming a[ arcutrd that B€elzebubhimself brd surely penned the script. With petitioDs

circu.ladns, and the Kingsdown air hevy with talt ofsabotage and boycott, r4ANwATcrsR found thepreceding weeks alnost as €ntertaining as the thor-oughly waggish show itsef.

As the fifth years b€gEn to retum to fair Bristol,lunchtirhe talk s'as of elective tales of sun, satrd, andparasitic infestation. M€anwhile, wih rheir 6lst day rtwork a mere eighty w€eks away, the fourrh years have

become predictably impassiorcd about house omcerposrs. With l€vels ofcotrsffvative neuroticism reachingcomical new p€aks, the Glenicals' Presidetrt foundhimself only ooe step shon of being publidy dismem-ber€d by "his peopl€", after the moot€d introductionof a change in the dates for iob applicatioos-M-ANwArcrcR will watch avidly, confdent that ouifounh year Dob can generale more rumonr, suspicionand paratroia tha[ tbat other 1988 tob lottery, theAmericatr Presidential El€ctiotr.

To matteft less painfi . The Victoria Rooms hostedthis 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 felrsympathies are extend€d to the lone vmereoloSist whostoically mamed aII unvisited statrd, while droves ofdrooling lech€m queued to ogl€ the ever-scfai eaidenadornins the Deighboudtrg Rh€umatology display.

MrlNwarcnnR congxatulates those responsible forthe recent acqrisition of the sumptuous rcw s€tdes inthe Medical school common room. Now perhapG thos€garrulous frst y€ars cao confle to coffee breaks theirdiscussioDs of matErs ug€trt. Fr€e from such tawdrytalk as to whether Daddy will buy o$e a fat in Clifto&or jusr Redlaad, Iie library ca! bop€fuly regaitr itspreviously peacetul air.

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

cals ofrce suite; surely indisp€nsibl€ for a man cont;luaily "on t-he iob". MANVATCFER sees less merit.however, in the eflacement of those historic balloonswhich formerly grac€d the walls in the Dolphin HouseBar. One hopes rec€trt rumours ftat the now blank wallis sootr to be adomed with porrlairs of "key" Galedcalscobmittee membe$, past ard present, proveuDfounded.

FiDally, iiANwArcsER congratulaEs RichardBra$oa and his virgin empire on extending theirinfluence to the murky realds of the Medical School

roilers- Orc can bllt speculate on the date of mstalladonof a llrther "Mates" machine in tle D.H.B. linencupboard, whffe it is r€aly Deeded.

Competition TimeFolowiry the overwh€lmiry respons€ to our laslcompetitioo, Brart Ad8 now offers eveo more e.rLicingprizes. As {,ell as a botde of bubbly and a tour of theBla.k Bag offrce suite, the lucky \rrinner of dfseditiotr's competitio! wil also receive a rare copy of therecip€ for that most volatile of dishes, the "Black BagYindaloo". 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 ETHICSAt present, tle Curriculum Comnittee is seliously considering the introduction ofan ethics course tothe 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 ageat loss. Some polemic here may serve a purpos€.2 There has been a quier rcvolution in fie feld ofmedical etlfcs. Bristol, chiefly by rhe activities of theBri$ol Medical Group, has not been backwards in$ese ms[ers: the B.M.G. is holding a conlerence irthe ne.ar future on m€dical erhics.r Anyone knowitrgabour this conlerence who has nor, ar least, given irserious coDsideration probably shorld not qualifyl3 Just receDdy I came across a perfecdy ordinary,everyday, medic:.l dil€mma. A man was admitred veryill with extensive pleuEl eflirsions, s€condary toknovrn cancer of the lung. It was clear rhat he wouldshordy die. He was trot oyerdy in pain nor disrressed.Little was to be dore, but the iunior doctor rais€d thequesLion of morphiDe. The trurses were encouraging.

Now the point is not whether you rhink this is righrorrFrong not here at atly mte - bur rhar in the absenceof bdicarors for morphine rhe only possible pu rpose ingiving n was to eod rtre parient's life. lr was nor ,usr a

forseeable consequence: ir was fte iftentiotr. Alldknowinglv. witb premedirarion, to kill aD iDnocenrhuman beirog is, I thiDk, muder-4 Nov,/, of course, ].ou may obiecr that under thesecircumstances it did nor amount to murder. But ttrepoint is (herc) that ir mighr well have be€n murder.This decision, was withort doubr, the most importalrde(i.ion ro be made by that iunior docror rhar evedng.It was a decision for which ihe doctor, in five years ofmining, had received tro proper pr€pararioD.5 Medical erhics is uavoidable. But discussions ltrmedical etlics are often supertrcial. We may srare ourviews and listen to the opposing vie*s of others: thissort of civilised exchange is mexnr to be b€rcficial. Nodoubt there is some betrefrr in ir- Being able ro acceptsuch a process as suffici€trt, however, is only possible ifwe hold the belief that ethical views are subt'ective, rhatis, melely maners of taste.

I prefer btackcurre jam with its udque sharpnessaDd becars€ I love the fe€l of blackcuFanrs burstingbetween my tongue and patate. You prefer ttre mushysensation and swe€hess of strawberry iam. WelI, burarc ethical beliefs iust like ,iar? Would thousaDds ofcitiens lobby parliament to baa the mushing ofsligtrdy rotten stra$berries?6 This, then, is one say itr which medical €thics issuperfcial. Medical ethics is predicrably abour 'realproblems'. To prevaricate atrd insisr rhar we set asidereal problems to discNs obiectivity in erhics seems'academic'- by which we mean 'servitrg no rudlpurpos€'. In the medical wodd, rhar, which has ro deal

with reality, a son ofconsensus has es€rged accordingto ehich ethiel beliefs are tust beliefs. (But don'tpeople die for their belieG or lan8lish in concentraiioncamps?)

The deputy editor of the BMJ rccently wmte:"Abortion is : conplex medical :trd moral issue andmany doctors hold stmng, geouirc, and varyingviews on ir. . . TwetrtyyearsaiiertheAboltiollAcrshould not ihe profession have reached a

But how in the face of a "stotrg, genuine, andvarying views" could tlere possibly be a cons€nsus?For all sides believe their views to be rru?: Lhis is norl.ike stmwbenies v€nus blackcurrenrs. And it isunconfortable to cor$ider, ifone hankeN after cons€n-sus, that iforc side is speakitrg the tmth, rhe orher sideis damtrably lying.7 There is a way to avoid unpl€a$nhess and rlar is roplump for 'situation dhics'. Sir Douglas Black, whoseeminence iD medicirc is itrdispurable, has beetr a stesd-fast advocare of 'sifi.lation erhics' for some time. Itsmain tenet he has stated in t\e Jounal ofMednal Ethiu(lME) is 'every case has to bc considered on itsmerits'.r The problem with rhis view is that it leads tocotrtadiction which retrders it nodsensical. Forinstarce, although Sir Dougirs is against absolutes andpr€-ordaiftd rules he giyes plenry ofexamples of ruleswhich he applies (e.g. 'I wor d not mys€lf abetsuicide') and even ofabsolutes (e.g. 'I believe rhar atthe end of the roqd rhere are thitrgs which tro docaorshould do).4 Even in 'situatiotr ethics' it is a naruralincliDation to achieve consistercy as a gerequisite ofratioMlity. Of cou6e 'every case has to b€ consideredon its merits'. bur tbsr do€s not preclude rhe operarionof rules or absolutes. wlat is rhe altematiye bur molatanarchy?8 A G.P. frieod ofmiae, oow workiDg towards a higrherdegree, was very €rcit€d $sr be hed fitraly alier yearsofpractice beetr taqht medical ethics. He said he hadrcver previously heard of the difference berweetr utili-tarial and deonrological er]ics. I am sure ir is a goodLhing 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. Nobodywould sugg€st, for instarce, rhat leaming that rrar soriof rash is 'maculo-papular' is ail thar there is rodermatology.9 I am makiry the poitrt that medical erhics is essential,unavoidable, bua ftay be superfcial. Say tbat I go to alecture oo physiology aDd larer have a discussioD in atutorial gmup o! phFiotogy ad 6naly a(end a half

t0

day confercnce on aspects of ph]siology. Does tharequip ne to etrter a hospiral and unde$tatrd rhere allthe rcal phsiology? We[ ir might do, but actualy yorrhave to go drough two years ofphysiologjr l€ctures andtutodals before you are allowed into the hospiral. lrithless or perhaps no erposure, bow€ver. you calr go hto ahospital atrd decide to kill someone Fith morphine.10 Medical ethics, not mere 'matters of eriquette' (s€elast Blach Bas\, is a deep subject. For what is irsr timate aim but to iCetrtiS actions which are righr orwrong? And the performrnce (or avoidasce) or $rchactions will establish our goodness or badness. We mayhave ro begin, t[en, by reflectiog oo what is a distincdygood or bad humatr act atrd to do tiat we may have tocomider what it js ao be a good human being. Thequestion, 'what sort of creatures are we?' leads to therealms of philosophy of mind and of religion. ANwersto such questions may involve thought about thenature of language which distitrguish€s humaDs adchar"cterises or circur$cribes our utrderstatrding orthe wodd. A[ of this before we have el.etr aplxoach€dthe specfic questions of, say, whether to tamper wiihthe embryo.ff Ethics is also a higlly practical affair. For we cannotudenak€ the busin€ss oftrying to underscand *hat itis to be a good human being, what it is to Aourish as ahuman being, wilbour ar fte same riEe developing ourcapacities. Pady we develop precis€ly that capacity ofbunan dourishitrC whicb we s€ek to €lucidare, agaitrstressing that this study, by its mture, musr b€ deep.

Of course, we can act as good human beings withoutstudyiry efiics, but that our activities arc good acrio$camot be uncridcally takeo for gatrled. The pointhere is that this critical evaluatiotr, if profouDd alld norsuperfrcial, {'ill itself de€pen us.

12 Slot erhics ioro rle course, then, bet*eeD alatomyand biochemisrry? Perhaps rhar would do more barmthan good. No, the real change is radical. A degae€cours€ for iBtaDce, i! which rbe preclinical sciencesw€te rehitded down to essetrrials, wirhout rhe plerhoraofinformatioa soon forgotten a]ld not required again,inregat€d with a course iD lie srudy of rtre wideraspects of hJmaoity. Such a study must be philoso-phicxl but mieh include historical, social, potiricrl,teligious and even economic aspects. And would it Dorbe que€r if students coaiDg ro be doctors were norintercsted atrd commifted ro rhis study?

For our study ofhuma! beings: we seek ro und€r-stand, to work \rith, to affect, ro change hman b€iqsand we ourselves are humatr. Hence we begin and endwirh utrderstatrditra and krcwledge of ours€lves.

Philomphers are fond of quoting Eliot q'hose wordsseem opposite h€re roo:

'Ve sbrll not ceas€ from exploratiotrAtrd the end ofall our €xplorilg'Will be to arrive vrhere we sta{edAtrd ktrow the place for the 6rst time."T.S. F.Ltor, L;ttla C'idins

I B.M,G. olB on D.diel edics Friday 28th Mdch. Apply toDr Su€ Doeliry ai Ceylse HsI sln.

2 B,lLt l3lh Feboaly 19883 J.M.E. 1984, 10: 179-1824 J-M.E, 1984, I0: 12I

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l3

COMMENTSBlack 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 SmokingFrancis Roe's humorous articlc (Bla.l Bdg, Autumn1987) should not be taken too seriously. He is probablyfed up with his self-appointed position as lhe onlytoxicologist in Britein who is supposed not !o be toegainst tob.cco. As I am watcbcd continuou$ly by theagEnts of ASHr, HECI, OOMPAPA+ and $cverrl otherorgaDisations, I am obliaed to offer a brief counter-bla$t, I shall probably be elimineted if I fail to reach theEditor's deedline.

Careful readers E'ill have rctic€d that the articlecontains 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 thani[umiration).

2. The Redgrave gambit (use ofthe word middle classas a rerm of abuse).3. The Ilwis Carm endgrme (illustraling your

neaning with a melmuous but totally incomple-hensible piece of doggerel)-Dr Roe 6nds much Dastier things ilan tobacco iD his

toxicological woodshed. He is agai$t nuclear wasteand uncontoled asb€stos. Ve could add acid rain,rive$ of mercuy, fr€on h ihe strEtosph€re. Beingdighdy less against tobacc,o is not the same as beingfor it.

You can stil obtaitr Dany drugs that rot your liveratrd zap your finger Dails. 'Opren' was banned not iustbecause it sometim€s did those things but b€caus€ itspurveyors rcfus€d to admir ia time tlat it might, Th€repmbably is a place for a herbal s€dative with mildlyaddictive prcperti€s which caus€s catanh, emphy-sema, lung cancer, coronary discase, stomach ulcersand grangrene as wel ss respiEtory silnetrts in otherpeople. If the m.nufactuers of thfu remedy will notkeep the date sheet in front ofprospective buyers, thedishonest end inscnsitive health education lobby has todo this for them.

Dt. Gabrbl Laszlo

1 Acrjon on Smkinr dd Heltht Hc.trh Eduetion Coucil (!ow Autbdiry)+ Orsuietio! for Mcdi6 fo. thc PeF.tio! ol Abelut ly Purc

Hands Up All Those Who HaveHeard Of The Dawson Report

"That thz hospnah haoe fallcn on ail dqs * hnoun to

'Dawson R€port', 1920, para, 82

rwilliam Ree$-Mogg writirg to the Indz?endnt ('lues,9th Feb. 1988) on the daqer of clich6s and simplisricimagery distorrirg the complexity of ruth, makes alrimportsnt but uoderemphasised poitrt: "The trurhabout Lhe National Health Service is thar i( is over-sEetched ald sholr of money. The lie is thar all thar isneeded to rcstore the service is for rhe Treasury loprovid€ 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 offenhospital cssh itr NHS pay M deal", "Chariry cashhelps recruil extra nurs€s". Gsh, cash, cash . . .

In l9l9 Sir Beruatrd Dawson, later Lord Dawson ofPenII, became chairman ofrhe Consuftative Council onM€dicql and Alied Sereices. This body was set the taskofpmducing a repon (although the evennul documetrtwas only htetrded to be an interim repon) underthe following terms of rcfermce: "To consider atrdnake recommenilations as to the scheine or schemesrequisite for the systemised Fovision ofsuch forms ofmedical atrd allid s€rvices as should, in rhe opinioD oflhe CouDcil, be available for the inhabiranis of a givena&a." Without becoming bogged down in hisroricaldetail. ir is enough ro say ltut this was a visionarydocument that has remained in0uential (Thoug! irwas, at the time of publicatioD, quiedy shelved.)

It remains infuetrtial bccause it was controv€Isiali"Preventiv€ atd cuativc medicine cannot be separ-ated on any souad principlc, atd in any scherne ofmedicd services must be brought together i! close co-ordination." The celtrel fcatue was the concept of the'Primary Heslth Gntre', insritutions "equipped forservices of curstive aDd preveltiva medicine to beconducted by the Seneral practitioncrc of lhat district,in coniuoction with an efrcietrt Du$ing service andwith the aid of visiti[g cotrsultatrts aDd sp€cielists." Itenvisaged the burdeD of the ho6pitals b€iDg ersed byeffectively co-ordiMted communiry health servicesi"Domiciliary nursing is an €sseorial pan of a healthseIvice." Th€ documeDt psys scatrt allention to ques-tions of fundinS bur how irs proposals frmly rooted itrideology and redical rhinkirg.

So, iD our pr€sent clinat€ of cash crisis and cashclich6s, why mmtioD a documenr bom of an age

14

dedicated to creating a land 6t for heroes? The poliiicalclimate may have changed atrd th€ report's empbasison such ideas as 'pbysical cultue' msy s€€m ourmodeditr the extleme urder pr€sat improv€d stendards ofliving, but it do€s still addr€ss the complexity oftruth.

Everywbele itr the curretrt debate we s€€ thesimplistic images. We see p€ople taking sides. We reademotive 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 HcelthSelvice thet succe€ded it twenty-eigh! yeers leter, buiils attempt to widen understanding of service andstendards in a heahh system can still be appreciat€d.Will this bold exaFple ever be followed? Or will thedebare remain centered on babies with holes itr theheen and budgets wilh holes ell over the place? Handsup all fiose rvho bav€ heard of the Dawso! Repon?

Nisel Lestzr

Is the "Scheme" working?When applying for prercgistratio! house jobs lasr year,

I presum€d, rather naively, that fair play ]pould beuniverssl itr the "Bristol Scheme". Sadly however, thiswas trot to be. C,otrtact betwe€n studeDts and consul-t3trts was often made prior to interviews, and quiteoftetr utrfair or even chauvinistic tectics were employedto 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 LiahonCommitt€€, d€a$, consultrnts, and students allcrpress€d abhorrmce of thes€ plactices, TheysuSg€sted tha! Grlenicals should write to ell B stolconsultatrt$ end that they should deter students fromapproaching them. Many agrced on peper and yet jtapp€5rs now that practices are worse tlan eve!.

At the very last, ifconsuhalts do decide to allocatetheir 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 nothav€ a place to play itr the s€arch for a job, simplybecaus€ it doesn't wo!k. It should b€ scrapped, thusslowi$g individuals to apply for iobs wh€n and wherethey like. Whilst this should mtke litde differ€nce todrcse already for iobs, it will at leastremove the molal obligatiotr whicb Lhe $heme imposesotr 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.

frKfis*r

@,@l5

CHILDREN AT RISKOn l3th and l4th February, the London Medical Group held a conference to discuss rhe manyhazards 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 focusedon many asp€cts of 'Cbildrm at Risk'; from childrenunder extreme stress in war zones to those living inacute poverty in developiog countries, to childrenabused by their parenrs in our modem 'developed'society-

Possibly, one special form of abuse b the premedi-tated termination ofthe Me ofa foetus, and because oflhis subiecr's populariry in the rccent media, wirh theDavid Ahon Bill. ir shall b€ discussed here, ulcorpor-ating some of th€ views of the conference speake$,such as Professor David Morley, ryendy Savage,Genld Hughes, Srephcn Wolkind and Dora Black.

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

It would seen rhat the foetus does indeed have somerights. It is a living senrient being, thar holds rhe valueof one dey becoming aD aduft. The baby in-urero doesnot, though, hrve lhe same claims es the adult. Forexehple, ahhough often beirg Siven the right to lifeand health care, it cleerly cannot be allowed to marry.

However, when does the developing child acquirethe privilege of righls, and do€s ir procure more as irgets older? The answers lie in deciding v,hich thingshave rights; iusr human beings, any living sentienrbeing, any living orgrnism, or nonliving materialobiects? Mayb€ the liae crn be drawn ar living thingswhi.h respond to stimuli. For example, the butterflyhas a right to live. and a morher mighr stop a six yesrold boy from rearing off its win8s. However, does rhehuman embryo shortly aft€r cotrception have tie sameability to respondl Thus, does it have a claim on lifegreater or lesser lhan rhe burrerfly. The argument isclearly more complex than this- The €mbryo has agrearer value because of its porenrial ro become ahuman being.

Presumably though, society presenrly assumes thatthe glowing foctus is nor worrhy of life unril it reachesrweoly-eigbr weeks ofgesrariooal ag€. ar wHch pomt iris protected by law from anifcial abonion.

Twenty-eight weeks has b€etr chosen as the lower-limit of the age acquisirion of the righ. lo live be€ausethat 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 ilto claim a right to life ilr-urerc. The limir is farcical, norbeing Mscd on fte foerus'senlienr qualiLies, oreven ilslevel of consciousn€ss, nor irs pot€trtial ro be a useful

valued adult, but otr some outdated estimat€ of itscapacity to survive if ir were ro be exp€ ed suddenlyitrtQ the outside world. A double standard €xish. Fori$taDce, a child who6e life could be termitrated att$enty-four we€ks may have the potential to live, andyet legally not have the riglt. However, the same ch-ild

who is bom prcmanrely can be help€d to survive withthe aid of neonatal htetrsive care.

Ideally, teminalion of pr9gtrstrcy only occurs wheothe dsk to the mother's physical or menral self if theprcgnancy werc allowed to continue arc greater than ifit were stopped, or trcause th€ foetus is so severelyrnslformed thar it can oDly lmk forward to a demon-strebly awful life. The crse of the 6ve year old who isquadraplegic, has a proFessive kyphosis, suffers fromftcurrent chesr iDfections, is cortically blind, andknows no life outside a hospital bed may be clear cut. Ifantenrtrl diagnosis could have predicred the quality ofthis child's life possibly ir would heve been kinder tohave ended ihc moiher's pregnancy end ler the babydie. 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 havevery happy and fulflled lives.

Maternal rights musr bc considered in rcleiion rorhose of the fo€tus. Ce! the pregnancy be allowed roconlhue if it is goirg lo ruin th€ already $tablished lifcof the motber or her femily? !?hat is the impact of aseverely handica$,ed child being boln into a fami.lywhere the mothct is alteady sEess€d ard ove!-burdened looking efte! he! orher cNldren? Is thefoetus to be p€rmitted lo live despire hersh economicsnd €motioDal deprivation thar may subsequentlybefall the other children?

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The dilemma's of ethics in 'Children at Risk' arematry. Above, I have oudined some of those moratproblems that we face conc€rning the foetus, whoseright to life, health care, and so on, must be carefullyevaluated, so that it can be decided whether thesedshts ar€ being violated, and wh€ther the chnd in-utero is being abused. A peDultimate thought is "whatis the burden of these foetal rights on rhe communily?"Can we afford up to f100,000 per child for neonatalbtensive care, or is ii wrong to even conremplare thechild's value and tuture in lerms of money?

V'hat of boderlirc cases in prenatal diasnosis? Ifthe unbom child is recognised as having TurnerSyndrome when its chromosomes are studied toexclude Dovvn Slndrome. is $erc case for termitra-tion? If the chitd is going to be infertile, a bit shorterthan average, and with a webbed neck are these suf-fcient grounds to take away this developing baby'sright to life?

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

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L7

IMPRESSIONS OF POLANDThe clinical attachments offer a valuable opportunity to sample medicine in a variety of settings andeven cultures. Here, Andreto Piotrowicz, who has recendy returned from an Obstetrics and Gynaeco-logy 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 moretrue than in Polad. At a time when one year wasdrawing to a close and the next could only promise yetanother round of price increases, the Poles were urged!o draw confort from the fact that 1988 would, at leastbe an average year. Although worse than 1987, it wouldstill be better than '89.

This little gem of wisdom, supplied by a T.V.presenter who, I believe, sdll has his iob, went downwell and was often repeated. Few Poles could havcconveyed berler rhe currenr climare of pessimismhangiry over the country, and even to th€ least obser-vant western visitor it is inrnediately obvious thatPoland has indeed fallen upon hard times. People donot need to be asked before telling you about thetwenty year long waiting list for flat, that the price of acar h equivalent tofive yea$'wages or how much timeis wasted searching and queuing for life\ bare necessi-ties,let alone its little luxuries.

This situation is trot unique to Poland and neitherare the resulting widespread coruption and flour-ishing blackmarket. No oner however, s€ems moleable in applvmg their talmrs in $ese 6elds ro s€eitgthemselves through times of crises than the Poles, afact which must reassure them far morc than do theirwitty T-V. presenters.

At no time was this crisis more apparena to me rhanwhile working in a major hospirai spccialisine inObstetdcs and Cynaecology. This hospital, despite itsimpressive array of ultrasound machinesr possessedonly one cardiorocograph, acquired by an enterprisingObstetrician fortunate enough to have colleagres in rheWest. Rubber glov€s and catheters, along with orheritems considered to be disposable over hete, wercpainstakingly rcsterilised and a steady supply of manyessential drugs was only possible thanks to rhe benevo-lence of Western charities. The lifespan, however, ofmedical equipment is limited, a6 must be rhe resources

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of charirable o.gatrisatiotrs, and it is dot difficult toenvisage the coDs€quences ofa Daive aod shon-sight€dSovemmenr policy wb.ich regards iDvesrmeDt in rlenation's heahh as wastefii and ecotromicslly uffew-ardiry. This poticy also go€s far ia explaining whydoctors are paid less than trvo thirds the wege of anunskilled manual lebourer, and who, es a result, mustsupplement their income by doing extra tetes ordemanding unoffrcial !,eymeDts from their patientswho in exchange receive swift and pain free Eeatmentin s hospital bed. I! such e system, where heshh carewolke$ are so hampered and frustrated by poorworking conditions and in whom quslities such asskill, dedication and professionalism are so undeava-lued, the human face of medicine is 6rs! to suffet,followed inevitably by declining standerds of care.This has rcsulted in claims stating thar health cerewould be far betrer offin privatehands, a response theris both predictable and imnically familiar.

Yet, despite all of rhes€ shorlcomings, Poles can atleast claim thar nowhere else behind lhe iron curraindoes lile seem tess dgid and flee liom tXe conslramts olparty dogma. Streets arc no longer liraered wift redstars or slogans, religion can be practiced freelywithout recrininations and the press callies aniclesopeDly debating controversial issues. Poles also 6nd itrelatively easy to travel to th€ wesr, and although theirlack ofmoney and dubious financial practices have notmade them popular guests, it srill rates mor€ high.ly intheir affections than any socialist neighbour. Notsurpdsingly, therefore, any cuftural imports come fiesame direction. Cinemas show lhe latesr U.K. andU.S. flm releases, aDd a significalr amount ofT.V. airtime is devoted to pop videos, game shows and hard-sellirg advertisiry.

As a result of being fed a diet of travel tales and sellimposed western values Poles have a concept of thewest to which they relate very well and regard them-selves, slightly ideslisticatly as potenrial equals of erywestem EuropeaD natio!, prevented from achievilgthis much sought afte! parity as much by low wsgesand atr ircotrvenible currency es by their politicalsystem.

This form of altemative communism is, in one sensea step forwcrd. Ttre adoption, however, ofsuch liberaland democratic relucs is ofdoubtful signficance to thecountry's rEal Ploblefn. Yet, it is this $ystem of valueswhicb continuG to b€coEe hore end more progressiveas its meatrs of$ppon drviodles, th.t the Poles unlikelheir westelD crEditoas arc reassur€d by. It must surelytr far easicr ro frcc up to a crisis with rhe veneer ofthese outwErd sigDs esseiat€d wirh prospe ty forsuppon.

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