Monday, 25 November 2013
Monday, 18 November 2013
I should make it clear from the start that while I don't think the NHS is perfect (not to mention the recent shambolic develpments across the Pond) I am absolutely in favour of social healthcare. I have seen children in shanty towns in Peru with no teeth, where those living in poverty will walk out of a hospital and die two days later from appendicitis because they can't afford to pay for the surgery. But I also know a man in the USA who had a kidney transplant but is no longer in work and can't afford health insurance which means he can't afford the medication he needs to prevent his transplant being rejected. Fortunately, the local transplant patients basically pool their meds so that if one month someone can't afford their tablets, then they will be supplied by someone else; a situation which strikes me as no less tragic (although on the other side, also restores one's faith in humanity). However, one of the biggest problems with free medicine (and the Welfare State in general) is what happens on the receiving end.
Research shows that people who get free prescriptions visit their GP when they are suffering from a minor ailment in order to obtain over the counter remedies on prescription rather than paying. This has led to the establishment of minor ailment schemes, whereby those people who are exempt from prescription charges can obtain such remedies free of charge. This frees up GP time and resources for people who have more serious problems.
Recently there has been a lot in the news about the pressure which A&E departments are facing this winter, with 40% of those patients seen in A&E not needing to be there: they could have been treated earlier and/or in the community. At the weekends, A&E is often full of alcohol-related (alcohol-fueled) injuries, and sometimes people will end up there because they are seriously ill and it is one of the paths to hospital admission. A while ago I saw an ambulance which bore an explanation of what was meant by a life-threatening emergency. (I was tempted to give my brother a similar list after he woke me up extremely early to ask where Mum was.) Tales of bizarre 999 calls, which often include people who want a lift to a hospital appointment, are frequent and mind-boggling.
Often it is the elderly who suffer, whether because they didn't go to their GP in time (couldn't get an appointment or didn't want to bother them), or because nobody took them or even noticed that they were a bit off colour. The point at which someone realises you have a mild case of cystitis shouldn't be when you're admitted to hospital with a broken hip (more common than you might suspect), because if someone is suddenly acting confused (often the first symptom of cystitis in older people) then your neighbour or your friend or your carer or someone should notice. And if someone is calling the ambulance service because they need help bringing the washing in and the path is icy, or they need a lift to the supermarket, then we should be asking ourselves why. Why is it that this person had to call 999 for help with a simple task? And I fear the answer has a lot more to do with individualism, loss of community and the selfish desire not to be burdened with other people and their problems (which some might call freedom) than the fact that our healthcare is free.
Sunday, 3 November 2013
And it's not just me.
Recently I have had a few conversations with friends and acquaintances who suffer from a weird problem. Actually it was a relief to me to find I wasn't alone, because after yet another conversation with my Mum which involved her threatening to throw a book which I was reading in the bin because it had the word 'Catholic' in the title I was starting to get a bit stressed out. The only reason that book didn't end up in the bin (or the recycling, at any rate) was because I pointed out that it was borrowed. Others have had similar conversations with their parents about books written by saints or popes. We are Generation Y: hiding our spiritual reading under the bed.
The strange thing is that we were all baptised and brought up Catholic by our Catholic parents and now they don't like it.
Now, I admit that when I discerned my vocation and then entered community I didn't hand it as well as I could have done. Announcing my decision in the car as we were driving along a dual carriageway might have had a very different ending and comments such as 'over my dead body' were perhaps only to be expected. But it started long before that. When I first went to university, there was mild concern over my regular attendance at daily mass. Attending social events at the chaplaincy was also considered worrying. It was the first time in my life I had the opportunity to have friends who were also Catholic, friends who, whatever else they were getting up to at the weekend, would make sure they went to mass on Sunday. The people who thought this was odd were the same people who insisted I came home at 9am after a Saturday sleepover when I was a teenager, so that I could go to mass.
I have a crucifix on the wall and a statue of Our Lady in my bedroom which is considered excessively pious of me, and yet there is a crucifix on the kitchen windowsill (in fact, now I come to think of it, there are two). We each own a copy of the Catechism, but knowing what is written inside it is over the top.
I know that it is traditional and expected for each generation to view the other with mild irritation and bewilderment (music isn't what it was, after all) but praying the rosary, going to confession, not talking in church; these are things our parents taught us which they now hope that we don't do. And then there are the things they hoped we would do, these being 'normal', but we choose not to because we are Catholic: things like sleeping with people we aren't married to, using contraception and talking openly about the fact that we are against abortion rather than just thinking about it. We try to keep up to date with Church news, keep an eye on what the Pope is saying in his weekly audiences, and pray for episcopal appointments. We don't eat meat on Fridays, wish the clergy would dress like clergy and also hold dangerous views about such controversial things as...guitars.
Our parents brought us up to be Catholics, and now that we are, they find it worrying.
Monday, 21 October 2013
I was browsing my September issue of Regula+e, published by the General Pharmaceutical Council, which is the regulatory body for pharmacies, pharmacists and pharmacy technicians, when I came across this article about a pharmacist who had had conditions placed on his practice, by the Fitness to Practise (FtP) committee, for 'imposing his beliefs on patients' (pp24-25).
The pharmacist, during the course of supplying the morning after pill (EHC), told a patient that it was "a chemical abortion, was ending a life, and that this would be on her conscience". The patient was shocked and felt "rotten and horrible". He did not give her the option to go to another pharmacy.
Recently I blogged, among other things, about the weirdness of the fact that while pharmacists do not have to supply EHC, they do have to tell the patient where they can obtain it. This pharmacist didn't tell his patient where they could get EHC, because he did not decline the supply. Yes, apparently he was in the habit of giving what the FtP committee deem 'an embarrassing and distressing lecture' and then giving the patient the morning after pill anyway.
There seems to be a whole lot of weird stuff going on here. The FtP committee, for their part, merely have to judge whether a pharmacist has breached the code of ethics and, if so, whether conditions should be imposed or the individual removed from the register, so I'm going to ignore them. It's the behaviour of the pharmacist in question which puzzles me. If it was for moral or religious reasons that the pharmacist gave these speeches to his patients, why did he then supply EHC? What was he hoping to achieve? Was he trying to absolutely prevent evil (ie the patient does not terminate her pregnancy) or just avoid co-operating (the patient gets upset and goes to another pharmacy instead). But if the latter, why did he then supply? It is a mystery to me (although I recogise that I don't have all of the information about the case). And then there is the patient, who reported the pharmacist because he made her feel "rotten and horrible". I'm not saying the pharmacist shouldn't have been investigated, as his actions come across as a bit odd, to say the least: was this his usual manner of advising patients? But as taking the morning after pill causes side effects of headache, nausea, abdominal pain, bleeding and fatigue (very commonly), and dizziness, diarrhoea and vomiting (commonly), the 'rotten and horrible' feeling was somewhat inevitable, if only on a physical level.
Whether you, healthcare professional, go with a straight refusal to supply or a slightly more in depth explanation as to why not, or an attempt to engage the patient in discussion as to the rights or wrongs of EHC (or whatever other substance), do so with charity and professionalism! Haranguing the inidividual is unlikely to achieve anything, and following the harangue with supply even less.
Interestingly, one of the conditions imposed is that the pharmacist is not to supply EHC in the future. Sounds like good news all round.
PS My viewing stats passed the 10,000 mark this week. The list of referring sites may suggest to me that a lot of these views are not real people, but to those actual people who are reading: thank you :-)
Tuesday, 15 October 2013
The American Psychiatric Association have published their new diagnostic guide (DSM 5) and according to quite a lot of people (just google it) they have classed grief as a type of depression. As far as I can tell (without actually buying a copy) this isn't actually true. What has happened is that they have removed the so-called 'bereavement exclusion' which said that major depressive disorder (aka depression) should not be diagnosed following a significant bereavement. They have also listed something called 'Persistent Complex Bereavement Disorder' as requiring further study.
Why does it make sense to remove this bereavement exclusion clause? Well, suppose you had got depression already and then a loved one died and you then sought medical help for your depression. You might not be able to get the treatment you needed because DSM-IV said you shouldn't be diagnosed with it and therefore your insurance company would not pay for your treatment. Maybe you didn't have depression before this event. Maybe you just had a tendency, or a past episode, or were just starting mild depression. Given that the causes of depression are not well understood, maybe you didn't have depression at all. The result would be the same. No DSM number, no drugs. As there don't seem to have been any other exclusions (such as job loss, divorce, or other severe stress) it makes sense (to me, at least) to remove this exclusion which might be preventing people who really need help from getting that help.
On the other hand, as there does seem to be a trend for doctors to overprescribe anti-depressants anyway, it does mean that there is now further potential to misdiagnose depressive disorders. Furthermore, evidence shows that many doctors end up prescribing as a way of ending consultations. Also, as all of this is taking place in the USA where prescription medicines can be advertised to the public (not allowed in the UK), there is a possibility that drug companies could target the recently bereaved, who will then go to their doctors demanding anti-depressants which they will be prescribed and which will not help them because they do not have depression, they are grieving. Due to the stigma attached to mental illness it might also mean that some people don't seek the support (by which I don't mean treatment) they need in their grief because they're afraid of the potential diagnosis. All of which begs the question: when did it stop being OK to be sad?
Or perhaps we are sadder than we used to be. With the loss of God from our culture, we have also lost the resurrection and life after death. Funerals are now termed 'celebrations of life' and even mentioning the deceased can be something of a taboo. Deciding whether to tell a friend or acquaintance that you are praying for them and their loved one presents itself as a dilemma (even if praying for them is the first thing you would do). A friend of mine told me recently that after agonising for some time, she decided to offer her condolences (and prayers) to a colleague whose father had died, with the awkwardness of trying to broach the subject with someone she didn't know that well compounded by the fact that everyone else in the department would fall silent as soon as he came into the room. Some time afterwards, he told her that she was the only person at work who had said anything at all to him.
We no longer seem to know that it's OK to be sad. It is wrong, and therefore pathological, an illness. And in a way, there is something 'wrong' in that sadness wasn't part of the original plan: sadness and grief, like death, are a consequence of moral and physical evil. We have no idea how to talk about death. We worry about exacerbating grief, making someone sadder, or causing offence or embarrassment (as if brief embarrassment on either side could really be worse than the death of a loved one?!). So here it is (for what it's worth), my opinion about being sad: it's OK to be sad. And this may be the key to telling the difference between grief and depression. Grief is not an illness, it is part of life, just as death is.
Monday, 7 October 2013
I suppose a baby factory is the obvious successor to the egg bank, but it wasn't something I was expecting to come across in last week's Metro.
The most ridiculous aspect (and now I've said that I am torn as to which bit is actually the most ridiculous) of this article is Dr Patel's claim that she is carrying out a feminist mission. As the Anscombe Bioethics Centre wrote in their review of the Human Fertilisation and Embryology Act:
Surrogate motherhood involves a further fragmentation and trivialisation of parenthood, in that a woman deliberately becomes a gestational mother with no intention of committing herself to caring for the child she gestates. This practice is exploitative of both the woman and the child, and damages the way conception and gestation are regarded in society as a whole. If surrogacy cannot be prohibited altogether (the option we would prefer), commercial surrogacy, at very least, should continue to be prohibited. We do not believe that agencies should be registered with the Department of Health, as the Brazier Committee recommends, as this would constitute official endorsement of such agencies. (An analogy might be with the case of prostitution: those opposed to prostitution are rightly unwilling to accept the official registering of brothels, as this effectively legitimises their existence.)
Dr Patel is clearly exploiting women; of the £28,000 a couple pay for a surrogate mother, the surrogate receives less than £5,000. For 9 months manual labour (a 'physical job') the mother earns approximately 73p an hour (based on a 40 week pregnancy). And paying a woman for the use of her body is definitely analagous to prostitution. But hey, at least facilities are sterile!
And then we have the desperate couples who choose this option and are willing and able to pay. Are they not also being exploited to a certain extent (albeit in a design of their own making)? This is not a good way to have a family: I know of one woman who regularly tells people how much her IVF twins cost her, apparently believing that their grades should be better than those of other children because they cost more. As they get older, will she dictate to them on the basis that she paid for them? Isn't that a form of slavery? As always it is the child who loses: exploited by both genetic and surrogate parents.
We are now way beyond the start of the slippery slope: there are those who are 'too posh to push', those who choose the gender or disability status of their children. It would not surprise me if there were also designer pregnancies, where the pregnancy happens to another person, whether a woman is fertile or not. Is this the new feminist ideal: the exploitation of one woman to spare another some nine months of inconvenience? Even organs are not commodities to be traded, selected, bought, sold or even rented, so why do we seem to think that children are?
Monday, 30 September 2013
Yesterday, my brother Andy* and his girlfriend sat down and filled out a mortgage application. Every so often I was asked my opinion about what I thought certain questions were getting at. I did my best to answer them but mostly, given my total ignorance of mortgages, credit cards and money in general, I pointed them in the direction of more reliable answers. I found myself wondering whether I should refuse outright, be rather more non-comittal or launch into a lecture on how co-habitation is not in God's Plan for them, despite the fact that my big-sisterly-omniscience apparently doesn't extend to morals. Andy and Gertrude** plan never to marry (G wouldn't mind if A insisted, I am told, but A is against it) or have children (A would secretly like to but G is vehemently against) and wish to buy a house together so that they can live happily ever after. My other brother, Chris, married Adele*** earlier this year, and prior to this they had been cohabiting for two years in the house they bought together. Now, when Chris told me the two of them were moving in together I expressed my concern and talked about it with him. He was unreceptive, but there was no animosity. Chris and Andy are extremely different in their openness to different ideas, and Chris at least has some basic appreciation for Christian morals. It was worth a try. With Andy there would be no point.
This issue of what counts as co-operation has been on my mind for some time, and I have a tentative plan to follow up my post on healthcare professionals and the law with one on conscience. Here's the deal: Pharmacists have a conscience clause in our Code of Ethics. We can refuse to do something if it is against our moral or religious beliefs. However we must "make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers". In general, among pharmacists, it is agreed that a conscience clause is a good idea because healthcare professionals constantly have to make difficult decisions about what the best course of action may be. However, the fact that we have to refer the patient to another provider rather makes a nonsense of it: I won't give you the morning after pill but my colleague here/over the road will.
I often have conversations with people about how we should handle these ethical dilemmas. For practical purposes I think it is virtually impossible for a Catholic pharmacist to work in community pharmacy (ie a shop) because although 'Emergency Hormonal Contraception' is not an essential service under the NHS community pharmacy contract, it is locally commissioned by PCTs and unless you have the luxury of owning your own pharmacy its unlikely that you would be in a position to say that the pharmacy won't have anything to do with it, and in any case you would still have to tell the person where to access said service. In hospital pharmacy it is a bit easier to pick and choose what field you work in. Most hospitals do not supply contraceptives to in-patients (for obvious reasons), but if a patient is usually takes hormonal contraceptives, you still need to clinically check that prescription. So then what? Is clinically checking when you aren't going to supply a problem? Even if you work in geriatric medicine there is still the dispensary slot, the on-call time when you can't hand over to a colleague. Leaving scripts to one side for other pharmacists to handle is practically a hanging offence. One friend and I were shocked to hear that a consultant simply passes over the ethically problematic patients. For us, that is not how it works. Some people would say they wouldn't dispense Viagra, in case the person was not married, or having an affair, or other immoral behaviour...but surely there comes a point when you have to give someone the benefit of the doubt. What if the person is married and erectile dysfunction is placing a huge strain on their relationship? How far can we go down this line of thought: should we even be working in the NHS?
What should we be doing as Catholic pharmacists or other healthcare professionals? Where should we go and work? I don't think the answer is for us to seek out fields of healthcare without ethical dilemmas, because that would also limit our opportunity to transform all of the temporal order which is in contrast to the Gospel (always supposing such fields exist). And I think we definitely need Catholic healthcare professionals. Must we just accept that our career options will be limited, our colleagues will mistrust or despise us and that we end up doing an unfulfilling job because we need to provide for a family?
Answers on postcard, please.
*Not his real name; if I use a psuedonym myself I'm hardly going to reveal his identity.
**Obviously not her real name, but follows a pleasing pattern known only to myself.