The Potential Impacts of Brexit on the NHS

On the 23rd June 2016, 52% voted for Britain to leave the European Union. What are the potential impacts of Brexit on the NHS?

Workforce

55,000 of the NHS’s 1.3 million workforce have come from other EU countries. This includes 11,000 doctors (about 10% of doctors) and 20,000 nurses in NHS England alone. This is due to the EU’s current policy of freedom of movement and mutual recognition of professional qualifications within the EU. The BMA states that the “ongoing uncertainty and insecurity is having a destabilising effect on the medical workforce, affecting morale and causing a great deal of stress to those whose futures remain uncertain.” This is already affected staffing levels: nearly half (45%) of EEA (European Economic Area) doctors surveyed by the BMA are considering leaving the UK following the referendum vote. Of those considering leaving, more than a third (39%) have made plans to leave, meaning almost one in five EU doctors (18%) have made plans to leave the UK. Also, the Royal College of Nursing reported a 92% drop in registrations of nurses from the EU in March 2017. Even with current levels of migration, the NHS struggles to recruit and retain permanent staff. The NHS, therefore, cannot afford to lose so many highly skilled workers as this will greatly exacerbate staffing shortages in hospitals and GP surgeries. This could have drastic effects on the quality of patient care and patient safety.

Access to medicines

The UK is currently part of the European Medicines Agency, which regulates the approval of medicines to be placed on the EU market. 73% of UK pharmaceutical imports come from the EU. The worst-case scenario would be a hard, no-deal Brexit, which can halt the importation of drugs is overnight. This would have serious consequence for patients with serious medical conditions. If there is no solution agreed during Brexit negotiations, certain medicines and medical technologies may be delayed in reaching patients or may even become unavailable to patients. In preparation for this, drug companies have started stockpiling medicines.

Medical Research

UK organisations are the largest beneficiary of EU health research funds in Europe, with €760 million in EU funding having supported research in the UK between 2007 and 2013. We will lose this funding when we leave the EU, and therefore the opportunity to be included in research projects. Already EU-funded collaborative health projects are less willing to engage with UK organisations. This will lead to the unnecessary and costly duplication of facilities and product testing.

References:

Effect-on-the-NHS-of-the-UK-leaving-the-EU.pdf BMA

http://ukandeu.ac.uk/the-impact-of-brexit-on-nhs-staff/

http://ukandeu.ac.uk/brexit-what-are-the-potential-impacts-on-the-nhs/

https://www.kingsfund.org.uk/publications/articles/brexit-and-nhs

https://www.healthcareglobal.com/public-health/how-will-brexit-impact-uks-access-medicines

The Morality of Physician-Assisted Suicide and Voluntary Euthanasia (PASE)

Ethics

The teachings of the Roman Catholic Church would absolutely reject any form of assisted suicide or euthanasia claiming human life is made in the image of God, so purposefully ending life is a sin. On these grounds, suicide is also unethical. Thomas Aquinas, widely acknowledged as the greatest Catholic theologian and philosopher, summarised this in “It is not lawful for man to take his own life that he may pass to a happier life, nor that he may escape any unhappiness”[1] .Similarly, most religion traditionally rejects assisted suicide and euthanasia due to the principle of the sanctity of life (the idea that all human life is sacred, or holy, and so should not be violated), and the idea that the separation of the soul and body should be a natural process.

However, most major religious doctrines also reject abortion, the use of contraception and stem cell research, yet these processes are generally accepted in the UK as norm. Perhaps this is because it is questionable, by even religious philosophers, if these traditional views are too outdated to apply to today’s society. Further, even if religion does condemn PASE, this doesn’t mean it should be illegalised and taken away as a choice for others. More modern, or secular ethical theories may then be more applicable and useful today. For example, Joseph Fletcher’s situation ethics, states that PASE can be acceptable if it maximises agapeic (Christian) love. Aristotle’s virtue ethics also supports that PASE can be ethical as it involves the virtue of compassion[2] .However major questions about the morality of PASE still remain.

Is there a difference in morality between physician assisted suicide and voluntary euthanasia? It could be argued that in assisted suicide the patient self-administrates the barbiturate, so has more responsibility and the physician has less, compared to euthanasia when the physician is administrating. There is also less of a risk in lack of consent with assisted suicide than in voluntary euthanasia.

Right to death

Do people have a right to death? Suicide is legal, suggesting that people do. It seems unfair that people with health problems that prevent them from being able to commit suicide do not have the same rights as a person who can. Why shouldn’t people with a physical health problem be able to make an autonomous decision about their death, when people with psychiatric problems can? Patients currently have the right to refuse life-sustaining treatment, and to proportionate palliation, even though it may hasten death, so why don’t the right to death. Y. Tony Yang argues that “the ‘right to die’ is a euphemism for the putative ‘right to have a physician help me kill myself’, which he believes “is never justifiable”[3]. Another criticism of the ‘right to die’ argument is that suicide cannot be rational, so it would be irrational to allow PASE. However, Héctor Witter proves that “anyone arguing that doctors may not assist in suicide in any way because suicide is essentially irrational is arguing for a thesis for which no plausible justification can be found”, because someone who is burdened with both physical and mental illness is still capable of making a logical and well thought out decision[4].

Attitude of the Public

The public attitude on PASE is difficult to assess, as support varies greatly depending on how the question is phrased, and if additional information such as prognosis, age and symptoms are given. See table below[11]:

However, generally research has concluded that in Europe there is a East/ West divide where most of Western Europe is becoming more permissive to PASE and most of Eastern Europe is becoming less permissive[6]. The British Social Attitudes Survey, one of the most reliable surveys of public opinion, has conducted several questionnaires on the issues of assisted dying and voluntary euthanasia[7]. The results find that the majority of the public support assisted suicide and voluntary euthanasia, particularly if it is conducted by a physician, and the patient’s illness is terminal.

2005 BMA survey

 

 


Attitude of Doctors

Voluntary euthanasia tends to be supported more than physician assisted suicide.[8] The consensus of doctors is equally important in the discussion of legalising PASE. Research concludes that physicians generally oppose both physician-assisted suicide and voluntary euthanasia, generally on the basis that it is not compatible with the role of a doctor. Even physicians who supports the legalisation of PASE are less likely to be willing to participating in the process. In 2014 Medix held a survey to research the views of 600 UK doctors on physician-assisted suicide and euthanasia[9]. 58% said that they would not support a change in the law for physician-assisted suicide, and 54% said that they would not for euthanasia either. Only 29% said they were in favour of both being legalised[10].

 

References:

[1] Thomas Aquinas, 1485, Summa Theologica, II-II, Qu.64, Art.5

[2] John Frye (2017) AQA A-level Religious Studies Year 1: Including AS. Hodder Education. Pg 119-204

[3] Y. Tony Yang (2016) Why physicians should oppose Assisted suicide. Journal of the American Medical Association, 315(3), 247-248

[4] Héctor Wittwer (2013) The problem of the possible rationality of suicide and the ethics of physician assisted suicide. International Journal of Law and Psychiatry, 36, 419-426

[5] Ezekiel J. Emanuel, Bregji D. Onwuteaka-Phillipsen, John W. Urwin, Joachim Cohen (2019) Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada and Europe. Journal of the American Medical Association, 316(1), 79-90

[6] Joachim Cohen, Paul Van Landeghem, Nico Carpentier, Luc Deliens (2014) Public acceptance of euthanasia in Europe: a survey study in 47 countries. International Journal of public health, 59(1) 143–156

[7] Ruth Campbell, Jacqueline Connolly, Judith Cross, Martin Davies, Fay Davies, Veronica English, Gail Grant, Daniel Hodgson, Lucy Merredy (2015) End-of-life care and physician-assisted dying. British Social Attitudes, 20(1), 82-83

[8] Clery E, McLean S, Phillips M “Quickening death: the euthanasia debate”, in Park A,

Curtice J, Thompson K et al. (eds.) (2007) British Social Attitudes: the 23rd Report –

Perspectives on a changing society. Sage: London. p.41

[9] Ruth Campbell, Jacqueline Connolly, Judith Cross, Martin Davies, Fay Davies, Veronica English, Gail Grant, Daniel Hodgson, Lucy Merredy (2015) End-of-life care and physician-assisted dying. British Social Attitudes, 20(1), 90-92

[10] Medix (2014) “Euthanasia & Physician-assisted-suicide – a summary of results”.

[11] Ezekiel J. Emanuel, Bregji D. Onwuteaka-Phillipsen, John W. Urwin, Joachim Cohen (2019) Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada and Europe. Journal of the American Medical Association, 316(1), 79-90

Dementia

“Dementia is a chronic decline in cognitive function that causes impairment relative to a person’s previous level of social and occupational functioning”. (G.K. Gouras, in Reference Module in Biomedical Sciences, 2014).

Dementia affects memory, making it difficult to remember who family members are, where they are and what everyday objects are called. It can also make people behave in a way that they’ve never done before, escalating emotions of anger, sadness and confusion. Ultimately it leads to the loss of ability to live and function independently. Dementia can affect people of all different ages, but it usually affects the elderly. As the global population ages and with no cures currently available, it is becoming an epidemic. According to the Alzheimer’s Society, there are around 850,000 people in the UK with dementia. One in 14 people over 65 develop dementia, and this becomes 1 in 6 for people over 80. There are multiple causes of dementia, and it is common for people to have mixed dementia where they suffer from a combination of different types of dementia.

The most common cause of dementia is Alzheimer’s disease. In Alzheimer’s disease, the transmission of information via chemical and electrical signalling between neurones in the brain is disrupted leading to the death of neurones, affecting the processes of communication, metabolism, and repair. Alzheimer’s disease typically starts in the entorhinal cortex and hippocampus, parts of the brain associated with memory. It then progresses to kill neurones in the cerebral cortex which is responsible for language, reasoning, and social behaviour. Alzheimer’s disease is thought to be triggered by the accumulation of proteins in the brain, particularly of amyloid-β peptide. Overproduction and failure of clearance mechanisms of amyloid-β peptide leads to the formation of amyloid oligomers and plaques that collect in the brain’s parenchyma and blood vessels. This blocks synapse signalling by affecting proteasome function, inhibiting mitochondrial activity, altering intracellular Ca2+ levels and stimulating inflammation. A build-up of amyloid-β peptide also interacts with the signalling pathways that regulate the phosphorylation of the protein tau, causing hyperphosphorylation. Tau usually binds to and stabilizes microtubules, however the hyperphosphorylation of tau which causes it to detach from microtubules and stick to other tau molecules, forming threads that join to form neurofibrillary tangles. These tangles block the neuron’s transport system, which harms the synaptic communication between neurons.

Another type of dementia is Lewy body dementia. This disease is caused by deposits of the protein alpha-synuclein, called lewy bodies, inside neurones causing them to work less efficiently and eventually die. Other types of dementia include frontotemporal disorders, and vascular dementia.

 

References:

https://www.nature.com/nrn/posters/ad/index.html

https://www.alzheimers.net/difference-between-alzheimers-and-dementia/

https://www.nia.nih.gov/health/what-happens-brain-alzheimers-disease

https://www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tour_part_2

https://www.nia.nih.gov/health/what-lewy-body-dementia

How does smoking cause cancer?

When a cell divides by mitosis, it is usually controlled by cell cycle checkpoints. If a cell has abnormalities it can start uncontrollably dividing, producing a mass of abnormal cells called a tumour.  Tumours can be benign (doesn’t spread), or malignant. Malignant tumours are cancerous and can grow into surrounding tissue, including organs, affecting the usual function of the body. These cancerous cells can break away from the tumour and travel through the blood or lymphatic system to other parts of the body, creating secondary tumours called metastases. There are over 200 types of cancer, but the most common are breast, lung, prostate and bowel cancer.

The biggest, and most preventable, cause of cancer is smoking. It is responsible for about 75–80% of lung cancers- the most common type of cancer, with one of the lowest survival rates. Cancer causing chemicals are known as carcinogens. Cigarettes contain more than 70 carcinogens, for example, benzene, polonium-210, benzo(a)pyrene and nitrosamines. Once they enter the body, cytochrome P-450 enzymes catalyse the process of metabolic activation, which enables them to bind covalently to DNA, forming DNA adducts. A build-up of DNA adducts causes insertion mutations because it stops DNA polymerase processing the DNA correctly during DNA replication. This leads to a frameshift mutation which can ultimately result in cellular proliferation and cancer.

References:

Alison C. MacKinnon, Jens Kopatz, Tariq Sethi (2010) The molecular and cellular biology of lung cancer: identifying novel therapeutic strategies, British Medical Bulletin, 95(1), 47-61

(2010) How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. NCBI

Stephen S. Hecht (1999) Tobacco smoke carcinogens and lung cancer. Journal of the national cancer institute, 91(14), 1194-1210

How smoking causes cancer. Cancer research

Cancer, NHS

An introduction to oncology…

Cancer seems to be one of the diseases which cannot be uttered without a trace of compete terror. Perhaps this is because it is so familiar to us- 1 in 2 people in the UK will be diagnosed with cancer in their life.  Most of us, then, at least knows, or has known someone who has cancer, and has seen the devastation it can cause. I, however, lucky enough to be not be in this majority, have grown up only hearing about cancer through books and television. It first came as a shock to me then, on my work experience in palliative care and an oncology ward, seeing how cancer can leave a person so vulnerable.

As I stepped into the room, I instantly felt that I was disrupting something so massively personal and private that it was insulting for me to be there. The patient was laying on the hospital bed, writhing in pain, her skin gaunt and jaundice- a classic sign of her terminal pancreatic cancer. There was a bed on the floor next to hers, and sat on it, her husband- elbows resting on his knees, and hands holding his weeping head. Bizarrely, I found it equally distressing to see a fully grown man completely broken, and a woman delusional in pain.

It seems dismissive of me to use such intense suffering as a lesson; horrible even to think that this experience heightened my interest in oncology. However, it has. Oncology intrigues me both as a science, and as a potential to support people in some of the most important and terrifying moments of their life. As my interest grows, I’ve done more research.

Should assisted suicide be legalised?

The debate about legalising assisted suicide is an increasingly relevant and controversial topic among both medics and the public. It is also one I have accounted multiple times during work experience and volunteering in palliative care. It further must be discussed to protect both doctors from being sued and vulnerable patients.

To start I would like to make clear some basic definitions. Assisted suicide or assisted dying is the deliberate act or encouraging in assisting someone to commit suicide. Euthanasia differs in that it is the deliberate act of ending someone’s life to stop suffering. Currently the UK law states that all acts or euthanasia and assisted suicide are illegal, with euthanasia being treated as murder or manslaughter, and a maximum of 14 years for assisted suicide.

However, there is a call to the change the UK laws. In multiple countries, for example Belgium, Luxembourg, The Netherlands, Switzerland and some states of America, there are acts that legalise the assisted dying of terminally ill patients. One of the most successful schemes is Oregon’s dying with dignity act. It allows physicians to prescribe lethal doses of a drug (usually a barbiturate) to citizens of Oregon who are over 18, terminally ill with a prognosis of less than 6 months to live, and are proven to be mentally competent. In Oregon’s annual report it states that the top three reasons patients request assisted suicide are due to loss of autonomy (89.5%), loss of dignity (65.4%) and the loss of ability in engaging in activities that make life enjoyable (89.5%). It seems compassionate to allow terminally ill adult patients to have control and dignity over their death, which is guaranteed to be safe and peaceful by assisted dying. Many of these people would instead commit suicide in their homes, risking a painful and gruesome death, or instead have to travel to Switzerland to do this, spending around £10,000. Making assisted dying illegal therefore seems disrespectful and unreasonable  when (according to the dignity in dying British campaign group) 82% of the public would support to legalise assisted dying for the terminally ill, and schemes around the world show that it can realistically work without being violated. So, why is it still illegal?

Firstly, and perhaps most importantly, patients may agree against their will to assisted dying due to pressures from family, caregivers and doctors. This is backed by Oregon’s research which stated that in 2017 65% of those that requested assisted dying did so because they felt they were a burden on their family. In this perspective encouraging people to commit suicide therefore seems unethical. This is largely backed by The British Medical Association and the Royal College of General Practitioners, who share the view that assisted dying would be contrary to the ethics of clinical practice, as the principal purpose of medicine is to improve a patient’s quality of life, not to intentionally foreshorten it. Religious people also generally see suicide as a sinful act as all life is sacred so must not be deliberately ended.

Further, assisted suicide requires self-administration of a drug often taken orally. This prevents those who are incapacitated from being granted help to die. Surely everyone will a terminally illness should have the same rights? This raises the question if assisted suicide is legalised, should voluntary euthanasia be legalised? From these questions, many people worry that legalising assisted suicide will lead to a ‘slippery slope’ towards widespread euthanasia, where euthanasia becomes a cheap alternative to palliative care and the vulnerable are exploited. There is also worry that introducing assisted suicide into the UK will downgrade palliative care.

In summary, it is obvious that there is no clear answer to: is assisted suicide right or wrong, and can it be safely introduced into the NHS? It is not a question that should be taken lightly, however I think there is great importance in raising awareness about the debate, and seriously considering a change in the law.

IQ- nature or nurture?

As an aspiring medical student, I am preparing to take the UKCAT exam this summer. Whilst practising a mock paper my immediate thought was that it is similar to an IQ test. This intrigued me and lead me to question the nature of IQ and, more specifically, if it is derived from genetics or environmental factors.

IQ, which stands for Intelligence Quotient, is a method of measuring the abstract nature of intelligence. It aims to score an individual on their general cognitive ability, or the general factor of intelligence written as “g”, from a series of standardised tests. These scores are also closely correlated with other aspects of life such as health, happiness, choice of romantic partner and longevity.  This is because the same variant of a gene can have a positive effect on intelligence, but a negative effect on a different trait, for example seven genes for intelligence are also associated by a negative correlation with schizophrenia.

The ‘Twins Early Development Study’, conducted by Richard Plomin, investigated the cognitive abilities of nearly 15,000 pairs of British twins (both monozygotic and dizygotic) at the ages of 2, 3, 4, 7, 9, 10, 12, 14, 16, 18 and 21 in order to gain understanding of the relationship between IQ and genes. The aggregation of single-nucleotide polymorphisms (DNA sequence variations often referred to as SNPs) in genome wide association studies concluded that inherited differences in SNPs accounts for approximately 50% of an individual’s intelligence. Each SNP has very little effect on IQ, only increasing or decreasing IQ by an average of 0.005%, and so 10,000 of them must be aggregated to equal the 50%. Genome Wide association studies can be used similarly to link gene variants with around 2,000 other traits including likeliness to have heart failure, depression and diabetes. 

A year ago, no specific gene had been associated with performance on an IQ test, however since then an experiment directed by Danielle Posthuma in Amsterdam has caused a major advancement in understanding the genetic underpinnings of intelligence. The study began in May 2017 by comparing the genotypes of 78,308 people with their IQ scores to successfully establish links with variants of 22 genes. By March 199,000 peoples’ genotypes had been investigated to identify links with over 500 genes variants.

From this research, Plomin proceeded to explain the potential to generate genetic IQ scores of infants to predict their future academic potential, and even set them into groups of similar ability, changing the education system massively.  However, this is unlikely and very controversial as the IQ predictions so far have not been very precise with Plomin himself coming across many twins who have performed both much better and worse than expected. Posthuma states how unlikely it is realistically because “We will never be able to look into someone’s DNA and say your IQ will be 120.”.

In conclusion, IQ is affected equally by genetics and environmental factors. Calculating the likeliness of developing traits, such as a high or low IQ, from gene variants is momentarily too inaccurate to act on but is an exciting prospect to investigate further in the future.

sources:

  • https://www.kcl.ac.uk/ioppn/depts/sgdp-centre/research/twinsearlydevelopmentstudy(teds).aspx
  • https://www.technologyreview.com/s/610339/dna-tests-for-iq-are-coming-but-it-might-not-be-smart-to-take-one/
  • https://www.nature.com/articles/nrg.2017.104.epdf?referrer_access_token=TpmBb9w5DmYbL0VYuSCqStRgN0jAjWel9jnR3ZoTv0PkVtiAvh55KM2rQWkSJWLRkkxao8puND2Er8uFF3y2mPqm98JjW8kcZqvrNYKUPYE2p_wem-nkcrZORQbyyzTPMIvm0BrEpBE_A4Q21rPMjGfrAt7-k_HYC9wqRJrHhf85lRgZhWECJ4-Kr_FKKCJkGeuCOvgywX3dpuKVcdzwSAOgPa8ZF55yiw9Qx0AwAz9Fd3EewMTKOhJafvZY1L4nbOYs2tdOvuGD65416CoDndQHhDqMceB3elZM7YUs4Gk%3D&tracking_referrer=www.technologyreview.com
  • https://www.vu.nl/en/news-agenda/news/2017/apr-jun/scientists-find-new-genetic-roots-for-intelligence.aspx

 

Hello world!

Hi, I’m Hannah. I’m sixteen and am studying chemistry, biology and religious studies in the hope that I will become a medic in the future. I have created this blog to document areas of medicine which I am particularly  interested in or enthusiastic about, as well as direct experiences I have from work experience, volunteering and wider reading. I  am also keen to read blogs from other aspiring medics, medical students, junior doctors and more senior medics.  I trust that this will help me gain a greater insight into the life of a medic and, ultimately, to earn a place in medical school.

Although I am not fixated upon a specific speciality in medicine, I find myself more curious about surgery. The multitude of controversial ethical issues in medicine also interests me, for example the political and moral correctness of euthanasia, stem cell research and abortion.

Hannah Young.