1615
Such issues, in the context of the provision of care for children with problems that were potentially "preventable", have already been raised in North America, and have been related to cases of "wrongful life", and to health insurance provided by employers.’ Do we want to see this happen in Britain too? If society answers Collins’ question by charging the cost of refusing blood transfusion to Jehovah’s Witnesses themselves, will the provision of nationalised health care for children with genetic disease be similarly restricted? Will National Health Service (NHS) care be denied to those whose parents are labelled as irresponsible because they have declined to take part in prenatal diagnosis or screening, or because they have declined to terminate a pregnancy at high risk of some disorder? Will budget-holding general practitioners seek to remove from their lists those families that refuse antenatal screening? The reasons for declining to participate in such programmes, of course, may vary-but these reasons are
HIV infection in Victoria, and a social justice payment was added for those people whose cases in law were weakest. Group settlement in late 1991, despite grossly disparate payments for equally infected people, has resolved much of the anger and divisiveness that was destroying our patients and our centre. The enormous relief, consequent upon settlement, which is shared by patients and their carers, allows patients to plan for quality, not merely in financial terms, in their shortened futures. The gloomy days of HIV disease remain but the distress of litigation no longer affects the immune system.
quite irrelevant if a "medicine of the bottom line" is all that the NHS will seek to provide. The restriction of access to health care in such circumstances could doubtless be justified as the promotion of autonomy and responsibility; appeals to autonomy in this sense (of self-reliance, rather than self-determination) are used to justify cuts in public services by those inclined for political reasons in that direction.2 In addition to these questions of principle, there is also a practical question to be addressed. Do Jehovah’s Witnesses really cost the NHS more, on average, than other citizens? Or do they make less use of it, perhaps dying sooner after trauma, or just preferring to avoid contact with contemporary medicine for minor ailments ? If so, they may actually be saving NHS money. If they, or some other identifiable group, in fact consume fewer NHS resources than the average, should they then pay less tax than the rest of the
SjR,—For the newly qualified junior hospital doctor the stresses and strains of final examinations pale into insignificance when compared with the prospect of the first day of August, this being the start, in the UK at least, of "house jobs". Much folklore and handed-down anecdotal tales abound about this, possibly the most stressful and eventful month of the houseman’s year. The psychological and emotional impact on the new graduate is well documented/,2 but what of the organic signs? We sent a two-part questionnaire about diet and weight to all (102) doctors who graduated in 1991 from the University of Leicester. Part A was completed within the first week of August and part B in the first week of September. 61 forms were returned for part A and 48 for part B. Data for analysis were thus available for 31 women and 17 men (age 22-30, mean 23 years). No subject was actively dieting during the period under consideration. About two-thirds (30) lost weight during their first four weeks as a houseman; 10 gained weight; and 8 remained the same weight. 19 women and 11 men lost an average of 2-6 kg (range 0’4-6-4). Of these, 28 thought their diet had been adversely affected by their job and 2 thought not. 17 had found their hospital canteen unacceptable whereas 13 thought it was acceptable or good. Common reasons given for weight loss were lack of time for eating and increased energy expenditure. 8 women and 2 men gained an average of 1 -7 kg (04-1). 7 had found their diet to be adversely affected and 3 had not; 6 found the hospital canteen unacceptable; and 4 thought it was acceptable or good. 4 women admitted to a partiality for chocolates, which were readily available on the ward and were therefore consumed more liberally than usual. Of the 4 men and 4 women whose weight remained stable, although all thought their diet had been adversely affected by their job, all, surprisingly, found the food in their hospital canteen acceptable. The year spent as a houseman is the subject of two witty novels3,4 which are read avidly by medical students. The year is not all roses, however, and many find the hours long and arduous. Chronic tiredness, lack of support, and a feeling of being uncared for, among others, contribute to stress. The stress and pace of the job also leads to a change in diet, as shown in our series where 43 of the 48 (90%) thought that their diet was adversely affected and 62% did lose weight. That the weight loss was almost certainly occupational is probably not in doubt. Does this then commend house jobs as a way to diet? In the short term, perhaps yes; in the long term, thankfully
population? We believe that health care should be provided for all, irrespective of race or religion, and with full respect for any constraints imposed by the patient on the grounds of their religious, moral, or cultural beliefs or customs. To make any other decision would be a violation of human rights, of medical ethics, and of the obligation of our secular society to respect the various sets of values of all its citizens. Institute of Medical Genetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
ANGUS CLARKE CARINA WALLGREN-PETTERSSON HELEN E. HUGHES
Billings PR, Kohn MA, de Cuevas M, et al. Discrimination as consequence of genetic testing. Am J Hum Genet 1992; 50: 476-82. 2. Chadwick R. What counts as success in genetic counselling? Med Ethics (in press). J 1.
Compensation for medically acquired AIDS SiR,—Iwould expand Mark Ragg’s (Feb 15, p 419) comments about compensation for medically acquired AIDS in Victoria, Australia. Claims made since 1985 by haemophilia patients, infected with HIV, against State and Federal Governments, as producers and administrators of contaminated plasma concentrates, were almost completely disregarded. The Federal Government had set up a "token" trust in 1990 with staged minimum payments. Patients sought further legal retribution, having been inflamed by Government advice that this was their only recourse. The haemophilia community was deeply divided in taking such action not only between HIV infected and uninfected factions but also within the infected group. Many were deeply embarassed about suing their haemophilia treatment centres in three-way suits against hospital, Red Cross Transfusion Service, and Commonwealth Serum Laboratories. A landmark court case was brought in Victoria, the only state to have a jury for civil cases, in 1990. It was won by the plaintiff against a haemophilia treatment centre only. This case was noteworthy not
only for the verdict but also for the notoriously high legal costs disbursed from state-funded legal aid and other public sources. A formula, based on legal likelihood of successful case prosecution, was crafted for out-of-court settlements in South Australia in 1991. This model was applied to all known cases of transfusion-related
Haemophilia Treatment Centre, Alfred Hospital, Melbourne, Victoria 3181, Australia
Acute
weight reduction
ALISON STREET
in junior doctors
not.
Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, UK
N. WILLIAMS G. K. ROSE
DI, Gruzelier JH. Adverse changes in mood and cognitive performance of house officers after night duty. Br Med J 1989; 298: 21-22. 2. Dudley HAF. Stress in junior doctors. Br Med J 1990; 301: 75-76. 3. Colin Douglas. The Houseman’s Tale. London: Canongate Publishing, 1975. 4. Samuel Shem. The house of God. NSW: Transworld Publishers, 1985. 1. Orton
Safety guidelines for use of nitric oxide SiR,—There is interest in inhaled nitric oxide (NO) as a pulmonary vasodilator which, unlike intravenous pulmonary vasodilators, does not affect the systemic circulation.l-3 One suggestion is that inhaled NO may reduce intrapulmonary shunting
Such issues, in the context of the provision of care for children with problems that were potentially "preventable", have already been raised in North America, and have been related to cases of "wrongful life", and to health insurance provided by employers.’ Do we want to see this happen in Britain too? If society answers Collins’ question by charging the cost of refusing blood transfusion to Jehovah’s Witnesses themselves, will the provision of nationalised health care for children with genetic disease be similarly restricted? Will National Health Service (NHS) care be denied to those whose parents are labelled as irresponsible because they have declined to take part in prenatal diagnosis or screening, or because they have declined to terminate a pregnancy at high risk of some disorder? Will budget-holding general practitioners seek to remove from their lists those families that refuse antenatal screening? The reasons for declining to participate in such programmes, of course, may vary-but these reasons are
HIV infection in Victoria, and a social justice payment was added for those people whose cases in law were weakest. Group settlement in late 1991, despite grossly disparate payments for equally infected people, has resolved much of the anger and divisiveness that was destroying our patients and our centre. The enormous relief, consequent upon settlement, which is shared by patients and their carers, allows patients to plan for quality, not merely in financial terms, in their shortened futures. The gloomy days of HIV disease remain but the distress of litigation no longer affects the immune system.
quite irrelevant if a "medicine of the bottom line" is all that the NHS will seek to provide. The restriction of access to health care in such circumstances could doubtless be justified as the promotion of autonomy and responsibility; appeals to autonomy in this sense (of self-reliance, rather than self-determination) are used to justify cuts in public services by those inclined for political reasons in that direction.2 In addition to these questions of principle, there is also a practical question to be addressed. Do Jehovah’s Witnesses really cost the NHS more, on average, than other citizens? Or do they make less use of it, perhaps dying sooner after trauma, or just preferring to avoid contact with contemporary medicine for minor ailments ? If so, they may actually be saving NHS money. If they, or some other identifiable group, in fact consume fewer NHS resources than the average, should they then pay less tax than the rest of the
SjR,—For the newly qualified junior hospital doctor the stresses and strains of final examinations pale into insignificance when compared with the prospect of the first day of August, this being the start, in the UK at least, of "house jobs". Much folklore and handed-down anecdotal tales abound about this, possibly the most stressful and eventful month of the houseman’s year. The psychological and emotional impact on the new graduate is well documented/,2 but what of the organic signs? We sent a two-part questionnaire about diet and weight to all (102) doctors who graduated in 1991 from the University of Leicester. Part A was completed within the first week of August and part B in the first week of September. 61 forms were returned for part A and 48 for part B. Data for analysis were thus available for 31 women and 17 men (age 22-30, mean 23 years). No subject was actively dieting during the period under consideration. About two-thirds (30) lost weight during their first four weeks as a houseman; 10 gained weight; and 8 remained the same weight. 19 women and 11 men lost an average of 2-6 kg (range 0’4-6-4). Of these, 28 thought their diet had been adversely affected by their job and 2 thought not. 17 had found their hospital canteen unacceptable whereas 13 thought it was acceptable or good. Common reasons given for weight loss were lack of time for eating and increased energy expenditure. 8 women and 2 men gained an average of 1 -7 kg (04-1). 7 had found their diet to be adversely affected and 3 had not; 6 found the hospital canteen unacceptable; and 4 thought it was acceptable or good. 4 women admitted to a partiality for chocolates, which were readily available on the ward and were therefore consumed more liberally than usual. Of the 4 men and 4 women whose weight remained stable, although all thought their diet had been adversely affected by their job, all, surprisingly, found the food in their hospital canteen acceptable. The year spent as a houseman is the subject of two witty novels3,4 which are read avidly by medical students. The year is not all roses, however, and many find the hours long and arduous. Chronic tiredness, lack of support, and a feeling of being uncared for, among others, contribute to stress. The stress and pace of the job also leads to a change in diet, as shown in our series where 43 of the 48 (90%) thought that their diet was adversely affected and 62% did lose weight. That the weight loss was almost certainly occupational is probably not in doubt. Does this then commend house jobs as a way to diet? In the short term, perhaps yes; in the long term, thankfully
population? We believe that health care should be provided for all, irrespective of race or religion, and with full respect for any constraints imposed by the patient on the grounds of their religious, moral, or cultural beliefs or customs. To make any other decision would be a violation of human rights, of medical ethics, and of the obligation of our secular society to respect the various sets of values of all its citizens. Institute of Medical Genetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
ANGUS CLARKE CARINA WALLGREN-PETTERSSON HELEN E. HUGHES
Billings PR, Kohn MA, de Cuevas M, et al. Discrimination as consequence of genetic testing. Am J Hum Genet 1992; 50: 476-82. 2. Chadwick R. What counts as success in genetic counselling? Med Ethics (in press). J 1.
Compensation for medically acquired AIDS SiR,—Iwould expand Mark Ragg’s (Feb 15, p 419) comments about compensation for medically acquired AIDS in Victoria, Australia. Claims made since 1985 by haemophilia patients, infected with HIV, against State and Federal Governments, as producers and administrators of contaminated plasma concentrates, were almost completely disregarded. The Federal Government had set up a "token" trust in 1990 with staged minimum payments. Patients sought further legal retribution, having been inflamed by Government advice that this was their only recourse. The haemophilia community was deeply divided in taking such action not only between HIV infected and uninfected factions but also within the infected group. Many were deeply embarassed about suing their haemophilia treatment centres in three-way suits against hospital, Red Cross Transfusion Service, and Commonwealth Serum Laboratories. A landmark court case was brought in Victoria, the only state to have a jury for civil cases, in 1990. It was won by the plaintiff against a haemophilia treatment centre only. This case was noteworthy not
only for the verdict but also for the notoriously high legal costs disbursed from state-funded legal aid and other public sources. A formula, based on legal likelihood of successful case prosecution, was crafted for out-of-court settlements in South Australia in 1991. This model was applied to all known cases of transfusion-related
Haemophilia Treatment Centre, Alfred Hospital, Melbourne, Victoria 3181, Australia
Acute
weight reduction
ALISON STREET
in junior doctors
not.
Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, UK
N. WILLIAMS G. K. ROSE
DI, Gruzelier JH. Adverse changes in mood and cognitive performance of house officers after night duty. Br Med J 1989; 298: 21-22. 2. Dudley HAF. Stress in junior doctors. Br Med J 1990; 301: 75-76. 3. Colin Douglas. The Houseman’s Tale. London: Canongate Publishing, 1975. 4. Samuel Shem. The house of God. NSW: Transworld Publishers, 1985. 1. Orton
Safety guidelines for use of nitric oxide SiR,—There is interest in inhaled nitric oxide (NO) as a pulmonary vasodilator which, unlike intravenous pulmonary vasodilators, does not affect the systemic circulation.l-3 One suggestion is that inhaled NO may reduce intrapulmonary shunting
