A Mother’s Choice, A Baby’s Risk: The Right to Be Wrong in Obstetric Care

When does autonomy outweigh safety?

In the high-pressure modern maternity ward, the obstetrician is viewed as the guardian of safety. So what are we to do when patients decline standard care and advocate for birthing options that cause us to wipe the sweat from our brow?

We all approach risk through different lenses, adjusting our proclivity to take risks depending on the information accessible to us. If we allow Mary to be our hypothetical patient and say that she faces a one-in-100 chance of stillbirth, to a clinician, this may be a statistical trigger for intervention, for example, admitting the patient for monitoring. For the patient, however, risk is not a maths problem but a lived experience.

So what are we to do when, despite the increased risk, patients advocate for non-conventional maternity care, such as free births? For Mary, when she refuses admission, she is rejecting the medicalisation of a natural process that she perceives as a greater risk to her psychological well-being than the statistical risk of stillbirth. As doctors, we may bemoan the irrationality of such choices, but do we have an ethical case to intervene and prevent them?

Midwifery Moral Injury

In accommodating Mary and her natural home birth, a midwife will be in attendance, but is this fair to the midwives in our profession? Many midwives describe the distressing reality of being present at a home birth that goes wrong in a high-risk patient. We may be forcing many of them to witness the trauma of avoidable harm.

You have an absolute right to refuse a C-section, something we can term negative autonomy. But do you have the right, conversely, to demand that a midwife attend your home birth when you are already at increased risk of labour-related harm? The classic issue that arises here is the recognition that if a hospital refuses to support Mary’s home birth, it may inadvertently drive her towards ‘freebirthing’, where women give birth in the absence of healthcare professionals, which may lead to far more dangerous outcomes.

The final, and most difficult, intellectual friction concerns the status of the foetus. In the UK and many other jurisdictions, a foetus lacks legal personhood until birth. Consequently, the mother’s bodily autonomy is the only legal trump card in the room.

As doctors, we are trained to care for two patients, but the law recognises only one. We must reconcile the fact that while we may feel a moral duty to the future child, we have no legal authority to protect it against the mother’s wishes.

The Prestige Trap Amongst Doctors

“Man is the creature who does not know what to desire, and he turns to others in order to make up his mind. We desire what others desire because we imitate their desires.”

That was a segment from Walter Burkert, René Girard and Jonathan Smith’s Ritual Killing and Cultural Formation. Are you the same person that you were ten years ago? I submit that the answer is a resounding no. Rather, would you want to be that same person? Would it not suggest a decade of wasted time? We change, and this change can often be attributed to our changing environment and the changing people around us…

We think we choose our specialities through pure (almost romantic) affinity, yet if we are honest, we often find ourselves gravitating towards things for other reasons. We gravitate toward the most competitive fellowships and the most oversubscribed rotations, not necessarily because they align with our values, but because their exclusivity signals value. If they are competitive, it means a lot of people want it, and if a lot of people want it, then that must be for a reason, right?

Yet, when desire becomes circular, wanting something simply because others want it, we risk becoming nothing more than an echo of someone else’s ambition.

Want to know how this applicant scored 100% at ST3 interview?

The New Decade of Oncology

Examining The Government’s New National Cancer Plan

Approaches to tackling cancer nationally will always attract the public, given how personal cancer feels to us all and its prevalence in society. One in two of us will get it, and many of us at least know someone who has had to endure the disease. The government’s national ten-year cancer plan is the first published in a decade and aims to bring cancer care into the 21st century.

Bridging The Coastal-Urban Divide

The postcode lottery of cancer, in accessing gold-standard treatment, was a specific target of this plan. The plan commits to attracting more cancer specialists to rural and coastal areas. We have long known that hospitals in poorer areas tend to have fewer senior specialists than those in cities and large teaching hospitals. This leads to longer waiting times while patients wait for referrals to larger centres, increasing the likelihood of poorer outcomes. So how does one attract more consultants to the great British coastal towns? It will involve new training places located in rural and coastal areas. Given that we know the place where one undertakes speciality training predicts where they will take up a consultant post, this could be a solid solution.

Streeting, who was diagnosed with kidney cancer in 2021 at the age of 38, has made it clear that there are plans for the Royal Colleges to encourage more doctors to specialise in clinical and medical oncology. How this will be achieved is yet to be confirmed.

One of the most significant shifts for patients is the integration of the Be Part of Research service directly into the app interface. Patients with rare cancers, including brain tumours, can now search for and request contact regarding trials without waiting for a specialist referral. By 2027, the roadmap suggests the app will use genomic data to push relevant trial opportunities to patients automatically, with a goal of reducing clinical trial setup times from 250 days to under 150.

‘A Sponge-on-a-String’ For Oesophageal Cancer?

You may have guessed that part of this plan is to ensure the NHS is utilising the best technology available in cancer care.

The first of these technologies to be rolled out is a sponge-on-a-string test that detects early signs of the deadly oesophageal cancer in minutes. This Cytosponge is a ten-minute, non-sedation, GP-based procedure for identifying Barrett’s oesophagus or early-stage cancer. It involves swallowing a capsule containing a sponge that expands in the stomach. As the string is withdrawn, it collects cells from the oesophageal lining. If, like us, you had not heard of this sponge on a string, you may be looking at the next significant oncological breakthrough.

Alongside the sponge, smarter software for analysing prostate and breast cancer samples is being rolled out, as well as AI programmes that can help read chest X-rays, enabling GPs to catch lung cancer sooner.

“As a psych reg, I often remind the medical students that most illnesses and physiological problems are self-resolving, so most interventions given at the point of presentation will appear effective.”

“A Consultant asked me a question that has been on my mind: When contemplating making a major purchase, do you tend to focus on one aspect of it, or do you consider how it will impact your life minute to minute?”

“Is there anything quite like a Consultant telling you to document ‘Plan: Continue same’“

“I physically cannot imagine anything more interesting as a vocation than spending the day in theatre and operating.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Lung Ultrasound is an incredibly useful diagnostic tool that is becoming more popular for clinicians to learn. Many doctors are still unclear on what is needed from them in terms of Ultrasound training. We found this document from the British Thoracic Society to be of particular use here. Read it here.

Boom or Crash? If you have ever looked at house prices and wondered where the housing market is currently at in the UK, here is a brilliant breakdown from one of our favourite YouTubers. Damian brings you the latest figures from the ONS on what’s really happening in the property market. Here’s the link to the video.

Weekly Poll

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When Is The Right Time To Help Out Your Children Financially?

For many in our community, ensuring a child’s future is a top priority. However, the traditional model of leaving an inheritance upon death is increasingly being viewed as "too little, too late."

The On-Call team were reading Bill Perkins’ Die With Zero, and it got us thinking. Perkins argues that the utility of a pound is not constant; its value depends entirely on when it is received.

The average age for receiving an inheritance in the UK is now estimated to be between 55 and 64. By this stage, most recipients are already in their peak earning years or approaching retirement.

Data suggests that financial assistance has the highest impact when the "Utility Gap" is widest. This is typically between the ages of 25 and 35. This is when young adults face the "triple threat" of: house deposits, costs associated with raising a family, and career building.

The value of money is relative to one's current income. A gift of £5,000 to an F1 doctor, who may be struggling with relocation costs and MRCS fees, has a life-changing impact. That same £5,000 gifted to an established NHS consultant is often just a "nice to have" addition to what should be a solid financial portfolio.

No doubt, financial help is not just about bank transfers. We know many parents have already invested early through educational foundations, character development by funding extracurricular activities and finally, financial literacy. These are all examples of worthwhile practices that should be pursued earlier, rather than later in life.