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Telegraph
21 hours ago
- Health
- Telegraph
Flagship British project to boost global surgical standards under threat of closure
A flagship British project created to improve the safety of medical surgery around the world could shut down next year because of the government's aid cuts. The Global Surgery Unit (GSU), launched in 2017 by the Royal College of Surgeons, conducts large-scale studies across a network of 120 countries to find ways of making surgical care both more effective and accessible, particularly in developing countries. Every year more than four million people die from conditions that could be treated with surgical procedures – a greater number of deaths than HIV/Aids, malaria, and TB combined – yet it remains one of the most neglected components of global health. In recent years the GSU has conducted some of the biggest surgical research studies in history, and claims to be the largest global research network in science. In 2021 it set a Guinness World Record with a landmark study on the impact of Covid-19 on surgical patients that involved collaboration from over 15,000 scientists and researchers. But it could now be forced to close in June next year when its current funding runs out, said Professor Dion Morton, GSU co-lead and the Barling Chair of Surgery at the University of Birmingham, which co-created the unit. 'They've already funded us through to June 2026, they can't take that back – [but] if they could, they would,' he told The Telegraph. Prof Morton said the GSU 'has been run on a shoestring' since its launch, costing only around £20 million and focusing on a public health intervention that plays a vital role in nearly every area of medicine. Some 28 per cent of the global disease burden stems from conditions that are treatable with surgery – from infections and trauma wounds, to blindness and maternal health. Improving surgery is also a key component of the fight against antimicrobial resistance (AMR), which kills more than 1.1 million people around the world every year, including 35,000 in the UK alone. By preventing and managing infections, it helps to reduce unnecessary antibiotic use. The GSU, which involves 40,000 surgeons across 120 countries, conducts large-scale trials to tackle major global surgical challenges across many countries at the same time. The initiative has driven advancements in low-cost and practical interventions to improve surgical care in low-resource settings - innovations that are also feeding back into surgical practices in the UK. One of the GSU's landmark studies, known as the CHEETAH trial, conducted across three continents, found that simply changing gloves and instruments before wound closure prevents one in seven wound infections. This practice has now been adopted into routine practice in Britain and around the world. Another major initiative, the EAGLE trial, tested in 70 countries, introduced a standardised medical checklist to improve outcomes in bowel surgery. 'Global surgical care is probably the greatest world health challenge today and the one that we are currently failing to meet,' said Prof Morton. 'It is a fundamental part of the health system and if we're going to provide effective global health care and we must strengthen the whole system, it's not enough to just treat single conditions.' A 'bottom up approach' to transforming care Experts have warned that Labour's decision to slash its overseas aid budget by around £6 billion, including a 46 per cent drop in health related spending, could reverse vital progress in some of the world's most vulnerable regions. Shrinking development budgets means politicians are focusing on threats like single disease interventions, pandemics, and conflict. 'There's a tendency in global health to look backwards…but it's not actually treating the whole health system. It's not addressing the real need in the world. And I think that this is a mistake,' said Prof Morton. Last month, The Telegraph reported that the Fleming Fund, a major £265 million British programme designed to tackle AMR in the developing world, is being closed by Labour's aid cuts. Sir Jeremy Hunt, the former health secretary, told The Telegraph that the move 'directly puts our national security at risk'. Prof Morton also challenged a common misconception that surgery is 'only a crisis treatment of last resort', adding that it 'is not simply something that's carried out in an operating theatre.' Some global health and development institutions have come under increasing scrutiny for perpetuating so called 'colonial power dynamics'. But Prof Morton said the GSU takes 'a bottom up approach to transforming care.' Instead of allowing Western high-income countries to dictate the agenda, the GSU prioritises collaboration with local surgeons and healthcare providers in poorer countries to co-create interventions tailored to their specific needs. 'In some respects, it bypasses the policy makers and allows the clinicians to improve the care for their patients, and that's the key element in the global surgery network that makes it different from anything else,' he added. The consequences of not having access to surgery are profound. It means that every year millions of people die from treatable conditions, such as hernia repair and obstructed labour, which is treated with basic procedures like caesarian sections. The burden falls heaviest on the world's poorest. Some 93 per cent of people in sub-Saharan Africa don't have access to basic surgical care. One survey suggests that 40 per cent of donated surgical equipment in poor countries is out of service. Yet, some surgeries can rank among the most cost-effective of all health interventions, such as cataract removal, which reverses blindness at a remarkably low cost. Research suggests expanding access to surgical care in poorer countries would boost the global economy by $80 billion annually. Training enough surgeons, anaesthetists and obstetricians remains a key challenge to widening access, with over 160 million patients unable to receive surgery each year. In higher income countries such as the UK, there are around 35 surgical specialists per 100,000 people, whereas in Bangladesh there are 1.7 per 100,000 people. Only 26 per cent of countries have met the Global Surgery 2030 goal to ensure everyone has access to essential surgery within two hours. Yet basic training can make a huge difference. Research shows that trained junior staff, such as clinical officers with around three years of experience, can perform caesarean sections just as safely as doctors. Prof Morton, who has an Officer of the Order of the British Empire (OBE) for services to innovation in the NHS, warned that the UK's aid cuts will have profound global consequences. 'It will likely result in the suspension of national surgical obstetric and anaesthetic plans in most countries around the world,' he said.
Irish Times
2 days ago
- Entertainment
- Irish Times
Have we no more active rights over life, birth and death?
Stephanie O'Connor, a research officer at the Royal College of Surgeons in Ireland, was awarded this year's Hubert Butler Essay Prize in the Parade Tower of Kilkenny Castle on Saturday. John Banville, honorary patron of the prize, said: 'With courage, clarity and subtle discrimination, Stephanie O'Connor addresses fundamental questions that arise, as she writes, 'at the edges of human life', and presents an argument that affirms the dignity and respect that are due to all of us no less in the process of our 'going hence' than at the moment of our 'coming hither'.' This year marks the fortieth anniversary of the publication of Hubert Butler's first essay collection, Escape from the Anthill , which appeared in 1985- the author's 86th year. It was also the first production from Antony Farrell's Lilliput Press. The essay prize, brainchild of Jeremy O'Sullivan, was founded seven years ago and is now an integral part of the Kilkenny Arts Festival. READ MORE This year's essay theme was the question of how far we can and should control our destinies over lif birth and death, instancing Edgar's stoical monition to his despairing father Gloucester in King Lear : 'Men must endure/Their going hence, even as their coming hither.' Historian Roy Foster, who judged the prize with Catriona Crowe, Nicky Grene and Barbara Schwepcke, said the winning essay 'went straight to the point of asking whether we were any the wiser for the increased options available in an age of reproductive technology and end-of-life planning. 'Stephanie O'Connor concentrated on the legal and moral ethics of keeping a brain-dead woman on life-support for the sake of an unborn infant who will almost certainly not survive. She discusses with compassion and empathy the 'uncanny ambiguity where the dead might remain legally ambiguous', and incisively states the need for 'a new ethical framework, shaped by legislation and public debate': medical ethics being 'the scaffolding by which we try to uphold the human spirit in a world increasingly seduced by the procedural and drawn to the utilitarian'. 'The clarity with which she addresses issues described rightly as intimate and harrowing is deeply impressive, and her definition of 'dignity' as a guiding principle strikes a powerful concluding note.' The winning essay is reproduced below. Have we no more active rights over life, birth and death? ' Men must endure / Their going hence, even as their coming hither .' So speaks Edgar to his blind and broken father, Gloucester, in William Shakespeare's King Lear (Act V, Scene 2), reaching for some scrap of consolation amid the wreckage of betrayal, madness, and loss. It is a fantastic line. It is a fatalistic line. This is not hope. His words carry the chill of stoic resignation, a frail attempt to impose meaning on the brute finality of death, a comfort as thin as the wind on the Cliffs of Moher. To accept that birth and death lie beyond our control. I recently witnessed the death of someone I loved very deeply – a moment of quiet surrender, beyond my control, that left an unfathomable gulf in my life. I desperately wanted them to live, and yet, to be there, as they let go, quietly, peacefully, after years of the struggle with ill health, was a profound and beautiful privilege. In that stillness, death felt less like a rupture and more like a final act of grace. And yet, even after witnessing what is called a ' good death ' – peaceful, dignified, and free from suffering – I find myself questioning whether Edgar's words still hold true. Can we really, in our modern world, still accept that we must simply endure our coming and going? In an age of reproductive technology and end-of-life planning, it would appear we have long since moved into an era where such a fatalistic acceptance of our helpless arrival and helpless departure is no longer passive, but shaped by choice, by law, and by technology. The question is: are we wiser for it? I find I cannot consider the question of our active rights over life, birth and death without revisiting the harrowing case of P.P. v. Health Service Executive (2014) , a case that personally gripped me, and I suspect many others, and would echo through Irish legal and ethical discourse for years to come, making me wonder: What if Edgar's lines are no longer merely literary, but legal? What if, in our era, death itself must await constitutional interpretation? And what if the body, in its going hence, becomes hostage to a cause it never chose? In December of that year, a young Irish woman, only 26 years old – daughter, partner, and mother of two – suffered a catastrophic brain injury and was declared clinically dead. She was 14 weeks pregnant at the time. Her heartbroken family, already reeling from the suddenness and irreversibility of her passing, was told that her body would be kept on life support – not for her sake, but to prolong the gestation of her unborn child. For three weeks, the young woman's dead body remained tethered to the apparatus of somatic support, sustained artificially in a state of biological animation, while the medical team monitored the foetus in her abdomen – her heart mechanically pulsing, her organs perfused. Eventually, the High Court permitted what her distressed loved ones had requested from the outset: that the machines be stopped because the woman was dead, and that the treatment was ' unreasonable ', ' experimental ' and therefore unethical. There was, the court found, no realistic prospect that the unborn child would survive, and ' in the best interest of the unborn child ' authorised the withdrawal of ongoing somatic support. She could be allowed, at last, in that long-honoured phrase, to rest in peace. It is worth pausing to consider how we arrived at a point where such a scenario was not only conceivable, but could unfold in reality, and be upheld in law. The answer, in large part, lies in the legacy of Ireland's constitutional recognition of the unborn's right to life. The now-repealed Eighth Amendment, inserted in 1983, was shaped not only by theological conviction but by the moral anxieties of a devout society. It created a legal equivalence between the lives of women and their unborn, and in doing so, an uncanny ambiguity, where the dead might remain legally ambiguous: both people and legally bound vessels burdened by gestational obligations. In practice, creating situations such as P.P. v HSE , where legal obligations forced doctors to override death itself in the interest of potential life. Its repeal, in 2018, returned legislative authority to the Oireachtas, allowing for a new ethical framework shaped by legislation and public debate. However, while progress has been made, the fundamental legal and ethical dilemmas at the heart of P.P. v. HSE remain unsettled, leaving open the possibility that such tragic circumstances could arise again. In a searing editorial at the time, the woman was referred to as a ' cadaveric incubator .' The term is terrible, and its honesty is unmerciful. For what else, legally speaking, was she during those weeks? She was no longer a citizen. No longer a patient. No longer capable of consent. She had become, by a certain line of reasoning, a resource, one whose utility had not yet expired. And yet: this young woman had been someone. Someone who had made choices, who had loves and fears, and who might have left an advance directive had she ever imagined such a grim fate. Her family's grief was compounded not only by her loss but by the State's intrusion into what should have been a sacred and private time of reckoning with death. It brought into sharp focus ethical questions that, while deeply significant, are often approached with caution or even skirted in public discourse – What is life? Who owns death? Who decides its terms? And does the unborn's fragile spark of potential outweigh the dignity owed to the dead? The High Court, to its credit, ruled with sobriety and deference to expert medical consensus that there was no reasonable prospect that the foetus would survive to viability. But it still took weeks of judicial intervention to affirm that a woman who was clinically dead should not be subjected to experimental prolongation. I revisit the case here not to reopen wounds, and indeed, I thought long and hard, hesitant to write at all out of deference to those who lived its reality. But then I recalled something Hubert Butler once said of another historical silence, when atrocities in Yugoslavia went unmentioned because naming them would mean naming our own complicity: '.. silence did not help me ... It became increasingly difficult to be silent .' And so, it is here. We must speak with clarity and compassion about where medicine, law, and human dignity intersect – and where they diverge. In this instance, we were forced to ask ourselves whether a dead woman could be called upon to continue a pregnancy she could no longer consent to, whether she could, as some bioethicists starkly put it, ' be used '. The question was no longer whether the unborn had rights; instead, it was whether the dead had any rights left? It is important to stress here that no argument was presented to diminish the moral status of the unborn. Rather, the arguments were made to try to assert the indivisible dignity and bodily integrity of the already lived life, and the rights of families to mourn without being conscripted into bioethical theatre. In cases such as this, when all evidence points to futility, continuing life support is no longer an act of care – it is an act of fear, driven by legal shadows, not moral light. And it seems, we are no longer mere witnesses to birth and death; we are, increasingly, their stewards. Modern medicine has given us powers that previous generations could never have imagined – the ability to keep bodies functioning after the mind is gone, after death, to intervene in birth and delay death. But these powers have brought with them difficult questions: just because we can act, does it mean we should? In cases such as P.P. v HSE , where a woman declared clinically dead was kept on somatic support for the sake of her unborn child who has no chance of survival, and against her family's wishes, we see how the boundaries between life, death, and duty blur and just how complicated these questions can become. When we ask if we have no more active rights over life, birth and death, but instead are forced to confront the clash between medical possibility, legal obligation, and human dignity. Is this not best answered by opposing principles, but by turning toward the moral terrain where those principles collide: a space requiring not only legal interpretation, but imagination, conscience, and care. This is not a simple clash between religion and secularism, or between tradition and progress. Nor is this tragic paradox in any way confined to Ireland. This case is only one of a number of rare, tragic, high-profile, and contentious medico-legal cases, which have gone before courts around the world in recent years. Some are cases where pregnant women, have been clinically diagnosed as brain-dead but are kept ' alive ' artificially, to preserve the life of the unborn until such time that a Caesarean section can be carried out. In such cases of maternal-foetal conflict , the pregnant woman's interests conflict with the interests of the foetus because clearly, to allow the mother's death would result in the unborn dying because its intensive care support would be withdrawn. Again, I stress that what I write here is in no way a debate about the moral status of the foetus, nor a contest between the right to life and the right to die. It is, instead, an attempt to consider how we act when the old moral frameworks no longer fit – and how we honour the living and the dead when the answers aren't written down. For while P.P. v HSE may bear the peculiar imprimatur of our constitutional and religious legacy, the underlying conflict is something more intimate and harrowing – between technological capacity and moral restraint – the redefinition of the human identity in an age of technical possibility. And across Europe and beyond, similar cases have arisen to highlight the global resonance of these issues and underscore the universality of the dilemma: the collision between medical capability and moral uncertainty, between the language of law and the needs of grief. Instances where medical possibility outpaces ethical consensus, and where law, unsure of its footing, stumbles into the most private regions of life and death. In Texas, the high-profile case of Marlise Muñoz in 2013 echoed with chilling familiarity: a brain-dead woman, pregnant, was kept on life support against her family's wishes due to state laws protecting the unborn. In Germany, the debate continues over how to balance prenatal life with posthumous dignity in the absence of explicit legal directives. Even in secular France, the Vincent Lambert case in 2019, though not involving pregnancy, laid bare the painful entanglements of familial love, legal ambiguity, and medical endurance. These are not the accidents of jurisdiction, but the growing pains of a civilisation increasingly unsure how to interpret the sacred in the age of the mechanical. The principles of medical ethics – autonomy, beneficence, non-maleficence, and justice – known collectively as the Beauchamp and Childress framework, form the quiet architecture by which medicine seeks to balance power with compassion, and are not merely philosophical ornaments. They are the scaffolding by which we try to uphold the human spirit in a world increasingly seduced by the procedural and drawn to the utilitarian. Each principle carries distinct weight and, when in tension, reveals the intricacy of end-of-life decision-making: Respect for autonomy, in the context of P.P. vs HSE , becomes paradoxical. It affirms the individual's right to have meaningful agency and moral authority over the most fundamental aspects of their existence – how they are born, how they live, and how they die. This includes making decisions about their own body and life, including the choice to refuse life-prolonging treatment or to seek medically assisted death. It means honouring a competent person's wish to die with dignity, even when that wish contradicts societal norms or professional instincts to preserve life using systems that neither knew us nor will mourn us. But the dead have no will – they once had one. Is it beyond our moral imagination to give it voice and let it be heard? Interest Theory allows for the possibility of posthumous rights, including, for example, the right to have one's remains treated with dignity, the right to have one's wishes regarding burial or cremation respected, or the right to protect one's reputation from posthumous defamation. But in the age of technology, has society chosen to limit the principle of posthumous autonomy and posthumous moral and legal rights? The right to die a natural death is supported by the right to respect for autonomy. But many states, including Ireland, invalidate a woman's advance directive if she is pregnant because of the compelling legal right to life of the foetus. Often, irrespective of whether the woman's wishes are known or not, courts will use a best interests test or substituted judgment standard. Some will argue, understandably, that beneficence – our duty to do good – extends most urgently to the vulnerable unborn. But beneficence, if severed from context, becomes blind and can even lead to tyranny. In trying to preserve a hypothetical life, we may violate an actual death. In doing so, we may dishonour both. Regarding non-maleficence, a dead person experiences no physical harm from continued somatic support because they are dead. However, if we consider posthumous rights, it could be argued that somatic support of a decomposing dead body potentially violates the cultural norms of dignity and respect that society confers to dead human bodies. Regarding the principle of (social) justice, intensive somatic support is expensive and it is arguable that the State should not direct such limited resources, for an indefinite time to the care of one dead individual, even when balanced against the costs of caring for a baby for a prolonged time in a neonatal intensive unit care if gestation were not delayed to allow the foetus to mature further in utero. When making decisions, particularly in situations involving maternal-foetal conflict, doctors must balance these ethical principles with professional practice guidelines and responsibilities under the law. But in navigating, we encounter the limits of law in matters that are deeply human. The law may compel action, but there are moments when law, though meticulously reasoned, proves insufficient to capture the full scope of human experience or embody compassion. Yes, legality can codify duties, define rights, and offer structure to our moral instincts. Still, even the most carefully constructed legal frameworks cannot fully account for love, grief, or the emotional, ethical, moral and familial complexity of life-and-death decisions, let alone the unspoken complexities that shape human lives. In cases like P.P. v HSE , and many others, the boundaries of law meet the raw edge of human sorrow. What follows is not merely a legal question but an ethical reckoning with what it means to honour the dead, to protect the unborn, and to listen to the quiet dignity of those who mourn. And where competing rights, such as the sanctity of life or the rights of the unborn, are applied as absolutes, is it possible that they can obscure more than they resolve, especially when they collide with the dignity owed to the dead? It raises the question – when we cling to principles too tightly, do we risk losing sight of the person? As Hubert Butler observed, ' Science has enormously extended the sphere of our responsibilities, while our consciences have remained the same size .' In an age where the dead can be biologically sustained long after meaning has ebbed away, the question is not just what we can do, but what we should do – and why. Is there a point at which the machinery of law must yield to the compassion of humanity, where rigid adherence gives way to moral judgment grounded not in statutes, but in empathy, respect, and care? It is in this space – between what the law allows and what decency demands – that our truest responsibilities begin. Dignity is an elusive but crucial concept. It's not simply the absence of suffering, nor merely the preservation of respect for autonomy. Dignity might serve as a middle path – a humane principle in the absence of consensus, reminding us that medicine is not only a technical craft but also a humane one. In the bleak world of King Lear , mortal lives are at the mercy of fate and indifferent, as Shakespeare's characters are cast from birth to death with little control, their will overwhelmed by storm, folly, despair and madness. Today, medical ethics, biotechnology, and law offer tools that challenge this fatalism. Edgar's stoic call to ' endure ' in King Lear was a balm for despair, but in our modern context, endurance is no longer passive. It is curated, legislated, and medicalised. When endurance means tethering a dead woman to machines for weeks against her family's wishes, it is no longer stoicism – it becomes imposition. In this, perhaps, Edgar's words still hold – not as a declaration of helplessness, but stripped of its fatalism, it becomes a call to humanity. A reminder of the deep humility required at the edges of human life. Yes, men must endure their going hence – but not in silence, not without dignity, and not without the right to be mourned as more than a vessel. Whether we are choosing to end treatment, to intervene in birth, or to withhold the breath of a machine, we are not gods. Our agency is real, but it is bounded by mortality, by ethics, and by love. Yes, men must endure their going hence. But we, the living, must also ensure they may go in peace.
Irish Times
01-07-2025
- Health
- Irish Times
Can you really be ‘coached' to pass aptitude tests for entry to medical school?
The deans of medical schools want to change entry requirements for studying medicine in Irish universities following concern that many applicants are being coached for tests aimed at determining their aptitude for working in the sector. Tell me more about these tests Applicants for undergraduate medicine are required to combine their Leaving Certificate results with the Hpat (Health Professions Admission Test), which was introduced in 2009 to assess skills deemed important for medicine, such as reasoning, problem-solving and interpersonal skills. While the 2½-hour test was initially envisaged as one that candidates could not study for, there is now an extensive private tuition industry where students can prepare for the assessment. How much are candidates paying for private tuition? There are lots of 'preparatory courses' available for students, who can spend up to €800 for a 15-week series of classes and mock exams. Typically, they are operated by so-called grind schools such as the Institute of Education in Dublin, Hewitt College in Cork and many others; in addition, there is something of a cottage industry among medical students who have done well in the test offering their services. READ MORE How widely used is the Hpat? About 3,000 students take the test each year, which is required to study undergraduate medicine at University of Galway, the Royal College of Surgeons in Ireland, Trinity College Dublin, UCC and UCD. University of Limerick also requires the Hpat for entry to its master's courses in occupational therapy and speech and language therapy. Can you really be coached to do better in the Hpat? When it was introduced in 2009, the Australian Council for Educational Research (Acer), which devised the Hpat, said it did 'not endorse any training college and actively discourages candidates attending them. They are a waste of the candidates' (or their parents') money.' However, there is evidence that suggests they can pay off. A review by five medical faculties three years after its introduction found 40 per cent of successful applicants each year had improved their Hpat score after resitting it and so got a place in an undergraduate medical school. The report found the greatest improvement was in the non-verbal reasoning section. There have been adjustments to the weighting of components of the test and changes to rules around when candidates can sit the test over the years. Nonetheless, critics say those who can afford expensive preparatory and repeat courses retain a significant advantage. Is the issue of 'coaching' candidates a concern outside Ireland? Yes, it is an issue elsewhere. Studies highlight that in countries such as Germany and the UK, private companies offer expensive preparatory courses for similar medical aptitude tests. They, too, are grappling with ethical questions about equal access, as these courses may improve test results and thus increase the likelihood of admission for wealthier candidates. Interestingly, Australia combines the test with a structured interview process to help identify those suited to the profession. So, what changes are being planned to the Hpat? The Hpat is marked out of a total of 300 points, which is added to a candidate's Leaving Cert score. For example, a student who gets 500 points in the Leaving Cert and 200 points in the Hpat gets a combined score of 700 points. Under revised plans, the Hpat would be reduced to 150 points. This, say sources, means the test would carry the equivalent weight of about one extra subject for entry purposes. When will changes come into effect? The planned changes will require sign-off by the academic councils of universities. In theory, this should be simple, says sources. If implemented, they would probably have a two-year lead-in time from when the changes are announced. Why was the Hpat introduced in the first place? It was introduced following concerns that medical applicants needed to achieve 'a perfect Leaving Cert', while those with an aptitude for medicine were falling through the cracks. The system that came in – which is still in place – says that for school leavers to be eligible to compete for entry to undergraduate medicine they must achieve a minimum of 480 points, meet minimum subject entry requirement and complete the Hpat. Hpat scores are added to Leaving Cert points, although Leaving Cert points above 550 are moderated, with one point awarded for every five scored above that level.
