Dr Paul Heslin
Dr Paul Heslin argues that society needs to find ways of moving forward to open up space for civilised debate …
Adventures of the little kind. It is sometimes amazing how many little adventures we can have in only one day. Calling 999 can be one.
We were driving towards Wexford on a Thursday when a car passed us. Nothing new here. Except. He almost took my right wing off, he came far too close as he swerved back in lane. He saw the oncoming car at the last minute and succeeded in saving the lives of three full cars, by avoiding the car coming at him, the car he himself was driving and our car, whose front wing he almost brought home with him. As you might remember from a previous adventure I described on these pages, my left front car wing was already damaged from an encounter of the wrong kind, with a stressed young worker in a hurry. I know what you are thinking, that my credibility is wearing thin. That one prang is unfortunate, but two is careless. Except. You forget this driver did not touch my car or injure it. But it was a matter of millimetres. We were shaken.
Normally I flash or beep these dangerous drivers, especially the ones on the motorway who pass us out and then swerve back into the slow lane as if there was some danger. All despite the fact that there is no car for miles behind or ahead of them in the ‘fast’ lane.
This time was different. I considered it a misdemeanour turning into a felony. I slammed on my car horn and kept it there for so long that even I was becoming embarrassed. I wanted him to be very clear that the loud horn coming from his rear was not an accident, but a clear statement that he had transgressed some law of survival involving us all.
As happens in these cases he became stuck behind a tractor shortly afterward. We were now tailing him. We took his number and rang the police and described our adventure. Unfortunately we exaggerated just a little, for full effect don’t you know, and to be taken seriously. We described him swerving, driving dangerously and heading off “at great speed”. This was not entirely true as I felt the driver was somewhat chastened. We told the Gardaí on the phone that we were just behind him and could read his number plate. I hope the Garda did not think we were also driving dangerously to keep up with “the evidence”.
The woman Garda told us to ring her back and let us know what direction he was heading as we left town. We did. Wrong number. Did she give us the wrong number as a survival tactic or because she was new to this role of answering 999 calls? We will never know. We rang again and got a man Garda who gave the sound of someone who was going to do nothing about it. Busy-busy, under-resourced, not a priority. He did not have to say a word. I knew the score. I am a doctor after all. I understand these three impediments to effective workplaces.
And it got me thinking about all the services we pay for with our taxes that have become a mirage. The pioneering Americans called the British to task on “taxation without representation”. The Boston Tea Party. We should be calling our Government to task on “taxation without services”.
We all thought that we were paying taxes for basic services such as water, roads, infrastructure, health education, security. The social contract: We pay the taxes, the Government delivers the services. But no. We have free primary education, but it costs thousands between books and extras, putting poor families under pressure. We have free health except that private health insurance is an essential extra cost, never mind car parking costs and private donations on the street needed to keep Crumlin Hospital supported. We have water paid for by our taxes, but oops!, the political system saw no votes in water and so we are billions behind in infrastructure and planning for water. We have criminals with 200 previous convictions adding a few more to that number while on parole and with early release. They say there are no votes in more prisons. Our motor taxes pay for roads so why the road tolls? Is this double taxation? Is this taxation without services?
So increasingly we are getting more of what we thought was included in our social contract being taken out of our social contract. We now need to pay twice for health, education, legal services, policing, roads and water services. And when we do get that “service” it is too often a sham. You ring the police and nothing happens, except wasting your time and adding to the frustration of all involved. You ring the ambulance and there is a critical delay. You go to an emergency department to feel vulnerable to chaotic forces while waiting what seems like forever. People talk of paying their taxes their whole lifetime to discover the services are not there when they need them. People feel they are compelled to pay taxes and then more. More to pay for the actual services we thought we were paying for in the first place.
Before our recent abortion referendum, the threat to doctors was that the laws of Ireland wanted to put us in prison for 14 years if we acted in a certain way. In other words, if we got the balance wrong in caring for the mother-child couplet, we were culpable. An error in judgment, in their non-medical opinion, could be catastrophic. We were obviously too close to the situation to make a proper decision. They, who are busy judging us, are further away and, therefore, have divine objectivity and wisdom, even on one of the most contentious issues on the planet: Abortion.
Now it appears people (especially Joe Duffy callers) want to hang us GPs for NOT referring patients. At the momentous signing of a ministerial pen and in the one tiny second it takes to ‘just sign there Minister, please’, our world turns out of love with ‘termination’ of a ‘life’ and in love with ‘choice’ and ‘difficult cases’. And what is the solution to the conscientious objectors? ‘You must refer’ or risk the sanctions… unknown. Maybe 14 years not practising medicine.
The fact that the life of a doctor and his family and community might be impacted by any of this goes over the heads of all commentators. One moment, the doctor can be tried by press, lynch-mobs and lynch-tweeters, lay Medical Council majorities of two-to-one and by legal preying hyenas. These legal eagles, in the absence of a ‘natural’ ethical framework, fall back on ‘it is my responsibility to represent my client and not to make any judgment’. Legal culture falls back on the Constitution, or at least the absolute wording of the Constitution, rather than the spirit of the constitution. Here, words and pedantic interpretations mean everything. Twelve weeks or 24 weeks. One or the other. ‘Doctor guilty as proven’ for not referring at 11 weeks, six days and 23 hours. But like Cinderella, when the clock chimes midnight on the 12th week, then the doctor could then be deemed guilty for a very different reason.
We don’t know whether we will be prosecuted in such instances. A lot of recent Irish law and European processes are at their happiest when ordinary tax-payers and citizens don’t really know whether we are breaking the law or not. The great invisible mob called ‘They’ can decide on our innocence or guilt, depending on their mood or whether we are playing by the rules. Their unwritten rules.
But the real world of doctors, nurses, paramedics and judges is complex. The world of Médecins Sans Frontières has no boundaries or national identities. No ‘who is right?’ or ‘who is wrong?’ They risk their own lives to help all people, regardless of the truth that some might well be seen as terrorists. We treat horrendous criminals as we treat little innocent angels. The same. That is the medicine way. Our culture. Our ethic.
We are there with the patients and citizens of Europe as they, and we, together make difficult decisions. Sometimes all we can do is stand by their side. Cancer, death, dying, abortion, pain, suicide. We are there while some seem to look on, waiting for a time and place to put doctors in their place. Trying to confront the alleged arrogance of doctors and using the arrogance of black-and-white thinking to attack us. As Eliza Doolittle sang in My Fair Lady: “Just you wait, ’Enry ’Iggins, just you wait.” Some people just want to bring other good people down. Maybe her surname Doolittle was a subtle message from George Bernard Shaw about the people who want to bring good people down. Nothing better to do. Invested in the adrenaline rush of war and anger and judgment and scapegoating and black-and-white thinking.
I thought the referendum said we were moving away from those Irish addictions. Maybe not.
ometimes I read books about creating calm in my life and I wonder if they have any influence on my actual lived life. Are they good in practice as well as in theory?
A recent RTA gave me an insight into the answer. I turned right onto the main road and through the green lights. A car was coming at me from the left slip road. His front right wing connected with my left wing. Then I heard the gentle noise of slowly crushing metal. Time slows down in those dramatic times of our lives.
Both cars came to a standstill. We were now blocking the main road and rush-hour traffic. I was aware of cars to my right and behind me. We both wanted to get out of the way of traffic. We felt the invisible pressure from faces unknown in other cars. It was not a major crash, so I felt it was safe to get off the main road onto the path to allow traffic to flow.
I parked the car on the footpath and allowed myself 30 seconds to assess my muscle tension and stress reaction, to consider my options and choices for action. I took a deep breath. I realised that I was alive and very well.
I was now parked in a safe place. I considered the possibility that the guy in the other car might be a road-rage psycho. Maybe not. ‘Okay, I am ready’, I said to myself. I thought of Eckhart Tolle, who wrote the famous The Power of Now. His videos on YouTube have been part of my recent diet of inspiration. He would say: “All you have is now and all you have control over, is now.”
“Are you okay?” I asked him as I walked towards the other driver, now out of his car, heading for me. “Okay,” he replied. “So you are okay and I am okay”, I said calmly, aware of my tone, volume and body language. I was taking charge like a doctor in an emergency department. The driver seemed calm. “I am fine and you are fine. Now let’s get the facts.” People often rush to anger and judgment in these situations. That is why I specifically talked about focusing on the facts of the situation.
We inspected each other’s cars, and took mobile photos of registration numbers and insurance discs. It was dark and difficult to see the details of his insurance through the window and plastic cover. Should I have asked him to let me see the details in more light? Should I have got a photo of him and of any identity documents? Maybe. Probably. But I didn’t, because he seemed a reasonable human being and I saw it was a hired car. This might make things easier.
David was a solid human being and was contrite from the get-go: “I am sorry. I had a very stressful day. So sorry. It was my fault.”
As I drove home in my now battered and aching car, I thought that I had better text David to make sure the mobile number was in fact correct. He texted back straight away and apologised. This was a relief. That he took full responsibility in writing.
I had no neck injury over the next few days but I was surprised by two observations. The devil in my mind kept repeating that I should claim for whiplash. The same devil helped me remember others who had claimed whiplash against my insurance 20 years earlier for a total of £24,000. The devil in my head was quite intrusive. But unlike the Chris de Burgh song The Spanish Train, the devil did not win — this time.
My second surprise was how cheap a car side wing is: €70. But painting, colour matching, labour and taxes brought it to €500.
I would have guessed €250. What do I know? David asks me by text whether I would accept cash to save his no-claims bonus. But I had been burnt 35 years before with a doctor who drove into me. That doctor offered £200 on the spot. I, being collegial and naive to the world, said it would never cost that much. I would bill him later. It actually cost more but he was never seen again.
I wrote to the insurance company on this occasion that I would accept €500 as full and final payment. I intimated that I had not engaged legal, medical or administrative support. Yet. The cheque arrived faster than I expected. So I continued to breathe and stay calmly in the ‘now’. I am thankful that on this occasion, I was unlucky to have an accident but very lucky that I had no permanent scars. Thankfulness is good for your health. PS: I texted David, thanking him for dealing with it like a gentleman and the final cost. A lot less than £24,000. I am at peace.
Disgusting! Yes, medicine is disgusting. That is what some people think of ‘blood and guts’. Some react at an emotional level of fear. ‘Excrement is disgusting and dirty’, the narrative goes. The reaction to blood is another example of a learned, socialised emotion. These knee-jerk reactions are passed down by the reactions that kids see in adults and other social influencers. The tribes decided that fear of blood is good for survival and the thought that excrement is disgusting helps us be clean and to avoid infection and disease.
People who have more serious fear of blood have haemophobia. Apparently, up to 30 per cent of children have this and it commonly continues into adulthood. Yet, and at the same time, many kids love all sorts of disgusting things. They love being scared out of their wits. They love playing jokes on other kids with disgusting gunk and muck.
Adults too seem to have a thrilling interest and fear of all things medicine, as seen in the popular hospital soaps. The real-life, fly-on-the-wall documentaries show intimate open-heart surgery on your friendly TV screen. You might even be in bed drinking red wine and eating ‘healthy’ crisps. The bloody and messy deliveries of babies are seen on the massive 85-inch TV, watched by a wide-eyed audience. Some people can’t get enough. For many, this is ‘entertainment’.
And yet, our perceived role as doctors in society is to sanitise the difficult aspects of our existence. The bits that people like to deny. The messy, disgusting bits put away somewhere, out of sight. Old people end up in homes away from their own home. Psychiatric patients put away in institutions. We used to put the pregnant and their offspring away in working homes, away from the general public in a living hell, punishment for the sin of propagating the miracle of new life, but not abiding by the social rules of their time.
We all want to protect children and close relatives from the sight of awful car accidents, the human carnage of war and the decaying sight and smells of death itself. But doctors, nurses, frontline ambulance professionals and soldiers all have to get used to the disgusting reality, as it actually is. The trenches in World War 1 and Vietnam were not romantic. Opening a child’s chest for heart surgery is not romantic, nor easy.
We protect the people of Ireland from the cold realities of disgusting and complex life. We sanitise, romanticise and even make entertainment out of disgusting life. So when we ask the good people of Ireland to make clean, black-and-white decisions about messy, traumatic, complex, nuanced subjects at a constitutional level, we can hardly be surprised that the arguments for and against will probably be sanitised as well.
Life will be depicted as simple. Decisions as straightforward. One side or the other. The ‘opening of floodgates’ will be mentioned yet again. The fact that lives are being lost at present will be ignored. That the genie is already out of the bottle. That many citizens are buying medication online. That it is impossible to stop citizens from going online or travelling to England. That it is impossible to police the bodies of women anymore. That the past is dead.
This upcoming referendum to decriminalise both doctors and potential mothers who try to make impossible medical decisions in pregnancy will tell us where we are in Ireland in 2018. It is important for men to vote this time to support the legitimate concerns that many women have in Ireland on this issue. Savita and the Magdalene Laundries showed us all that we do not fully respect healthcare for women in this country and that life is often messy. Medical life is often a Sophie’s Choice. We can only do our best in often impossible, messy situations.
There has been much talk about sex lately: The behaviour of ‘rugby boys’ raising questions of what ‘consent’ really means in sexual affairs; the Eighth Amendment and situations that transpire as a consequence of sex; different types of sexual relationships and marriages. So let’s explore the ways that sex is understood in various traditions and narratives.
In biology, sexual behaviour is considered simply as a means for reproducing the species. All living life seems to do it, as if the only reason for life is survival and propagation. The strongest survive, depending on their strengths and adaptability. But all individual life is limited in time. No individual of a species lives forever. The genes move along with time, changing and evolving. Some species do not need mates, as such, because they are unisexual and just divide or self-impregnate.
In sexual politics, sex is seen as a battleground for equal rights and the rights of the individual to live their sexual life as they choose. Historically, men in some cultures had a number of wives, but the growth of sexual and social equality means this is less common nowadays. There are mixed reactions to group marriages or group sex, with such actions often frowned upon, presumably on the basis of ideas of hedonism, excess and public health. Of course, group activities are not everybody’s inclination, for many reasons, but there is a sense that what is enjoyed by one part of society must be the rule for all.
Religions and governing classes usually have strong ideas about how sex is organised in society. Some religions are more fixated on sex than others, but many seem to agree that society needs a core structure, namely a family with children. This was strongly challenged by Henry of the famous eight wives. It was fine until it did not suit him. His fixation was on a male progeny and an heir to the throne.
There is the genetic sense that life follows on after us through children; our life after death. However, many parents will challenge the idea that you can predict what your children will get up to and whether they will truly represent you into the future. The parents of Hitler cannot have expected the mass destruction that he engineered. Greatness, invention and human progress can come from any direction and from anywhere. In the modern world, great ideas and inventions, as well as horror, can come from anybody’s child.
William Shakespeare, Nelson Mandela, Steve Jobs and Stephen Hawking will be remembered for their influence on the world rather than having been of their own parents’ genetic material. It makes more sense to me that these exceptional people were accidents of genetic mutation, diversity and their lived experience rather than what genes they got from their parents. So it might be important that humans have babies in general, but it may not matter who specifically has babies so much.
Consent and sex is an evolving conversation. In fact, consent in life is an evolving conversation. Julius Caesar did not ask ‘pretty please’ as to whether his conquered slaves would build fantastic aqueducts and roads across Europe. He used the tactics of ownership, fear and subjugation. We, however, have moved towards ideas of democracy.
In modern societies, we have also thankfully moved on from the husband owning his ‘property’ — wife — and having rights to sex for pleasure or subjugation, to demands for equality, respect and consent. But some of the old ideas of ‘manhood’ and identity will linger in dressing rooms and pubs and secret dens. The difference now is that nothing is secret anymore, especially if it is posted on Facebook.
No! No! No!’
The Iron Lady Maggie Thatcher was never an icon of mine but, boy, could she say ‘no’, even to those feisty Irish. She said ‘no’ to three proposals for peace in the North. She did not follow-up with any constructive ideas of her own. Not too long afterwards, real dialogue did begin, which ultimately led to the peace in Ireland that we enjoy.
Maybe she is like me, in that I like to say ‘no’ first while I consider my position. I find the response by the other person helpful. If they differ in their opinion from me but respect my right to my opinion, I find I am more able to respect and listen to their point of view. If, on the other hand, they react with high emotion, anger, threat and manipulation, I find that I close my doors to further dialogue. I raise the bridge to my castle and concentrate on the threat and how I might defend myself against it.
If you are not listening to me, why on earth would I listen to you? This realisation hit me most obviously in relation to pharmaceutical reps visiting me in my GP surgery. It became the new vogue to sell the merits of three different drugs… on my time. So I developed a response. I wanted to hear new important information, but at the same time, I was hearing about a few drugs repeatedly.
So my response was to ask them to talk about one drug only. This went over the head of some reps and they continued on their merry way, as scripted in ‘rep school’. They tried to talk at me about, yes, three different drugs, indifferent to my glazed-over eyes. I remember nothing of this, because I was not there. If you expect me to listen, you first need to listen too. Some more mature reps, or should I say, more ‘emotionally intelligent’ reps, would hear what I said and give me a lot of information about their chosen drug, cream or application.
Better reps would take my less-than-subtle hint about one drug and ask me which of the three drugs I wanted to talk about; which drug would be most helpful for me to hear about? Happy days! But the gold star award went to the rep who never mentioned their wares directly and talked about other current events such as the Triple Crown, the Eighth Amendment or whatever you are having yourself, boss. They were real people having real relationships. We both knew our role in this sales dance and so I took my responsibility seriously and interrupted our pleasant tea-time natter with the obvious question: “So I suppose you are selling that drug of yours. Any new things I need to know?” The relationship continued.
And so in the upcoming debate about the Eighth Amendment, I am going to keep focused on my promise to say ‘no’ — ‘no’ to doctors having to consider that they might spend 14 years in jail, or even gaol, for the offensive thought and act of trying their best on the front line. Where the law prefers days and weeks and even years to decide what the right course of action is, in a particular set of circumstances, the doctor wants to save as many lives as possible and cause the least harm. The law and the delay caused by indecision can lead to the worst of all outcomes. We do not need to name those we have lost in these circumstances.
I am saying ‘yes’ to scrapping this Eighth Amendment. We need laws and constitutions that reflect the real world, with real people struggling to do the right thing. Compassion and fairness in a democratic world is what I want from the Irish Constitution.
Increasing demand for GP out-of-hours services could be the straw that breaks the camel’s back, writes Dr Paul Heslin
Dr Paul Heslin on the advice he plans to give at an upcoming careers talk at his old school
Dr Paul Heslin on how an unforgettable medical emergency highlighted protocol flaws in our ambulance system
Dr Paul Heslin on the male tendency to overdo fitness efforts and ignore the body’s sensible advice
Dr Paul Heslin ponders what constitutes acceptable risk and living one day at a time