- Email: [email protected]
TEN-SESSION CONSULTANT CONTRACT
429 of treatment. I should like to make the following comments on the treatment of rheumatoid arthritis with penicillamine. Freedom from toxic effects in my cases may be due (1) low dosage; (2) administration of pyridoxine; (3) consumption of the amine through chelation with a collagen link; (4) Walshe1 suggested that most of the toxic reactions to penicillamine are immunological rather than pharmacological, so there may be an increased risk of undesirable reaction in patients with an autoimmune disease, such as rheumatoid arthritis. Although I cannot claim any expertise in the field of rheumatoid arthritis, may I suggest that the benefit that these patients receive is not through chelation of dithiol links in the rheumatoid antibody, but may stem from changes in the cross-linkage of the collagen in the affected joints. Should this be so then equally good results may be expected with a much smaller dose of penicillamine.
to:
A full account of mv patients is being prepared for publication.
Guy’s Hospital, London SE1.
E. J. MOYNAHAN.
POSTOPERATIVE TUBERCULOUS PERITONITIS
SiR,-The report of Dr Warshaw2 throws light on one aspect of postoperative granulomatous peritonitis. We have drawn attention to another setiology—postoperative tuberculous peritonitis.3 Except for the longer incubationperiod from operation to onset of symptoms (4-10 weeks in postoperative tuberculous peritonitis compared with 11-17 days reported by Dr Warshaw), there could easily be confusion between these two " sterile " postoperative types of peritonitis. Starch granules in the fluid were not observed in any of our 4 cases but were carefully looked for in only 2. It is obvious that Dr Warshaw’s cases were truly benign because they were self-limited, but this clue can only be determined in retrospect. We would emphasise that in sterile " postoperative peritoneal reactions where starchgranules are not seen, where there is a longer incubationperiod than 3 weeks, or when the process does not remit, tuberculous peritonitis must be carefully considered. "
Presbyterian-St. Luke’s Hospital, 1753 West Congress Parkway, Chicago 60612, U.S.A.
STUART LEVIN L. D. EDWARDS RICHARD RAFOTH.
U.S. SUPREME COURT ON ABORTION
SIR,-You quote (Feb. 10, p. 302) the United States Supreme Court as justifying their recent ruling to permit abortion without regard to the child’s rights up to the stage of viability, and in some circumstances even beyond, with the statement that " We need not resolve the difficult question of when life begins. When those trained in medicine, philosophy, and theology, are unable to arrive at any consensus, the judiciary at this point in the development of man’s knowledge is not in a position to speculate as to the answer ". Perhaps those trained in philosophy and theology may have difficulties in deciding on the biological question of when life begins, but it is to be hoped that a training in medicine would leave no doubt that (a) a human fetus is by definition human, (b) it is alive, since it can be killed, and (c) in no biological sense does it form a part of its mother’s own body, being genetically as distinct from her as it will ever be, right from the start. As Lord Gardiner pointed out in a letter to The Times on Feb. 2, what the Supreme Court has in fact decided is 1. 2. 3.
Walshe, J. M. Postgrad. med. J. 1968, October suppl., p. 6. Warshaw, A. L. Lancet, 1972, ii, 1054. Scand. J. infect. Dis. 1972, 4, 139.
foetus does not become a ’person ’ protected by clauses of the Constitution until after it is born ". That of course is a matter of legal definition and not of biological fact, and there are certainly some precedents for " unpersons " being deprived of the protection of the law. And rather unhappy precedents too, on the whole.
that " ’
due
a
process ’
Gonville &
Caius College, Cambridge CB2 1TA.
C. B. GOODHART, Society for the Protection of Unborn Children.
TEN-SESSION CONSULTANT CONTRACT SIR,-We should like to add our voices to the growing volume of disagreement with the proposed new N.H.S. consultant contract. We accept that there is a problem to be solved, in that consultant manpower is unequally distributed in Britain, and some consultants work much longer hours than others. The acceptance of additional N.H.S. commitments (such as abortions and vasectomy) without any increase of staffing compounds the problem. The solution proposed in the new ten-session contract is to specify the number of hours for which a consultant must work in order to earn his basic salary, and to pay him for additional out-of-hours work. We find this suggestion distasteful. It will involve the profession in an unprofessional approach to the care of patients, and will progressively diminish our independence. Who will certify that
duty claims are reasonable ? It will not be long before we are " clocking in ", and obtaining certificates of attendance from the appropriate duty administrative officer. The details of the new contract must be settled before it is priced. It appears unlikely that it will result in a significant increase in the total sum available for remuneration of consultants. The basic salary will, therefore, tend to be reduced, and consultants will be in competition with each other for their share of the " overtime " or extra-duty monies. It is a disturbing thought that there will be a financial incentive to postpone urgent work till after normal working hours. We are equally disturbed by the proposal that even fulltime consultants will have the right to see private patients and to retain the fees. Although theoretically private practice after working hours is not incompatible with National Health Service responsibilities, we believe that in many specialties there is a conflict of interests which will be to the detriment of the Health Service. We have not yet met any large group of hospital staff who are in favour of the new consultant contract. Certainly in the teaching hospitals (where we work) opinion appears to be overwhelmingly against the features we have commented on. We understand the plight of overworked consultants in understaffed regional hospitals, but there must be better ways of helping than those proposed in the ten-session contract. In addition, the new contract would open a gap between N.H.S. staff and their university colleagues, which would weaken the medical schools and hamper improvements in medical education (both underour extra
"
graduate
and
postgraduate). L. BEILIN (Oxford) I. BOUCHIER (London) Secretary
Association of
W. GREIG (Glasgow) J. LORBER (Sheffield) R. LOWE (London)
University Clinical Academic Staff Chairman c/o St George’s Hospital R. SHANKS (Belfast) Medical School, Treasurer 9 Knightsbridge, C. WHITE (Cambridge). London SW1
"
to:
A full account of mv patients is being prepared for publication.
Guy’s Hospital, London SE1.
E. J. MOYNAHAN.
POSTOPERATIVE TUBERCULOUS PERITONITIS
SiR,-The report of Dr Warshaw2 throws light on one aspect of postoperative granulomatous peritonitis. We have drawn attention to another setiology—postoperative tuberculous peritonitis.3 Except for the longer incubationperiod from operation to onset of symptoms (4-10 weeks in postoperative tuberculous peritonitis compared with 11-17 days reported by Dr Warshaw), there could easily be confusion between these two " sterile " postoperative types of peritonitis. Starch granules in the fluid were not observed in any of our 4 cases but were carefully looked for in only 2. It is obvious that Dr Warshaw’s cases were truly benign because they were self-limited, but this clue can only be determined in retrospect. We would emphasise that in sterile " postoperative peritoneal reactions where starchgranules are not seen, where there is a longer incubationperiod than 3 weeks, or when the process does not remit, tuberculous peritonitis must be carefully considered. "
Presbyterian-St. Luke’s Hospital, 1753 West Congress Parkway, Chicago 60612, U.S.A.
STUART LEVIN L. D. EDWARDS RICHARD RAFOTH.
U.S. SUPREME COURT ON ABORTION
SIR,-You quote (Feb. 10, p. 302) the United States Supreme Court as justifying their recent ruling to permit abortion without regard to the child’s rights up to the stage of viability, and in some circumstances even beyond, with the statement that " We need not resolve the difficult question of when life begins. When those trained in medicine, philosophy, and theology, are unable to arrive at any consensus, the judiciary at this point in the development of man’s knowledge is not in a position to speculate as to the answer ". Perhaps those trained in philosophy and theology may have difficulties in deciding on the biological question of when life begins, but it is to be hoped that a training in medicine would leave no doubt that (a) a human fetus is by definition human, (b) it is alive, since it can be killed, and (c) in no biological sense does it form a part of its mother’s own body, being genetically as distinct from her as it will ever be, right from the start. As Lord Gardiner pointed out in a letter to The Times on Feb. 2, what the Supreme Court has in fact decided is 1. 2. 3.
Walshe, J. M. Postgrad. med. J. 1968, October suppl., p. 6. Warshaw, A. L. Lancet, 1972, ii, 1054. Scand. J. infect. Dis. 1972, 4, 139.
foetus does not become a ’person ’ protected by clauses of the Constitution until after it is born ". That of course is a matter of legal definition and not of biological fact, and there are certainly some precedents for " unpersons " being deprived of the protection of the law. And rather unhappy precedents too, on the whole.
that " ’
due
a
process ’
Gonville &
Caius College, Cambridge CB2 1TA.
C. B. GOODHART, Society for the Protection of Unborn Children.
TEN-SESSION CONSULTANT CONTRACT SIR,-We should like to add our voices to the growing volume of disagreement with the proposed new N.H.S. consultant contract. We accept that there is a problem to be solved, in that consultant manpower is unequally distributed in Britain, and some consultants work much longer hours than others. The acceptance of additional N.H.S. commitments (such as abortions and vasectomy) without any increase of staffing compounds the problem. The solution proposed in the new ten-session contract is to specify the number of hours for which a consultant must work in order to earn his basic salary, and to pay him for additional out-of-hours work. We find this suggestion distasteful. It will involve the profession in an unprofessional approach to the care of patients, and will progressively diminish our independence. Who will certify that
duty claims are reasonable ? It will not be long before we are " clocking in ", and obtaining certificates of attendance from the appropriate duty administrative officer. The details of the new contract must be settled before it is priced. It appears unlikely that it will result in a significant increase in the total sum available for remuneration of consultants. The basic salary will, therefore, tend to be reduced, and consultants will be in competition with each other for their share of the " overtime " or extra-duty monies. It is a disturbing thought that there will be a financial incentive to postpone urgent work till after normal working hours. We are equally disturbed by the proposal that even fulltime consultants will have the right to see private patients and to retain the fees. Although theoretically private practice after working hours is not incompatible with National Health Service responsibilities, we believe that in many specialties there is a conflict of interests which will be to the detriment of the Health Service. We have not yet met any large group of hospital staff who are in favour of the new consultant contract. Certainly in the teaching hospitals (where we work) opinion appears to be overwhelmingly against the features we have commented on. We understand the plight of overworked consultants in understaffed regional hospitals, but there must be better ways of helping than those proposed in the ten-session contract. In addition, the new contract would open a gap between N.H.S. staff and their university colleagues, which would weaken the medical schools and hamper improvements in medical education (both underour extra
"
graduate
and
postgraduate). L. BEILIN (Oxford) I. BOUCHIER (London) Secretary
Association of
W. GREIG (Glasgow) J. LORBER (Sheffield) R. LOWE (London)
University Clinical Academic Staff Chairman c/o St George’s Hospital R. SHANKS (Belfast) Medical School, Treasurer 9 Knightsbridge, C. WHITE (Cambridge). London SW1
"