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Had I talked James out of a cancer screening? If he’d gone, might it have been caught?

It was difficult not to feel disquieted reading my notes.

James consulted about a simple ear infection. It didn’t take long to deal with, and I was pleased at the prospect of making up time in a late-running surgery. But as he got up to go, the 60-year-old had a “By the way, doc” question for me: should he be screened for prostate cancer?

I motioned him to sit back down; it’s a difficult one to answer. We can try to detect the disease with a blood test for prostate-specific antigen (PSA). But in men without symptoms, PSA misses at least 15 per cent of tumours, coming back normal despite there being cancer there. On the other hand, fully 75 per cent of men with an abnormal result turn out not to have cancer after all – but they have to endure weeks of anxiety, as well as an unpleasant set of biopsies taken through the rectum, before they can be given the all-clear.

It gets even trickier for the 25 per cent with a positive result who do have a tumour on biopsy. They face a dilemma. Most prostate cancers are indolent and do not cause symptoms or shorten life; some, however, go on to behave much more aggressively. We can’t reliably tell which ones are which. Potentially curative treatments – surgery or radiotherapy – frequently cause substantial problems such as impotence and bladder or bowel incontinence.

If you try to “cure” everyone with a proven prostate cancer, for every life you save you end up blighting the lives of dozens of other men who ultimately derive no benefit from radical treatment.

Such is the inaccuracy of PSA, and the uncertainties over how to treat cancer if found, that there is currently no national screening programme for this common cancer. However, the Department of Health still recommends testing any man who requests it after being given full information. I explained the ins and outs to James. He weighed it up carefully, and decided against proceeding.

I didn’t see him again for another two years, but a few months ago he returned saying he’d developed a poor urinary stream and was needing to go to the loo several times each night. These are classic prostate symptoms, and I hoped that they would be due to common-or-garden, benign, age-related swelling of the gland.

A PSA is more accurate in men who have symptoms, so it was disconcerting to find James’s level substantially raised. I referred him for biopsies, and unfortunately these showed a cancer. Scans revealed spread to local lymph nodes and a possible deposit in bone. Cure is no longer possible at this stage, though James’s cancer is likely to be controlled for many years by hormone therapy.

Going back through his records, I revisited the entry from a couple of years earlier. It was difficult not to feel disquieted reading my notes. James’s cancer had almost certainly been present at that time.

If he had gone forward for screening, might it have been caught early enough to have effected a cure? I had tried to give him a balanced account of the pros and cons, but I also realise I have a personal view: which is that, given our current inadequate tests and knowledge, prostate screening causes more net harm than good. Had I allowed my own beliefs to colour our discussion, subtly biasing James against a PSA test? Had I, in effect, talked him out of it?

It’s one thing for me as a doctor to go through these imponderables in my mind; quite another for a patient now grappling with a serious diagnosis. I felt apprehensive when James came to see me after being given his results at the hospital. Would he be angry and blame me for his predicament? It would have been a understandable reaction, especially given the way hindsight can colour our view of past events.

But it was my own sense of guilt (rational or irrational) that I was wrestling with. James had lots of questions about the hormone treatment and the future, but he was entirely at ease with me, and was focused solely on the road ahead, rather than that which had passed.

This article first appeared in the 15 June 2017 issue of the New Statesman, Corbyn: revenge of the rebel

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You may call me a monster – but I'm glad that girl's lemonade stall got shut down

What's wrong with hard-working public servants enforcing perfectly sensible regulations?

Who could fail to be moved by the widely shared tears of a five year old whose innocent lemonade stall was brutally shut down by evil bureaucrats? What sort of monster would not have their heartstrings tugged by the plaintive “I've done a bad thing” from a girl whose father tells us she “just wanted to put a smile on people's faces”?

Well me, actually.

There are half a million cases of food poisoning each year in the UK, and one of the reasons we have stringent controls on who can sell food and drink, especially in unsealed containers, is to try to cut those figures down. And street stalls in general are regulated because we have a system of taxation, rights and responsibilities in this country which underpins our functioning society. Regulation is a social and economic good.

It’s also pretty unfair to criticise the hard-working public servants who acted in this case for doing the job they are no doubt underpaid to do. For the council to say “we expect our enforcement officers to show common sense” as they cancelled the fine is all very well, but I’m willing to bet they are given precious little leeway in their training when it comes to who gets fined and who doesn’t. If the council is handing out apologies, it likely should be issuing one to its officers as well.

“But these are decent folk being persecuted by a nanny state,” I hear you cry. And I stand impervious, I’m afraid. Because I’ve heard that line a lot recently and it’s beginning to grate.

It’s the same argument used against speed cameras and parking fines. How often have you heard those caught out proclaim themselves as “law-abiding citizens” and bemoan the infringement of their freedom? I have news for you: if you break the speed limit, or park illegally, or indeed break health and safety or trading regulations, you are not a law-abiding citizen. You’re actually the one who’s in the wrong.

And rarely is ignorance an excuse. Speed limits and parking regulations are posted clearly. In the case of the now famous lemonade stand, the father in question is even quoted as saying “I thought that they would just tell us to pack up and go home.” So he knew he was breaking the rules. He just didn’t think the consequences should apply to him.

A culture of entitlement, and a belief that rules are for other people but not us, is a disease gripping middle Britain. It is demonstrated in many different ways, from the driver telling the cyclist that she has no right to be on the road because she doesn’t pay road tax (I know), to the father holding up his daughter’s tears to get out of a fine.

I know, I’m a monster. But hooray for the enforcers, I say.

Duncan Hothersall is the editor of Labour Hame