To resuscitate or not to resuscitate: tattoos, medicine and intent

 

 

An ethical medical dilemma made the news this week, which was originally reported in the New England Journal of Medicine. It concerned an unconscious, inebriated patient brought into the University of Miami Hospital with a "Do Not Resuscitate" tattoo on his chest. The 70-year-old man had no identification, and the hospital could not find a next of kin, though the tattoo on his chest was signed, presumably with the man’s own signature.

What should the medics do? Did the tattoo represent a sane, living, up-to-date expression of the patient’s intent, or a joke – a variant of the "insert here" and "cut here" tattoos associated with youthful hi-jinks or an alcohol-fuelled night out? 

Cautionary tales abound, Like the 59-year-old diabetic who went into hospital for an amputation, only to unveil a D.N.R. across his chest. He was questioned by the hospital staff: was that what he wanted? No. If necessary, he wanted the doctors to try to resuscitate him, at least for a reasonable time. The man dismissed suggestions the tattoo was confusing. He didn't think anyone would take it seriously. 

For staff at the University of Miami Hospital, however, a conversation with the patient was not possible. He did not regain consciousness sufficiently for any discussion to take place. What the media coverage of this case failed to note, moreover, was that the patient was not just drunk, but in very bad physical shape. He had lived for some years with obstructive pulmonary disease, diabetes mellitus and atrial fibrillation. 

Though the medical team initially decided to disregard the tattoo, they changed their minds and referred the question to an ethical advisor. Presumably, they took this decision on the basis of the man's general health. And because the medical team was impressed by what they called the 'patient’s extraordinary effort to make his presumed advance directive known'.

Why might the man have wished to be DNR? A DNR order expresses a patient's desire not to receive intubation or Cardiopulmonary resuscitation (CPR) in the event that the heart stops beating. This might seem counterintuitive, but resuscitation can cause numerous ill effects, from broken ribs and ruptured spleens to brain damage. In the case of elderly patients, and those with a serious health condition, the risks might outweigh the predicted quality of life.

However, DNR orders are emotive. This is why some areas of the United States and the United Kingdom use the term Do Not Attempt Resuscitation. Without ‘attempt’, there is an implicit suggestion that resuscitation would definitely succeed. That is an upsetting belief for the patient's family, when resuscitation is not attempted.

Unfortunately, most attempts at resuscitation in the emergency room are unsuccessful. Many doctors I have spoken to admit to attempting resuscitation when they know it is hopeless. This is because CPR is a crucial part of the spectacle of emergency care. Distraught families and friends of patients have seen CPR on medical programmes like ER, and they expect it to be carried out. They are unaware of the damage to the body that can occur, along with the limited likelihood of success. 

DNRs are normally issued after discussion between the medical authorities and the patient and their family. The University of Miami Hospital staff would therefore have been in a particular dilemma. They had a moral duty to save the patient, except if he did not want them to do so. The legal issues were even more pressing. 

Many countries have their own DNR rules. In Saudi Arabia, for instance, patients cannot legally sign a DNR; the decision to resuscitate rests with the physician. In the UK, it is possible to write a living will that predicts whether or not you would want a DNR order in particular circumstances. In the US, DNRs are dealt with differently by different states.

Most relevant here is that the Department of Health for Florida, which covers the University of Miami Hospital, states that a ‘Do Not Resuscitate Order (Form 1896)’ must be printed on yellow paper and signed by the patient and her or his physician. ‘EMS and medical personnel are only required to honor the form if it is printed on yellow paper.’

So, it is easy to understand the hesitation of the medics. There was no legal necessity for them to honour the tattoo, and they could not be certain that the tattoo represented genuine intent on the part of the patient. Yet the ethical advisors decided that the man had taken the time to communicate deliberately, and with forethought, to his caregivers. In respect of that, the writing on the patient's body was given the same moral and legal status as an official DNR statement.

That evening, the man died. The medical team was subsequently 'relieved' to find that there was paperwork to support the tattoo evidence in the patient's case records. They had made a choice, under difficult circumstances, and with all the available evidence. And it turned out to be the right one. 

The usefulness of tattoos in conveying information about a person's health has been debated elsewhere. For there is growing trend, not only if tattoos in general,  but also in people communicating existing health conditions, like diabetes. This reflects other historical usage of tattoos to communicate medical information. In World War 2, for instance, members of the SS similarly carried blood group tattoos on the underside of their left arms. This bears a terrible echo of the Nazi's tattooing prisoners of Auschwitz.

Tattooing the skin clearly provides an indelible signifier that cannot be lost, mislaid or overlooked, in the case of DNR paperwork or medic-alert bracelets. But there remains the question of intent and a change of heart. People do change their minds about being resuscitated. But they may not remove their tattoos in accordance with this re-evaluation. 

I was struck by a number of other ethical and emotional issues when I read about this case. Firstly, the care and consideration exhibited by the medical team. They made an ethical decision to respect a tattoo despite the fact that this was against standard protocol. They recognised that the medical process was not always 'nimble enough to support patient-centred care'. And they wanted to ensure 'respect for patients' best interests', not just to protect the narrow limitations of the law and the hospital. 

It was a brave decision, and presumably not an easy one, given the pressures on individual medics and teams working together against the clock. It was a decision that also reflected the care the patient had taken in signing the DNR statement, as though his body was a legal document. 

I found that detail touching. Of course, the medical team and ethicists did not know for certain that it was the patient's authentic signature. And they must have decided the risk of litigation was reasonably low, balanced against the man's evident health and life expectancy. But the signing of the tattoo transforms what could have been a run-of-the-mill yet subversive challenge to mortality (akin to the tattooing of ‘Y’ incision autopsy scars perhaps) into something more political. 

We don't talk about death enough in life. We leave important decisions about organ donation and resuscitation to others, which leaves time-pressed medical professionals and distressed families and friends, to determine what a person would have wanted, should the worst occur. 

Yes, it's problematic to determine whether a tattoo can be taken as read. They have so many meanings, after all. But tattoos are also historically signs and tokens of resistance; commonly a way for people to stake their claim on their own bodies. They also take on meanings to others. At a time when our identities are increasingly commercialised and commodified, and when medicine in the UK is being privatised and seen not to care, a signed 'Do Not Resuscitate' tattoo takes on the quality of a political statement. 

Transforming the body into text in place of verbal communication potentially shifts the power-balance of the physician-patient relationship. It allows the patient's otherwise silent body - unconscious or anaesthetised, speaking only through a series of objectively measured signs like the heartbeat – to retain an essence of subjectivity: Look at me, it shouts. I am here. Not just a disease, or a body, but a real person, deserving of care.

In that, the unknown man's tattoo is a statement for our time. 

 

 

 

 

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Of legs and letters: fighting for the body of Sylvia Plath

I have been spending a lot of time lately with Sylvia Plath - reading her fiction, poems and journals, exploring her self-representation as a writer, and a woman coming of age in the 1950s. I have even read her undergraduate dissertation:  'The Magic Mirror: A Study of the Double in Two Novels of Dostoevsky', a copy of which is held at the British Library.

Fortuitously, a new edition of Plath's letters has been produced, which covers the early years of her life and ends with her marriage to Ted Hughes in 1956. The Letters of Sylvia Plath volume 1 provides key insights into Plath's relationship with her mother, her memories of her father, and her writing and romantic entanglements before Hughes. Volume 2, which will cover her marriage, breakdown and depression in the years leading up to her suicide in 1963, is due out in 2018.  

There is little contextual information in the Letters, other than an occasional footnote reference t. The significance of the book is not, therefore, its analysis, but in bringing together a vast body of previously unpublished material. Some of Plath's letters have been published before, in a volume published and edited by her mother Aurelia. Letters Home was a sanitised version of Plath's correspondence, removing anything that was uncomfortable to Plath's mother.

This is understandable: Plath's adult journals and letters contain negative and virulent writing about Aurelia; as Plath worked through her therapy, the vampirish 'blood sucking' mother was as important to her self definition as the absent, beloved father. (Otto Plath died when his daughter was eight, from complications linked to untreated diabetes.)

In poems like 'Medusa', and in autobiographical novels like The Bell Jar, Plath raged against the mother whose grip seemed all too tight. Working things out in prose was her way of being. Plath has been treated dismissively as a writer at various points. The term 'confessional' poetry, which Plath helped pioneer, has been used in a denigrating fashion. Her femininity has been linked to hysteria, and her poetry concocted as a 'witches' brew'. 

I wrote in my last blog that Plath is still not remembered in Poets' Corner, unlike her more respectable husband Hughes. Interestingly, Prince Charles, who encouraged Westminster Abbey to have an official memorial to Hughes, has a private shrine to the poet at his own residence. I say 'interestingly', because Prince Charles, like Ted Hughes, has more in common with his friend the poet than you might think: like Hughes, Charles was vilified over his adultery. Like Hughes, Charles' wife remains more popular than he after she died young. Both Princess Diana and Sylvia Plath suffered with mental health complaints, and both Charles and Hughes were accused of contributing to their wives' tortured state. 

Plath is far more than her relationship with Hughes, of course. She was an extraordinarily productive and accomplished writer, whose poems are regarded as some of the best in twentieth-century literature. She wrote a radio play, a children's book, short stories and novels, and won a Pulitzer Prize posthumously for her Collected Poems. Her literary talents were evident from childhood; she wrote poems, won prizes and published in magazines, ever determined to be a successful writer. 

Plath graduated from Smith College in 1955, and won a prestigious Fulbright scholarship to Cambridge, where she met Hughes the following year. As she wrote in her diaries, Hughes 'blasted' all other lovers from her mind, though she also discerned he might be 'a breaker of things and people'. By June 1956 the two were married, moved briefly to America and back to England, where they had two children, Frieda and Nicholas. 

Plath's first collection of poems, Colossus was published in 1960, with her novel The Bell Jar being published in January 1963 under the pen name Victoria Lucas. The book was met by lukewarm reviews. The following month, on 11 February, Plath committed suicide. A single parent living alone, suffering from severe mental anguish, Plath placed her head in the oven and gassed herself. A careful mother to the end, she had first sealed off the kitchen from the rest of the house with blankets and tape, and left food and drink for her sleeping children. 

It's easy to see why there will be a large audience for Plath's published letters. The nature of Plath's early death, her semi-autobiographical writing, her desire to write and to thrive in the male-dominated 1950s, and her dramatic relationship with Hughes, read like threads of a dramatic novel. In 2003 a celebrity-stuffed film was made that conformed to the most common narrative: the brittle but brilliant woman who gave it all for love, and lost. 

These are, of course, just narratives. And Letters has received mixed reviews. Sarah Churchwell in The Guardian isn't sure that they are worth reading, since so much is taken up with Plath's childhood and teenage years, when not much happened, aside from her first suicide attempt, which helped shape the writing of The Bell Jar. I think this is missing the point. We can learn a lot about Plath's self-representation as a daughter, a writer, a lover and a depressive in these letters; themes that I tackle in more detail in my forthcoming book about loneliness. 

What I want to draw attention to here, however, are the ways in which ownership of Plath's body - figuratively, in her writings, but also literally, through the meticulous picking over the bones of her suicide - reflects the pulling apart of the writer as a symbol for so much else: feminism, creativity, motherhood, depression, family trauma and the death of a father. 

Writers argue about whether Plath was co-dependent with her mother, biologically prone to depression, abused by her husband; whether she benefitted or lost out by her creative relationship with Ted Hughes; whether she was loved by him, abandoned by him, killed by him. Some of these claims are easier to prove than others. 

It is interesting that volume 1 of the Letters ends with Hughes, and that this is where volume 2 will begin. Hughes functions as a natural marker because, for good and ill, the two are always linked. I lingered over including a photograph of them both here, rather than Plath on her own. Since I am discussing them both, it seems necessary to include Hughes. There is also something about this portrait - the intimate expression under the public gaze - that seems appropriate. 

Plath had loved other men before Hughes, but the brooding poet absorbed Plath fully after they met at a party in Cambridge. In their marriage, Plath juggled her many roles, as mother, wife, cook, cleaner, academic, novelist, poet, learning to write between the lines, though not always happily since Hughes' career and writing always came first.

Critics have debated the extent to which Plath and Hughes' literary and personal relationship was positive; how far she was his muse, and how far he influenced her writing. Seldom the other way around. In one light, Hughes has been regarded by critics as an inspiration to Plath, a man whose presence impelled her to write, and whose talents sharpened her prose. In another, Hughes seemed to have wrung Plath out, to have taken what he needed and, like any great man of literature, put himself and his needs first.

When they separated, an event usually attributed to Hughes' infidelity with their friend and tenant Assia Wevill, Plath was devastated, and depressed. She was alone when she died, just as she had been alone most of her life. In the 1970s, Hughes was accused of killing Plath, at least through his indifference. Just six years after Plath's death, moreover, Hughes' mistress Wevill also killed herself in eerily similar circumstance. In March 1969, Wevill dragged a mattress into the kitchen of her flat, drugged herself and her four-year-old daughter with sleeping tablets, and turned on the gas stove.

Critics called Hughes a murderer, and repeatedly chiselled Hughes' name off Plath's headstone, incensed too because Hughes had buried Plath in the small village where he himself grew up. Hughes benefitted from Plath's estate after her death since the two were still married, and he destroyed her final journal, claiming he did not want the children to be harmed by it. He also lost Plath's penultimate journal. Hughes had also beaten Plath physically, according to her journals and her letters to her psychiatrist,  one such beating having apparently resulted in a miscarriage.

Yet the polarising of opinion, between Hughes as creator and Hughes as destroyer, has continued. Hughes did not only obliterate Plath's work, it is argued, he also helped created it. It was he who collected poems for the release of Ariel in 1965. In 1981, he also published Plath's Collected Poems. Notably, however, he also profited from the estate and he didn't include anything written before they met. These letters he dismissed as 'juvenilia'. Plath, in Hughes' view, was only born once they met.

Supporters of Hughes cite Plath's mental health problems. They see Plath's suicide as a product of her own instability (or her genetic encoding), rather than the circumstances of her sustained abuse, marital breakdown and abandonment.

Plath's physical body, it seems, provides evidence of her fragile mental state long before Hughes: she lashed her legs in a desperate act of self-harm (and revealed the scars to her mother) before her first suicide attempt. One that occasion, Plath had taken an overdose of her mother's sleeping tablets, and hidden herself away in the crawlspace of the cellar. While a search continued overhead, she lay unconscious for two days before she was found. Her cheek was cut and infested with maggots from where she had bashed her head when waking. She would be self-conscious of the resulting scar for the rest of her life.

Even before Plath met Hughes, then, her body carried the marks of her mental illness. Some critics have gone further in challenging Plath's idolised status; suggesting, for instance that she was jealous and competitive, particularly towards other women. Psychoanalytic concepts - oedipal, neurotic, hysterical - are bandied about as everyday descriptions that summarise Plath's behaviour before sweeping it neatly into a pile. The conclusion is unerringly gendered and tied in a pretty pink bow: she died for love, as so many women do.

Unsurprisingly, it is Plath's children who carry the biggest burden. Her son Nicholas suffered from depression and killed himself in 2009. He was a successful fisheries biologist and an expert in stream salmonid ecology, but that doesn't seem to matter. Nothing can disrupt the linear media narrative: he must be damned by the inevitability of genetics.  

You can understand the frustration and resentment of Plath's surviving daughter Frieda, a successful artist and poet in her own right. She is forever cast in her parents' shadow, and mediates between Plath and Hughes in death, as no doubt she would have been called to do in life, had they both survived. 

Fifty-four years after Plath's death, her body is still fought over. Not only her writings and their interpretation, but also her mental illness, its causation, and its legacy. There is something self-defeating about this struggle, as there is about any attempt at retrospective diagnosis

Plath was an extraordinary writer whose existence and struggles were both universal and particular; she fought for the right to write at a time when women were still defined by their bodies, and by gender. She wrote about her frustration of having been born with breasts and ovaries, rather than a penis, knowing that her sexed identity would imprison her. 

Yet Plath was also a complex individual, with desires and feelings that were a product of her own beliefs, and articulated according to genre. How ridiculous then to dismiss her as self-indulgent, especially when writing in her own journal. Yet this is all too often the fate of autobiographical women.

When Plath wrote, whether in journals, letters or fiction, it was always according to convention. Ever conscious of a potential reader, ever self-conscious about the way she would be read (or come to perceive herself), nothing was unmediated.

The Letters of Sylvia Plath are therefore a wonderful addition to our understanding of the life and experiences of a complex and fascinating woman. But they are no more 'real' than any other source. There is no 'there' there, after all. All we have is text. 

 

 

Sylvia Plath and Ted Hughes  

Sylvia Plath and Ted Hughes  

'Gut Feelings': Medicine, Gender and Health

 

BBC News reported today that gut flora - the trillions of bacteria that live in our digestive system - may ‘boost’ cancer therapy. Scientists in France and the USA tested the microbiome in cancer patients, finding evidence that a diverse biome, composed of a wide range of 'good' bacteria, contributed to the effectiveness of immunotherapy drugs.

This report is part of a more widespread recognition that the biome affects our physical and mental health. Other, recent stories reveal that gut bacteria can stop asthma  and provide a weapon against obesity.  Gut bacteria might, further, influence mental health conditions like anxiety, as well as the trajectory of debilitating diseases like Alzheimer’s. 

This is not the first time the gut has been seen as crucial to the conservation of health.  In 1907 The Abdominal and Pelvic Brain, written by the American physician Byron Robinson, identified the Enteric Nervous System in the gut as equivalent to the Central Nervous System associated with the brain.  Robinson anticipated more the American physiologist Michael F. Gershon's discussion of the gut as a ‘second brain’ in the 1990s.

The reason? The gut contains between 200 and 600 million neurons, the same number as the spinal cord. Moreover, more than two thirds of the body’s immune system can be located in the gut.

In this context, the most recent revelations about gut bacteria influencing immunology drugs makes sense: it is the manifestation of  'cross-talk' between brain and body: and a scientific explanation for ‘gut feelings’; that unproven yet instinctive sense we have about particular events, people and places. 

In the pursuit of health amongst the well, in addition to the sick, maintaining a healthy gut is crucial. Yet most modern Western diets don’t support microbial diversity, which is crucial to our well-being; loss of diversity is particularly linked to obesity. The over-consumption of chemically-produced and enhanced food, in addition to the over-use of antibiotics and antibacterial products, restricts and damages our gut flora, arguably making us more susceptible to allergies, infections and systemic problems.  

We can combat this erosion of healthy gut bacteria by eating probiotics that help defeat 'bad' bacteria, and prebiotics that enable 'good' bacteria to flourish. Naturally fermented foods, organic fruit and vegetables, ‘live’ cultures all point in the right direction. 

There is much that can be said about the militaristic battle lines drawn in the gut, as everywhere else, between the bacteriological forces of good and evil. Crucially, though, for theorising medicine and the mind/body relationship, listening to our guts turns conventional scientific ideas upside down, a theme I have discussed in This Mortal Coil: The Human Body in History and Culture It destabilises the brain from its pedestal as the dominant organ of the body in the neurocentric age, and creates a more holistic vision of the body. 

A focus on the gut challenges the idea that experiences like stress are transmitted just one way, from the brain to the belly, e.g. in conditions like Irritable Bowel Syndrome (IBS). In an alternative model, the  physical condition of the stomach and guts, and their nutritive and hormonal makeup, can be seen to run the show, sending information to the brain and even influencing mental health and brain structures.

As a historian of emotion and the body, I am interested in the imaginative and literary meanings of the body turned upside down. And in the fact that - as with with other anecdotal ideas about the body (like the emotional heart and transplantation) - science often finds material explanations for anecdotal or metaphysical concepts.

Many hormones and chemicals previously thought to exist only in the brain are now identified in the gut. About ninety-five per cent of the body’s serotonin, for instance, a neurotransmitter linked to appetite, sexual behaviour, pain and happiness, is found in the gut. So is dopamine, the 'pleasure hormone'.

If the gut/brain relationship is being re-jigged, however, it is at the expense of gender. We might not think of the gut as being gendered, but it is. Gender, like obesity, age and lifestyle, influences the hormones that are produced in the gut, and therefore the kinds of gut flora that might flourish. Whether or not there are ‘natural’ differences in gut flora is under-researched, though it is likely, given the role of hormonal influence.  It is known, for instance, that taking the contraceptive pill dramatically affects women’s gut bacteria, and that gut bacteria is gendered in BMI-specific ways - could this be a clue to the gender differences in metabolic and intestinal inflammatory disease? 

Why is gender missing from discussions of gut bacteria? And does it matter? Drugs and therapeutics have historically been developed for theoretically genderless (though inherently male) patient. According to the Institute of Medicine, women and men are perceived as different at the level of each individual cell. Each cell line is derived from a single donor and contains 23 pairs of chromosomes. Included in this group are the sex chromosomes, XX (female) and XY (male). Since 5% of the human genome 'resides on these chromosomes - 1846 genes on the X and 454 on the Y' - male and female cells are genetically different, a theme recently explored in the American Journal of Physiology.

Molecular biology is beginning to show how genes expressed on cell chromosomes 'impact cell function, and how they react to all sorts of stimuli'. For instance,female neurons uptake dopamine more quickly than male neurons, and female liver cells may metabolise drugs differently to male.

These cellular differences are rarely considered in medical studies or drug development. Since the 19th-century birth of scientific medicine, there has been a significant gender bias in favour of men. Yet the gender bias affects women's and men's experiences of healthcare in key ways. 

It remains to be seen how much difference gender will make to scientific understandings of the gut. There is a cultural stereotype that women are more able to access 'gut-feelings', though this ability is usually framed as 'intuition'.  Intuition has not historically been regarded credibly, but as evidence of women's connection with the emotional and the mystical (by contrast to men's reliance on reason and logic). Might it one day be re-imagined as a product of bacteria?

Electron micrograph of a common gut flora: Escherichia coli. Image courtesy of Wellcome Images

Electron micrograph of a common gut flora: Escherichia coli. Image courtesy of Wellcome Images

Writing Women at Westminster Abbey: the Case of Poets' Corner

I visited Poets’ Corner at Westminster Abbey this week. Poets’ Corner is the name traditionally given to a section of the South Transept of the Abbey because of the number of poets, playwrights and writers who are buried and commemorated there: from Geoffrey Chaucer to William Shakespeare, from Thomas Hardy to Philip Larkin. 

Firstly, it is an extraordinary place to visit, full of fascinating treasures and beautiful to behold. I entered before the tourists poured in, and it was extraordinary to be in that space alone, save for the odd hum of a Hoover. Amongst the busts and statues, a tapestry of floor stones decorates the space outside St Faith’s Chapel. I stopped at the stone of Robert Browning, the poet, and studied the inscription at the bottom. It commemorates Browning’s wife, a writer in her own right: Elizabeth Barrett-Browning, whose works include Sonnets from the Portuguese (1850), and such famous lines as: “How do I love thee? Let me count the ways.”

Elizabeth’s family was against her marriage, despite her being 40 years old when the pair eloped. Elizabeth was disinherited and she moved to Italy with her husband. There they had a son and despite Elizabeth’s various illnesses, seem to have been happy. Elizabeth died first. When Robert died, her parents refused permission for her body to be buried with her husband. There is, however, a symbolic irony in the Abbey’s half-hearted act of commemoration to Elizabeth. How often do women feature as the sub-plots or footnotes at the lives of great men?

I thought about this question a lot after my visit. Enough for me to contact the the archivist at Westminster Abbey to find out more. She confirmed that there are no women buried in Poets’ Corner, though the 17th-century writer Aphra Behn came as close as the Cloisters. The prolific writer, Margaret Cavendish, made it to the north transept, but she was also a noblewoman. Intrigued, I decided to find out more. 

In the 18th century, a hugely successful actress, Hannah Pritchard, who performed in many Shakespearean plays, was memorialised alongside Shakespeare’s statue. But she was subsequently booted out of Poets’ Corner, and replaced with a bust of Dr Samuel Johnson - he of the Dictionary fame. This seems apposite, since Johnson was scathing of Pritchard in life. He called her "a vulgar idiot" who had "no more thought of the play out of which her part was taken than a shoemaker thinks of the skin out of which the piece of leather out of which he is making a pair of shoes is cut".  Maybe it's the way he tells them. Pritchard was widely venerated in her day, and regularly performed alongside David Garrick. Did I mention Garrick was given a lavish state funeral before being laid to rest in Poets’ Corner?

No fewer than 91% of the writers, dramatists and poets remembered in Poets’ Corner are men. There are just six women writers commemorated: the Bronte sisters (3 for 1), Fanny Burney, Elizabeth Barrett-Browning, George Eliot, Elizabeth Gaskell and Jane Austen. Many significant women are missing from this list of 19th-century greats, including the writer and social reformer, Harriet Martineau. In fact, Martineau doesn't have a monument to her own writing anywhere in the country, despite the fact that she was a hugely respected social theorist and writer, read and enjoyed by Princess Victoria. Her name is inscribed on the east face of the Reformers' Memorial in Kensal Green Cemetery. And that's all she wrote. Except, of course, it wasn't. 

Historically there have been many more famous and successful male writers - and scientists, physicians and philosophers - than women. But no thinking person believes that this is because women lack aptitude, talent or drive. In the 18th century, however, early feminists like Mary Wollstonecraft, author of a Vindication of the Rights of Women argued against women's exclusion from education by virtue of their allegedly weaker minds and bodies. Wollstonecraft is not remembered in Poets’ Corner. Neither is her daughter, Mary Wollstonecraft Shelley, who wrote many important works, including Frankenstein; or, The Modern Prometheus (1851). The man she married, however, did. Percy Bysshe Shelley's tablet sits above the statue of Shakespeare. 

Despite considerable constraints, many other 18th-century women writers besides Wollstonecraft were successful.  Women like Anna Seward, the 'Swan of Lichfield' (1742-1809), educated themselves against the wishes of their parents; Seward's father feared she might become a "learned lady", typically not the kind most desired by suitors. And then there are Mary Astell, Joanna Baillie, Hannah Cowley and Elizabeth Hamilton. Diarists and letter-writers were even more prevalent, as ways for women to write 'between the gaps' in a culture that often denied them an education and a voice. The writings of Hester Thrale (1741-1821), for instance, are an important source of information about 18th-century life and culture. 

We can't even claim that the historical absence of these women in Poets’ Corner was a symptom of the age; that women writers today are more readily recognised. Yes, there are exceptions: the actress Dame Peggy Ashcroft was commemorated in Poets' Corner in 2005. But the other 20th-century additions include: W.H. Auden (1974), Sir John Betjeman (1996), Thomas Stearns Eliot (1888), T.S. Eliot (1967), Adam Fox (1977), Sir David Frost (2014), A.E. Housman (1996), Edward Horton Hubbard (1994), Sir Henry Irving (1905), Henry James (1976), Rudyard Kipling (1936), Philip Larkin (2016), D. H. Lawrence (1985), C.S. Lewis (2013), John Masefield (1967), Gilbert Murray (1956), and the War Poets.

Do you see anything wrong with this picture? What of 20th-century women writers; some of the most obvious being Enid Blyton, Beatrix Potter, Virginia Woolf and Sylvia Plath? Hughes, for whom Plath seems forever to be wedded, made the grade and was commemorated in 2011. But not Plath, whose book Ariel has been considered one of the most important poetry collections of the 20th century. 

Why does this iniquity matter? For the same reason that it matters women are represented on banknotes, and included in language as part of “human”kind. It matters for the same reason that Confederate Memorials in the 21st century matter. Commemoration is a political act that tells the world what we value, and who. It’s not ‘political correctness’, a ridiculously misused term to explain everything from the shape of EU-approved bananas to why Katie Hopkins shouldn’t call migrants cockroaches.

The accurate representation of women in the past, and the acknowledgement of social, political, economic bias, is crucial to the wellbeing of society as a whole. That’s why campaigns like https://putheronthemap.com/ exist: to reclaim women as part of public space. A tiny proportion of statues and commemorations are of women, and most are royal figures (especially Queen Victoria) or allegorical myths. Can you imagine a world in which statues of men, and and all the roadsigns and buildings that take men's names, were based on Zeus, Merlin and King Harold?

Rather than showcasing so many men on the Poets’ Corner website, it would be great to see Westminster Abbey talking about the women that are there, as well as making plans to commemorate more women in the future. I am quite sure that they will make room for J.K. Rowling (in many years and books from now, one hopes), but why not make more space now for writing women of the past? Most crucially, the Abbey could do what Donald Trump has failed to do, and engage with broader debates about the politics of commemoration.

Critics of Poets' Corner have complained that it is a "chaotic rockery". I rather like its haphazardness, because that makes it possible to stumble across unexpected literary delights. You can quite literally walk through several centuries of history in a few short steps. It is also positioned next to the Chapel of St Faith, which is humble, yet awe-inspiring in its own way.

It is the significance of the setting however, within such a nationally, politically and spiritually important building, that makes the gender blindness of Poets' Corner problematic. Most visitors will not notice the absence of women, but they may leave believing that literary greatness is both male and marble white. 

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“It’s not unusual” says Tom Jones, but he misses the point

On the Today programme this morning, Tom Jones revealed that sexual abuse and harassment was as prevalent in the music industry as in film. I doubt anyone was surprised by this revelation; many celebrities have come forward to reveal their dreadful stories of sexual harassment and exploitation, and assault, by senior male colleagues. In the wake of the Weinstein revelations, the misogynistic sexual politics of fame have been laid bare. The hashtag #rosearmy - coined by Rose McGowan, one of Weinstein’s most profilic victims, has been taken up on Twitter, along with #metoo, as millions of women identify themselves as victims of sexual violence and assault.

Which is why Tom Jones’ comments miss the point. Jones acknowledges that sexual bullying and predatory behaviour is wrong; that “people with power sometimes abuse it” and they should be called to account. And yet, the moralising nature of Jones’ comments, the belief that “you avoid it. You just walk out” is tantamount to victim blaming. It happened to Jones himself, I’m sad to say, early in his career. And that encounter made him feel "terrible... But then you think, 'Well, I've got to get away from this person and it can't be like this.'...You should know that yourself, you don't do things just because you think, 'I should do this.' Your own mind will tell you that. Not just in showbusiness, but in any thing you're in."

The implication is clear: women should not do anything that feels bad, that they should walk away - “your own mind will tell you that”. Yet many women can’t. And not just because in order to succeed, and survive in many cases, women from all walks of life are sexually abused and harassed and assaulted. What is most tragic and most infuriating about the wave of revelations of sexual violence is how commonplace they are. After Jimmy Saville, one would imagine women might be believed more, but they are not. Women are questioned about their motives and dress, joked about and dismissed. And told they should have behaved differently, that - in the words of Jones -”that’s the way it is with showbusiness, you are in the public eye, and that's it, you have to take the good with the bad. “ In other words, boys with be boys. 

According to his statement, Jones wasn’t forced into sex in a hotel room or harassed day after day in the studio by someone physically larger, stronger and sexually threatening. In his own words:  “It wasn't bad, just somebody tried to pull... it was a question and I said 'No thank you.'" Now I don’t doubt that Jones felt terrible and I am not diminishing that feeling. But, his described encounter is not what we are talking about here, though it’s symptomatic of a bigger picture. 

I don’t know of a single woman who hasn’t had ‘a question’, an attempt, feeble or otherwise, to invite a sexual encounter. More depressingly, I don’t know a single woman who hasn’t felt at some stage the threat of sexual violence, the fear of assault, the knowledge that a man in power could make things difficult for them if they weren’t more obliging. Living with the constant fear of intimidation and assault is something that lurks deep in the subconscious of all women, a fear that is passed down from mother to daughter, sister to sister, and that we are supposed to heed - so as not to be blamed for walking in the dark, or wearing the wrong clothes or getting drunk, or changing our mind about sex. 

Not all women are able to walk away, and many suffer every single day from far more than a question that can be politely rebuffed. The sexual violence at the heart of the film industry and the music industry and television is echoed elsewhere: in finance, academia, services and trade and every single place where men are in power and women are commodified not only by what work they can do and be paid for, but by their value as sexual objects. I have sat in an academic seminar and listened to senior scholars whisper behind me about the “sexy young Italian piece” they could hire with some research money. I have been asked to smile and ignore some lecherous comment or rumour about another female colleague passed over for promotion. And I have been propositioned by a senior colleague while away at a conference. 

The point about Weinstein - and Saville before him - is that the sexual violence and misogyny represented there is echoed throughout society. Look at the President of the United States - a self confirmed groper. Good for Tom Jones if he was able to walk away; not everyone, and certainly not every woman, has that choice. The reality is that women navigate assault and predatory behaviour every single day. And not just on the film set or the music studio, but also on the streets, where women are catcalled and harassed; on the Internet where they are threatened with rape whenever they put their head above the parapet, in workplaces and homes and school classsrooms.

The emphasis should never be, therefore, on women walking away. It should be on changing the structure of society that allows predators to be presidents and producers to exploit their positions of power. It’s should be on men to speak out when they see this behaviour, on education systems to teach sexual equality and respect, on businesses and academies to monitor and regulate male violence, and on us all to create generations of men that do not view women as sexual objects. Only then might we make sexual violence so unusual that people sit up and take notice. 

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