Monthly Archives: September 2008

Excellent pieces in the New England Journal of Medicine on military medical ethics, and psychiatrists‘ position in interrogations. There are concerns that army psychiatrists are being trained in areas which could conflict with professional ethics. Doctors are not meant to either conduct or participate in interrogations. However obtained documents suggest that the Department of Defense  still wants doctors to be involved.

There is a piece in the Observer this week about the Jeremy Kyle show. The author says that people with serious mental health problems are prey to the exposure these kinds of shows bring. These shows - where aggressive confrontation and public goading are to used to provoke and taunt people about personal problems or issues – are nasty to watch. On the Jeremy Kyle show there is apparently a “qualified mental health nurse and psychotherapist” who “found no evidence of mental illness” and decided that a “contestant” was “fit to take part”.

Is there really a way to decide if someone is “fit to take part” in such an exercise? Doctors are often asked to fill in certificates claiming that one is “fit to take part” in all sorts of things from skydiving to marathon running. One can say perhaps that there is no obvious reason why one should not do certain things, but there are seldom criteria where it is possible to say that one will be capable of a task. There are a few things where there is clear demarcation of acceptable risk; for example, the criteria for fitness to drive is something the DVLA is very clear about. These kinds of shows, however, are a different thing.

The Channel 4 show Big Brother hires psychologists. These shows look for people who are going to be “good entertainment”. In this context, it usually means that the people are chosen with the belief that they will provide drama. Again, in this context, it usually means conflict with oneself or the group. Presumably the presence of psychologists provide the television company with something to arm themselves with against charges that they place people in potentially damaging situations, played out live and in the public arena. Freedom to do as one wishes is one thing.  But the presence of a psychologist does not guarantee happy endings.

I do know one thing, though. The less television I watch, the happier I am.

Would anyone like to help the cause of homeopathy? There is an interesting job description in the British Medical Journal this week. It is for both an expert and a lay person to ‘contribute actively’ to the Advisory Board on the Registration of Homeopathic Products. The pay is £275 a day, and they have 11 meetings a year.

 It is tempting to ask how many thousands of pounds the goverment are spending on this exercise. It is even more tempting to ask how, possibly, the Board can function. Any other medicine that the Medicines and Healthcare Regulatory licenses has to have evidence of it’s efficiacy and safety. The members of this committee will have to “give advice about safety and quality” on substances that don’t actually have proof of working.

If any FT readers are up to the challenge of bringing some sense into the boardroom, please do let me know how you get on.

Many women suffer a great deal of heartache before reaching the thin blue line of a positive pregnancy test. There is a large number of infertility treatments and they do not work for everyone, by any means.

Thousands of women take clomifene citrate, a drug that stimulates the ovaries, as part of their attempt to conceive. But a recent study indicates that, for some patients, clomifene is no more help than “expectant management” – doing nothing. The researchers were studying couples receiving treatment at a clinic for “unexplained infertility”, which means that problems such as blocked fallopian tubes had already been excluded.

This paper, published in the British Medical Journal, is interesting for two reasons. First, the National Institute for Health and Clinical Excellence advises that women with unexplained fertility problems “should be informed that clomifene citrate treatment increases the risk of pregnancy, but that this needs to be balanced by the possible risks of treatment, especially multiple pregnancy”.

The remainder of this column can be read here. Please post comments below.

The Lancet has a great editorial today. It’s about the need for guidance for doctors who are asked to assess prisoners who are hunger strikers. They say that doctors should recognise that hunger strike may be the sole method of protest a prisoner has. People who are starving, however, may become confused and disorientated; the difficulty then is to decide whether the person is competent, with medical capacity to decline intervention. Intervention has and is used in this situation, for example in Guantanamo Bay, where prisoners have been, and are, force fed. However, says the Lancet, force feeding has no place in high quality medical care. Independent physicans are required to explain the risks to life that the striker is taking. However, advance directives written by a competent person should mean that if confusion afflicts a prisoner due to a chosen hunger strike, their preordained wishes should be followed.  

Force feeding is not nice. Dr David Nicoll, a neurologist in England, has done a huge amount to highlight this issue (correspondence between him and a previous commander of the Guantanamo military hospital is available here.) The picture of the ‘restraint chair’ that is used is especially harrowing. The bottom line is that individuals with mental capacity have the right to choose what medical care they want – and don’t want. Doctors have to respect that right.

There are yogurts with cholesterol-reducing properties and other dairy products which can supposedly produce “optimal” bowel health. Then there are baked beans with “added omega threes” and drinks that profess to reduce blood pressure. The European Food Safety Authority is now providing “opinions” on the science behind such claims. However a lot of the claims seem to rely on evidence about surrogate markers (eg a product may reduce cholesterol, however what we do not know if this method of reducing cholesterol will go on to have an effect on avoiding heart attacks or stroke.) 

In the end, I suspect that there will not be many adverts rivalling the qualities of ordinary fruit and vegetables –  generally for sale without much in the way of flashy health claims.

I was in central Glasgow last week. On my rainy travails down Buchanan Street, I came across a tent pitched just beside the statue of Donald Dewar. Beside that was a mat on the ground with pictures of hot coals on it, that invited people to try and experience the trial of “chronic pain”. The smiling ladies giving out leaflets were wearing t-shirts saying “Still in pain? Take Control”. The leaflets asked “Are you still suffering?” and offered “Help on discussing neuropathic pain with your doctor”.

Here are some quotes from the leaflet

“When will I feel better? … The ‘right treatment’ for you may mean speaking with your doctor to identify other treatments that may provide greater, long-term, pain relief or fewer side effects. Your doctor may have to prescribe more than one treatment before they find the one that is right for you and this may take time.”

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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