1546
Management of persistent vegetative state SiR,—The British Medical Association’s (BMA) ethic’ committee concluded that "artificial means of nutrition are medical treatments and that medical treatments can be withdrawn on the basis of a clinical decision".’ This strikes many doctors and even more lay-people as extraordinary. An unnamed general practitioner reports on the emotional problems confronting a family coping with a young man in a persistent vegetative state.2 I would like to tell him (or her) of four families who have found tube feeding a great relief to their burden of care. An 8-year-old girl was born with a tracheo-oesophageal fistula and needed a permanent tracheostomy and gastrostomy tube. After initial hesitation the parents are now coping well and she is a wellintegrated member of their large family and flourishing at school. A 10-year-old boy had a cardiomyopathy. He had a cardiac arrest at school and was later resuscitated in hospital but left in a persistent vegetative state. He returned to the district general hospital from the regional cardiac unit with a nasogastric tube in situ and survived another 2 years before his death. He was visited regularly by his family and died peacefully, having contributed much to the open ward community by his presence. Many items of equipment were donated later by a trust in his name. A 15-year-old girl with Rett’s syndrome was severely retarded and was becoming increasingly difficult to feed before an oesophageal stricture was diagnosed. A gastric feeding tube eased her feeding immeasurably and she is now managed wholly at home, is at her expected weight, and is responding to her parent’s warmth. A 6-year-old girl developed Batten’s disease and became blind and eventually retarded with nearly uncontrollable fits. Feeding became very difficult but a nasogastric tube greatly aided feeding, removing one of the stresses from her family who nursed her with much support from community carers, hospice members, and her vicar until her inevitable death at home, in accordance with their wishes. The one thing that these four families had in common was that they wanted their children to go on living, and for them the suggestion of tube feeding being a treatment that could be withdrawn would seem absurd. It was merely an enormous relief to be able to nourish them properly. Worcester Royal Infirmary, Ronkswood Branch, Worcester WR5 1HN, UK
A. P. COLE
1. BMA examines the persistent vegetative state. BMJ 1992; 305: 850-51. 2. Anonymous. Managing the persistent vegetative state. BMJ 1992; 305: 666.
Doctors to be SIR,—The British Broadcasting Corporation book (Oct 24, 1023) Doctors To Be, is, I believe, a valuable insight into the de-humanisation of our junior doctors. The inevitable consequence of putting doctors through several years of humiliation and hardship is that they are forced to adopt long-term coping mechanisms usually reserved for post-traumatic stress syndrome. Some cope by avoidance: they can of course opt out of surgery and abortion and delegate the handing out of bad news to the junior doctors. These young people have no experience of death before they begin their training, yet they are expected without warning or preparation to break the news of a death to relatives. New medical students have soft hearts and high ideals. They want to care for and help people, save lives, ease pain, and make the sick well again. The process of hardening teaches them to hide their feelings, but so inadequately that they later display frighteningly high rates of alcohol abuse, suicide, and marital breakdown (the last two especially among the women). They are clearly not coping very well at all. I suggest that a part of the first year of medical training should be to spend at least a week in a local hospice for the dying, and p
afterwards the students should have a chance to share their feelings with each other in group seminars. New students should also have a chance to act as patient counsellors, either in a designated part of the hospital or in several wards, moving from bed to bed. Patients would thus be heard, the student would gain understanding of how it feels to be a recipient of medical treatment, and useful extra
information would be available to consultants. Most places of education and training provide a personal tutor with whom students can share feelings and difficulties. This system is already in place in medical schools, but is underused. A little encouragement to deal more openly with the moral and emotional strains of medicine would in time change the medical profession’s image of itself, and make it OK to be human. 89 Harpenden Rd, St Albans, Herts AL3 6BY, UK
A. M. HAYTON
SiR,—The General Medical Council (GMC) proposes to improve the medical curriculum by fostering the spirit of inquiry rather than dull learning by automatons (Oct 24, p 1009). How does the GMC expect to accomplish its goal in the stultifying atmosphere brought about by the peer review/audit/guidelines movement, in which the only thing that counts is adherence to accepted medical practice?l I know it is risky to comment from across the Atlantic. Nevertheless, when dissent is heresy, it appears thoughtless or dishonest to encourage eager, gifted, and curious medical students to think for themselves. Such brave souls must be warned to expect trouble in their career, even if they do not harm their patients. Henceforth let no man care to learn, or care to be more than worldly-wise; for certainly in higher matters to be ignorant and slothful, to be a common steadfast dunce, will be the only pleasant life, and only in request. John Milton (1644)
17 Main St,
ROBERT CARLEN
Sayville, New York 11782, USA 1. Carlen R.
Audit, peer review and intellectual conformity. Lancet 1991; 338: 822-23.
Meaning of human sexual intercourse SIR,-I found your Nov 14 editorial offensive and insulting to Roman Catholics. I believe that a medical editorial should present the consensus opinion on medical matters. The woefuly inadequate knowledge and understanding of true Roman Catholic teaching that you show invalidates your arguments. I recollect first seeing the comment "The Church condemns the rubber condom which can save lives, yet makes no comment on the rubber feeding nipple which can be harmful" within the pages of the tabloid press; such remarks have no place in a prestigious medical journal. Although comparative biology has much to offer, Hamo sapiens is not merely another member of the animal kingdom functioning at the base instinctive level. If it were not for the supernatural and spiritual dimensions of our existence, the subjects of morals and ethics would be of little relevance. In the same way that chemistry and molecular biology are not the basis of our understanding of transsubstantiation, so too the sexual proclivities of the pygmy chimpanzee are not a valid basis for the foundation of our sexual ethics. 6 St Andrews Road, Willesden Green, London NW10 2QS, UK
A
MICHAEL JARMULOWICZ
right to reproduce?
SiR,—Iam reassured that at least one other individual (Professor Emson, Oct 31, p 1083) shares my recognition of the United Nations’ declared "universal right to found a family" as the that it is. The assertion of such a "right" fails the simple test of any behaviour that should inform any inquiry into morality or social organisation-namely, can I do this (ie, have as many children as I like) without detriment to the interests of my neighbour? Any code of morality or behaviour-including definitions of rights--arises not only out of specific historical and cultural conditions, but also as an expression of the more or less enlightened self-interest of its promoters and adherents. Since the UN in nonsense
Management of persistent vegetative state SiR,—The British Medical Association’s (BMA) ethic’ committee concluded that "artificial means of nutrition are medical treatments and that medical treatments can be withdrawn on the basis of a clinical decision".’ This strikes many doctors and even more lay-people as extraordinary. An unnamed general practitioner reports on the emotional problems confronting a family coping with a young man in a persistent vegetative state.2 I would like to tell him (or her) of four families who have found tube feeding a great relief to their burden of care. An 8-year-old girl was born with a tracheo-oesophageal fistula and needed a permanent tracheostomy and gastrostomy tube. After initial hesitation the parents are now coping well and she is a wellintegrated member of their large family and flourishing at school. A 10-year-old boy had a cardiomyopathy. He had a cardiac arrest at school and was later resuscitated in hospital but left in a persistent vegetative state. He returned to the district general hospital from the regional cardiac unit with a nasogastric tube in situ and survived another 2 years before his death. He was visited regularly by his family and died peacefully, having contributed much to the open ward community by his presence. Many items of equipment were donated later by a trust in his name. A 15-year-old girl with Rett’s syndrome was severely retarded and was becoming increasingly difficult to feed before an oesophageal stricture was diagnosed. A gastric feeding tube eased her feeding immeasurably and she is now managed wholly at home, is at her expected weight, and is responding to her parent’s warmth. A 6-year-old girl developed Batten’s disease and became blind and eventually retarded with nearly uncontrollable fits. Feeding became very difficult but a nasogastric tube greatly aided feeding, removing one of the stresses from her family who nursed her with much support from community carers, hospice members, and her vicar until her inevitable death at home, in accordance with their wishes. The one thing that these four families had in common was that they wanted their children to go on living, and for them the suggestion of tube feeding being a treatment that could be withdrawn would seem absurd. It was merely an enormous relief to be able to nourish them properly. Worcester Royal Infirmary, Ronkswood Branch, Worcester WR5 1HN, UK
A. P. COLE
1. BMA examines the persistent vegetative state. BMJ 1992; 305: 850-51. 2. Anonymous. Managing the persistent vegetative state. BMJ 1992; 305: 666.
Doctors to be SIR,—The British Broadcasting Corporation book (Oct 24, 1023) Doctors To Be, is, I believe, a valuable insight into the de-humanisation of our junior doctors. The inevitable consequence of putting doctors through several years of humiliation and hardship is that they are forced to adopt long-term coping mechanisms usually reserved for post-traumatic stress syndrome. Some cope by avoidance: they can of course opt out of surgery and abortion and delegate the handing out of bad news to the junior doctors. These young people have no experience of death before they begin their training, yet they are expected without warning or preparation to break the news of a death to relatives. New medical students have soft hearts and high ideals. They want to care for and help people, save lives, ease pain, and make the sick well again. The process of hardening teaches them to hide their feelings, but so inadequately that they later display frighteningly high rates of alcohol abuse, suicide, and marital breakdown (the last two especially among the women). They are clearly not coping very well at all. I suggest that a part of the first year of medical training should be to spend at least a week in a local hospice for the dying, and p
afterwards the students should have a chance to share their feelings with each other in group seminars. New students should also have a chance to act as patient counsellors, either in a designated part of the hospital or in several wards, moving from bed to bed. Patients would thus be heard, the student would gain understanding of how it feels to be a recipient of medical treatment, and useful extra
information would be available to consultants. Most places of education and training provide a personal tutor with whom students can share feelings and difficulties. This system is already in place in medical schools, but is underused. A little encouragement to deal more openly with the moral and emotional strains of medicine would in time change the medical profession’s image of itself, and make it OK to be human. 89 Harpenden Rd, St Albans, Herts AL3 6BY, UK
A. M. HAYTON
SiR,—The General Medical Council (GMC) proposes to improve the medical curriculum by fostering the spirit of inquiry rather than dull learning by automatons (Oct 24, p 1009). How does the GMC expect to accomplish its goal in the stultifying atmosphere brought about by the peer review/audit/guidelines movement, in which the only thing that counts is adherence to accepted medical practice?l I know it is risky to comment from across the Atlantic. Nevertheless, when dissent is heresy, it appears thoughtless or dishonest to encourage eager, gifted, and curious medical students to think for themselves. Such brave souls must be warned to expect trouble in their career, even if they do not harm their patients. Henceforth let no man care to learn, or care to be more than worldly-wise; for certainly in higher matters to be ignorant and slothful, to be a common steadfast dunce, will be the only pleasant life, and only in request. John Milton (1644)
17 Main St,
ROBERT CARLEN
Sayville, New York 11782, USA 1. Carlen R.
Audit, peer review and intellectual conformity. Lancet 1991; 338: 822-23.
Meaning of human sexual intercourse SIR,-I found your Nov 14 editorial offensive and insulting to Roman Catholics. I believe that a medical editorial should present the consensus opinion on medical matters. The woefuly inadequate knowledge and understanding of true Roman Catholic teaching that you show invalidates your arguments. I recollect first seeing the comment "The Church condemns the rubber condom which can save lives, yet makes no comment on the rubber feeding nipple which can be harmful" within the pages of the tabloid press; such remarks have no place in a prestigious medical journal. Although comparative biology has much to offer, Hamo sapiens is not merely another member of the animal kingdom functioning at the base instinctive level. If it were not for the supernatural and spiritual dimensions of our existence, the subjects of morals and ethics would be of little relevance. In the same way that chemistry and molecular biology are not the basis of our understanding of transsubstantiation, so too the sexual proclivities of the pygmy chimpanzee are not a valid basis for the foundation of our sexual ethics. 6 St Andrews Road, Willesden Green, London NW10 2QS, UK
A
MICHAEL JARMULOWICZ
right to reproduce?
SiR,—Iam reassured that at least one other individual (Professor Emson, Oct 31, p 1083) shares my recognition of the United Nations’ declared "universal right to found a family" as the that it is. The assertion of such a "right" fails the simple test of any behaviour that should inform any inquiry into morality or social organisation-namely, can I do this (ie, have as many children as I like) without detriment to the interests of my neighbour? Any code of morality or behaviour-including definitions of rights--arises not only out of specific historical and cultural conditions, but also as an expression of the more or less enlightened self-interest of its promoters and adherents. Since the UN in nonsense
