243
doctor in 1983 he would not have told her the true diagnosis or even the fact that a malignancy was suspected. This radiologist was the only witness, and he claimed that his view represented that of most Japanese doctors. The judges believed him. They stated that the patient’s decision may be respected in certain circumstances but the "doctor’s decision is primarily superior over the patient’s decision or right". Her decision making, they went on, "was evidence of her disobedience to the doctor hence she was solely responsible for the outcome, and a doctor was not obliged to tell her family anything". The court decision implies that well-intentioned medical paternalism is superior even to the law since item 23 in Ishi-Ho (the Doctors’ Acts) states that a doctor must advise a patient or guardian about the means necessary to improve the patient’s health. Attitudes towards disclosure of a diagnosis of cancer are changing in Japan. The proportion of people who would want to be told the truth rose from 34% in 1979 to 61 % in 1980, according to media surveys.3 The failure of Japanese clinicians to tell the true diagnosis to cancer patients2 presumably stems from an out-of-date, chauvinistic paternalism of doctors. The proportion of Japanese doctors who would never tell patients the truth was 36% in 1980, whereas those who themselves would want to be told was 50%, the corresponding figures in 1981 were 27% and 65%.3 Thus, the
radiologist’s testimony was misleading. Although the Government Task Force has concluded that the truth should be told’ a breakthrough is still necessary. In this case, the patient’s family has now appealed to the Supreme Court, and I hope that patients’ rights will be valued there properly. Department of Internal Medicine 4, Hyogo College of Medicine, Hyogo 663, Japan
NORITOSHI TANIDA
1. Brahams D. Right to know in Japan. Lancet 1989, ii 173. 2 Swinbanks D. Japanese doctors keep quiet Nature 1989; 339: 409. 3. Taniguchi M, Hayakawa M, Naito K, Yoshimori M. Patients’ wish for truth telling of cancer Kangogaku Zasshi 1983; 47: 1157-59 (in Japanese). 4 The Ministry of Health and Welfare and the Japan Medical Association. Manual for terminal care of cancer patients. J Jpn Med Assoc 1989; 102 (suppl) (in Japanese).
Automated records SIR,—The simplistic argument that Dr Goodman
uses
(Dec
22/29, p 1586) should be rejected. It is an extrapolation from a very constructed documentl and does Goodman no credit. Human error still accounts for most adverse events in anaesthesia and the frequency of such events could indeed be lessened by appropriate teaching, which includes attention at all times to the patient. Tools, complex or simple, are merely means to that end of safety and shall never be allowed to replace that aim. Automatic recording may allow the anaesthetist freedom to concentrate on the main concern-the patient.
carefully
Department of Anaesthetics, University of Wales College of Medicine,
(chair) The quality of medical care. London: HM Stationery Office, 1990.
Tobacco subsidies and health SIR,-We were shocked to learn from your Oct 27 editorial (p 1036) that the European Community subsidises tobacco growers to the tune of c740 million. One of us wrote to local National Health Service managers, a sympathetic newspaper reporter, and a Member of Parliament (MP) on this subject. The local newspaper ran the story. The local MP wrote to the Ministry of Agriculture, Fisheries and Food. MAFF replied that it was critical of EC tobacco policy but that (1) the EC had lately agreed a directive limiting the maximum tar content of cigarettes to 12 mg by 1998; (2) one has to accept that tobacco is an important crop for economic reasons in Greece and Italy; and (3) one needs to put pressure on the other eleven national governments in the EC British Government with respect to
agricultural policy.
Rotherham Health Authority, Oakwood Hall, Rotherham S60 2UN, UK
T. BAXTER P. C. MILNER
Clinical research SIR,—Your Jan 5 editorial, and its title (Clinical research: disturbing present, uncertain future) is based on a false premisenamely, that British clinical science is in decline. To support that proposition, you cite a study that reported a fall in the proportion of UK papers and citations in biomedical and clinical research between 1976 and 1984.1 But that study is very out of date. Martin et al2 have since shown that "the long-term decline in the UK’s share of world publications first slowed during the earlier part of the 1980s before finally levelling off between 1984 and 1986" and "UK clinical medicine and biology seem to have benefited from a considerable expansion in financial support". The bibliometric data are clear: between 1970 and 1985, British science was in relative decline, but thereafter it started to recoverThat growth was hardly surprising in view of the very considerable expansion in the number of British academics, and in the universities’ income.4 Your concern over the decline in the British and American share of publications is misplaced. As poor countries, like those of the Pacific rim, become richer, so will they increase their share of publications. That is to be welcomed. The reassuring point is that the total number of British scientific reports has expanded by about 7% per year since 1970 (world totals did so by about 7-5% per year over those decades).5 Department of Clinical Biochemistry, Addenbrooke’s Hospital, Cambridge CB2 2QR, UK
TERENCE KEALEY
1. Martin BR, Irvine J, Nann F, Stemtt C. The continuing decline of British science. Nature 1987; 330: 123-26. 2. Maron BR, Irvine J, Narm F. Stemtt C, Stevens KA. Recent trends in the output and impact of Bntish Science. Sa Public Policy 1990; 17: 14-26. 3. Kealey T. Government funded academic science is a consumer good, not a producer good. Scientometrics 1991;20: 413-38. 4. Kealey T. Condition of Bntish science. Nature 1990; 344: 806. 5. Evaluation of national performance in basic research (ABRC Science Policy Studies, no 1). London: Advisory Board for the Research Councils, 1986.
JOHN N. LUNN
Cardiff CF4 4XW, UK
1 Stroud E
Our response to the first of these points is that smokers changing low-tar cigarettes tend to compensate by smoking more cigarettes. They need to stop completely to obtain health benefits. Our response to the second is that tobacco does a hundred times more damage than heroin and yet we would never use this economic argument to justify the subsidy of heroin producers. However, we strongly agree with the third point. There is a very great need to influence politicians, opinion leaders, and public health workers throughout the other eleven EC countries to bring about the end of tobacco subsidies in the EC. All Lancet readers who care about public health and who have access to these individuals should start lobbying.
to
to
take the same line as the in the common
changes
SIR,—Of course it would be splendid if the UK could spend a higher proportion of its gross domestic product on both research and the National Health Service. However, the low expenditure by the UK is mainly determined by the poor performance of the economy: weaker economies not only have less money to spend but also tend to devote a smaller proportion of their gross domestic
product to health care than do richer countries.! Few, if any, countries, and certainly not the UK, can afford all the demands from doctors and patients for treatment and care. Selection by unavailability of treatment or waiting-lists has been used in the past but it is hoped that in the future the choices will be more open and better informed. Much more research is required to find out which old and new treatments work either to improve health or to reduce suffering. The NHS provides a wonderful opportunity for outcome studies, and the new information systems being introduced in hospitals and general practice should considerably increase the potential for such research. As your editorial suggests, this health practice assessment will be very much part of the remit of the new director of research and development for the NHS, and he will need enthusiastic support from doctors and
doctor in 1983 he would not have told her the true diagnosis or even the fact that a malignancy was suspected. This radiologist was the only witness, and he claimed that his view represented that of most Japanese doctors. The judges believed him. They stated that the patient’s decision may be respected in certain circumstances but the "doctor’s decision is primarily superior over the patient’s decision or right". Her decision making, they went on, "was evidence of her disobedience to the doctor hence she was solely responsible for the outcome, and a doctor was not obliged to tell her family anything". The court decision implies that well-intentioned medical paternalism is superior even to the law since item 23 in Ishi-Ho (the Doctors’ Acts) states that a doctor must advise a patient or guardian about the means necessary to improve the patient’s health. Attitudes towards disclosure of a diagnosis of cancer are changing in Japan. The proportion of people who would want to be told the truth rose from 34% in 1979 to 61 % in 1980, according to media surveys.3 The failure of Japanese clinicians to tell the true diagnosis to cancer patients2 presumably stems from an out-of-date, chauvinistic paternalism of doctors. The proportion of Japanese doctors who would never tell patients the truth was 36% in 1980, whereas those who themselves would want to be told was 50%, the corresponding figures in 1981 were 27% and 65%.3 Thus, the
radiologist’s testimony was misleading. Although the Government Task Force has concluded that the truth should be told’ a breakthrough is still necessary. In this case, the patient’s family has now appealed to the Supreme Court, and I hope that patients’ rights will be valued there properly. Department of Internal Medicine 4, Hyogo College of Medicine, Hyogo 663, Japan
NORITOSHI TANIDA
1. Brahams D. Right to know in Japan. Lancet 1989, ii 173. 2 Swinbanks D. Japanese doctors keep quiet Nature 1989; 339: 409. 3. Taniguchi M, Hayakawa M, Naito K, Yoshimori M. Patients’ wish for truth telling of cancer Kangogaku Zasshi 1983; 47: 1157-59 (in Japanese). 4 The Ministry of Health and Welfare and the Japan Medical Association. Manual for terminal care of cancer patients. J Jpn Med Assoc 1989; 102 (suppl) (in Japanese).
Automated records SIR,—The simplistic argument that Dr Goodman
uses
(Dec
22/29, p 1586) should be rejected. It is an extrapolation from a very constructed documentl and does Goodman no credit. Human error still accounts for most adverse events in anaesthesia and the frequency of such events could indeed be lessened by appropriate teaching, which includes attention at all times to the patient. Tools, complex or simple, are merely means to that end of safety and shall never be allowed to replace that aim. Automatic recording may allow the anaesthetist freedom to concentrate on the main concern-the patient.
carefully
Department of Anaesthetics, University of Wales College of Medicine,
(chair) The quality of medical care. London: HM Stationery Office, 1990.
Tobacco subsidies and health SIR,-We were shocked to learn from your Oct 27 editorial (p 1036) that the European Community subsidises tobacco growers to the tune of c740 million. One of us wrote to local National Health Service managers, a sympathetic newspaper reporter, and a Member of Parliament (MP) on this subject. The local newspaper ran the story. The local MP wrote to the Ministry of Agriculture, Fisheries and Food. MAFF replied that it was critical of EC tobacco policy but that (1) the EC had lately agreed a directive limiting the maximum tar content of cigarettes to 12 mg by 1998; (2) one has to accept that tobacco is an important crop for economic reasons in Greece and Italy; and (3) one needs to put pressure on the other eleven national governments in the EC British Government with respect to
agricultural policy.
Rotherham Health Authority, Oakwood Hall, Rotherham S60 2UN, UK
T. BAXTER P. C. MILNER
Clinical research SIR,—Your Jan 5 editorial, and its title (Clinical research: disturbing present, uncertain future) is based on a false premisenamely, that British clinical science is in decline. To support that proposition, you cite a study that reported a fall in the proportion of UK papers and citations in biomedical and clinical research between 1976 and 1984.1 But that study is very out of date. Martin et al2 have since shown that "the long-term decline in the UK’s share of world publications first slowed during the earlier part of the 1980s before finally levelling off between 1984 and 1986" and "UK clinical medicine and biology seem to have benefited from a considerable expansion in financial support". The bibliometric data are clear: between 1970 and 1985, British science was in relative decline, but thereafter it started to recoverThat growth was hardly surprising in view of the very considerable expansion in the number of British academics, and in the universities’ income.4 Your concern over the decline in the British and American share of publications is misplaced. As poor countries, like those of the Pacific rim, become richer, so will they increase their share of publications. That is to be welcomed. The reassuring point is that the total number of British scientific reports has expanded by about 7% per year since 1970 (world totals did so by about 7-5% per year over those decades).5 Department of Clinical Biochemistry, Addenbrooke’s Hospital, Cambridge CB2 2QR, UK
TERENCE KEALEY
1. Martin BR, Irvine J, Nann F, Stemtt C. The continuing decline of British science. Nature 1987; 330: 123-26. 2. Maron BR, Irvine J, Narm F. Stemtt C, Stevens KA. Recent trends in the output and impact of Bntish Science. Sa Public Policy 1990; 17: 14-26. 3. Kealey T. Government funded academic science is a consumer good, not a producer good. Scientometrics 1991;20: 413-38. 4. Kealey T. Condition of Bntish science. Nature 1990; 344: 806. 5. Evaluation of national performance in basic research (ABRC Science Policy Studies, no 1). London: Advisory Board for the Research Councils, 1986.
JOHN N. LUNN
Cardiff CF4 4XW, UK
1 Stroud E
Our response to the first of these points is that smokers changing low-tar cigarettes tend to compensate by smoking more cigarettes. They need to stop completely to obtain health benefits. Our response to the second is that tobacco does a hundred times more damage than heroin and yet we would never use this economic argument to justify the subsidy of heroin producers. However, we strongly agree with the third point. There is a very great need to influence politicians, opinion leaders, and public health workers throughout the other eleven EC countries to bring about the end of tobacco subsidies in the EC. All Lancet readers who care about public health and who have access to these individuals should start lobbying.
to
to
take the same line as the in the common
changes
SIR,—Of course it would be splendid if the UK could spend a higher proportion of its gross domestic product on both research and the National Health Service. However, the low expenditure by the UK is mainly determined by the poor performance of the economy: weaker economies not only have less money to spend but also tend to devote a smaller proportion of their gross domestic
product to health care than do richer countries.! Few, if any, countries, and certainly not the UK, can afford all the demands from doctors and patients for treatment and care. Selection by unavailability of treatment or waiting-lists has been used in the past but it is hoped that in the future the choices will be more open and better informed. Much more research is required to find out which old and new treatments work either to improve health or to reduce suffering. The NHS provides a wonderful opportunity for outcome studies, and the new information systems being introduced in hospitals and general practice should considerably increase the potential for such research. As your editorial suggests, this health practice assessment will be very much part of the remit of the new director of research and development for the NHS, and he will need enthusiastic support from doctors and
