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BMJ No 7100 Volume 315 Saturday 12 July 1997 This Week in BMJ | Editor's Choice | Press releases
Editorials
69
Managing established coronary heart disease
70
Pigeon fancier's lung
72
"Non-lethal" weapons: precipitating a new arms race
73
End of life decisions in mentally disabled people
74
Who wants a career in academic medicine?
News
75
Public health strategy to tackle inequality
Papers
81
DDT (dicophane) and postmenopausal breast cancer in Europe:
case-control study
85
Case-control study of oestrogen replacement therapy and risk of
cervical cancer
88
Retrospective study of doctors' "end of life decisions" in caring
for mentally handicapped people in institutions in the Netherlands
92
Who should decide? Qualitative analysis of panel data from public,
patients, healthcare professionals, and insurers on priorities in
health care
96
Genetic linkage of mild malaria to the major histocompatibility
complex in Gambian children: study of affected sibling pairs
General practice
98
Antimicrobials for acute otitis media? A review from the
International Primary Care Network
102
Feasibility of screening toddlers for iron deficiency anaemia in
general practice
Clinical review 104 Recent advances: Cardiac surgery Tom Treasure 108
ABC of mental health: Schizophrenia
Education and debate
112
The real ethics of rationing
115
Health in China: Traditional Chinese medicine: one country, two systems
Letters
118
First myocardial infarction in patients of Indian subcontinent and
European origin
120
Facial disfigurement
120
Few government forecasts of public expenditure have been realistic
121
Several studies have shown salmeterol to be more potent than salbutamol
for systemic effects
121
Integration of hepatitis B vaccination into national immunisation
programmes
122
Treatment of postnatal depression
122
Sri Lankan refugees
124
Let them eat asparagus
124
Surgical training
125
Save our service
Obituaries 126 J S Groves, D W Hendry, P B Maxted, H Moussalli, S Sabanathan, J A Shaikh, R Simpson, D H Smith, P J Sonnek, C J H Starey, H Stirling, S M Tocher Medicopolitical digest 128 The BMA's annual representative meeting Views & reviews Soundings
133
Lesson of the year
Personal views
133 Resonant images from the United States
On both sides of the table
Medicine and books
135 A New Form of Warfare: the Development of Non-lethal Weapons
COPC Depression and Anxiety Intervention Guide Minerva 68 S2 Career Focus Classified supplement Specialist training in medicine in Germany David Maclachan Editor's choiceDifficult issues for doctorsWhere do the responsibilities of doctors end? In a mythical world attractive to most doctors the patient comes through the door and presents a problem that the doctor solves with the remedies to hand. Doctors have responsibilities to care for their patients and to understand clinical medicine. Nothing more. In reality, the patient may have a problem that is more social than clinical, the doctor depends on a team and a system to be able to make a response, and the system constrains the doctor - "We don't have a bed for your patient, we don't offer in vitro fertilisation, the hospital has closed down and the doctors have fled." Inevitably doctors are drawn into a broad arena. This is especially true of doctors who must care for the health of the public - and isn't that all doctors? Factors like smoking, poverty, war, torture, and environmental destruction have profound effects on health. So are they not the business of doctors? The BMJ thinks yes, but life can then be uncomfortable - as three issues raised in this journal show.Firstly, we have contributed to debates on rationing health care and will be holding a conference on the subject this week. The BMA annual meeting last week argued that the government must take the lead on rationing (p 129), and researchers from the Netherlands describe how panels of patients, doctors, and others often disagree about priorities (p 92). But Donald Light is bothered by the whole rationing debate (p 112). He argues that those who devote their energies to finding ways to ration should instead eliminate "entrenched, institutional, political, and professional interests [that] lock in waste." He writes approvingly of the Anti-rationing Group, but a recent meeting between it and the Rationing Agenda Group saw everybody agreeing that we should reduce waste but that it would still be necessary to find a way to decide what would be provided and what would not. More difficult still for doctors is to decide their role in limiting the spread of weapons. Vivienne Nathanson reviews a book that shows how scientific knowledge has long been used to develop better weapons (p 135), while Robin Coupland discusses the growth of misnamed "non-lethal" weapons (p 72). Those already deployed include dazzling devices, calmatives, "stickums," and "slippums." Coupland argues that doctors have a responsibility to advocate control. Finally, we carry six letters (p 122) bitterly attacking a letter from Sri Lankan doctors which in its turn attacked us for carrying a report from the Refugee Council on the plight of Tamils. Some of the letters have suggested that we should stay out of reporting on human rights issues, and we have debated that possibility. We decided against because human rights abuses have an important influence on health - and we are concerned with all, not just some, factors that affect health.
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