Choice GP

Big and fundamental questions

Douglas Black, one of Britain's best loved doctors, has a growth in his pancreas and is experiencing intimations of mortality (p 1342). How best, he wondered some time back, to prepare for a terminal illness? His thoughts include several of those wonderful, understated asides for which he is famous. "Even healthy doctors may not be brilliant at managing their affairsthere are so many more interesting things to do . . . The best way to discover what people really think is not to consider what they say or write (though that can help), but to observe what they actually do." His answer to his question on preparing for death is to "find a good doctor and trust him or her. You might not guess from reading the media that good doctors can be found, but in the real world, they greatly outnumber the ignorant, careless, and maladjusted, let alone the rare lethal criminals." Good doctors are made not from formal instruction but through "the development of justified trust through `the build up of experience in the responsible and sensitive care of numbers of actual patients.' "

How we confront our own mortality is perhaps the biggest question for us all, but the biggest question for the world is what to do about the widening gap between the rich and the poor (p 1321). "Over 40% of the 614 million people in less developed countries live in absolute poverty and average life expectancy is 25 years less than it is in developed countries." Jeffrey Sachs, a Harvard economist and chairman of the WHO's commission on macroeconomics and health, has argued that the response of rich countries has been woefully inadequate. "It's not millions of dollars worth of aid poor countries need . . . but billions$10-20bn."

This BMJ includes not only big questions but alsothe next best categoryfundamental ones. Is it right that miscarriage is usually managed with surgical evacuation? Isn't this a natural event best managed without medical intervention? A review thinks probably yes (p 1343), but an editorialist is less convinced (p 1315). Even more fundamental, has medicine been entirely wrong to accept that it's "natural" that women have lower haemoglobin concentrations than men (p 1355).

Unfortunately elections don't tend to be associated with questions that are either big or fundamental, and that's certainly true of Britain's current election. We have reported on the plans of the main parties, and we conclude this week with those from Labour (p 1326). We've also fast tracked a study that shows that Labour hasn't made any progress with addressing relative inequalities in health (p 1336). This is unsurprising as the problem is so longstanding, as Douglas Black showed in his famous report on inequalities in health.

Footnotes

To receive Editor's choice by email each week subscribe via our website: www.bmj.com/cgi/customalert