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EDITORIALS: Raanan Gillon, Roger Higgs, Kenneth Boyd, Brendan Callaghan, and Raymond Hoffenberg Wanted: a social contract for the practice of medicine BMJ 2001; 323: 64 [Full text]

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consent for treatment/research

Duncan Paterson   (14 July 2001)

Wanted: acceptable practice determined by the public

Roger M Goss   (17 July 2001)

Wanted: a social contract for the practice of medicine

Raj Mohindra   (17 July 2001)

A social contract for doctors!

Darryl Hoffman   (19 July 2001)

no more quangos

N Sarkies   (20 July 2001)

A social contract for accountablility

Judith Harvey   (27 July 2001)

consent for treatment/research 14 July 2001
Duncan Paterson, consultant surgeon Rooyal Victoria hospital Barrie Ontario Canada Send response to journal: Re: consent for treatment/research	A thoughtful article. Theissue of consent has become of paramount importance. My experience is that with honest and full disclosure poeple make reasonable choices about treatment or research. The time has long gone when the doctor could paternalistically make dscisions for the patient. sincerely D M Paterson F.R.C.S.(Eng.).,F.R.C.S.(C).
Wanted: acceptable practice determined by the public 17 July 2001
Roger M Goss, Director Patient Concern Send response to journal: Re: Wanted: acceptable practice determined by the public	Editor - Raanan Gillon et al's proposal has merit. (1) A standing commission would fill a need insofar as it succeeded in breaking the profession's long held stranglehold on what constitutes socially acceptable medical practice. But I doubt that its establishment by healthcare professionals and patient organisations would achieve this goal. In my experience, professionals invariably dominate such bodies making consensus a chimera. Raanan et als' suggestions indicate how little the lessons of Bristol and Alder Hey have impinged on professional ethicists' consciousness. Having suggested that obtaining consent for medical interventions "could" be a definitive norm, (it already is on paper and in law) they then propose presumptive norms that destroy the core principle of informed consent - for example experimentation on patients requiring emergency care without their agreement. This is going backwards, rather than learning from patients and the public's reactions to recent disclosures of medical practices that were apparently acceptable to the profession. Only if such a body consisted of general members of the public, with healthcare professionals and patient representatives involved merely as expert witnesses, might a standing commission produce genuinely independent recommendations. Roger M. Goss Director - Patient Concern (1) Gillon R. et al: Wanted: a social contract for the practice of medicine. BMJ 2001; 323: 64 (14 July)
Wanted: a social contract for the practice of medicine 17 July 2001
Raj Mohindra, SpR General (Internal) Medicine John Radcliffe Hospital, Oxford Send response to journal: Re: Wanted: a social contract for the practice of medicine	It seems correct that a clarification of the rights and duties that flow from the healthcare professional - patient relationship is required. Given this fact the Rawlsian approach1 proposed by Gillon R et. al. begs many questions. Which community is bound by the terms of the proposed social contract? Is it patients as individuals, NHS patients in general or society as a whole? The proposed contract appears to be aimed at identifying and crystallising moral values that are already shared and accepted by society. How would it deal with minority views and interests? What would be the rights of appeal? Could an individual raise an appeal? If so this would resemble the unstable balance between act-utilitarianism and rule- utilitarianism.2 If not the effect would be to collectivise the rights of patients allowing them to be restricted on plain utilitarian principles perhaps influenced by political exigencies. Would the overall result truely be a net benefit to all patients as individuals? What would be the principles that enforced the terms? Would the terms carry simple moral or, more powerfully, legal force? Note how breaches could be prevented by resource restriction or the threat of organisational sanctions. 1 Rawls J. A theory of Justice. Oxford University Press (reprinted 1992) p.11-17 2 Smart JCC; Williams B. Utilitarianism: for and against. Cambridge University Press. (reprinted 1991) p. 9-12
A social contract for doctors! 19 July 2001
Darryl Hoffman, Attending Cardiac Surgeon Beth Israel St. Luke's hospital New York Send response to journal: Re: A social contract for doctors!	Dear sir Bravo to Gillon et al for identifying the urgent need to reshape medical practice. If doctors fail to organise to shape the future of health care, lawyers and business professionals will gladly fulfill the perceived needs of society. Doctors will follow American style defensive medicine and suffer the ultimate indignity when the traditional doctor- patient relationship is replaced by that between "consumer" and "provider". What happened to the unwritten social contract that expected dedication and exceptional responsibility from medical practitioners and provided commensurate rewards?
no more quangos 20 July 2001
N Sarkies, Consultant Ophthalmologist Addenbrooke's Hospital Send response to journal: Re: no more quangos	While the need for ethical guidelines in disputes between doctors and patients is urgent, the notion that a high level committee can furnish us with one is doomed. All citizens should be concerned with this debate and the best judge of these difficulties is the person in a jury of 12, informed by experts and counsel as in any court of law. Should the schizophrenic's rights of confidentialty overwhelm the safety of society for example is already a matter dealt with in the courts. Our current breakdown in confidence and trust between layperson and professional is a symptom of unease about committees and bureaucracy to deal promptly and fairly with professional interests, and another body of experts would be equally distrusted.
A social contract for accountablility 27 July 2001
Judith Harvey, GP non principal London Send response to journal: Re: A social contract for accountablility	The NHS is still free at the point of delivery. It seems to me reasonable that those who avail themselves of this flawed but still extraordinary benefit should accept minor curtailments of their theoretical rights to enable the system to run smoothly and economically. One example is consent to post-payment verification of GPs' item of service claims. Currently many GPs feel that the signed consent of each patient is required before notes can be examined. If a commission could establish that by opting into NHS care, patients accepted that their notes should be available for PPV checks by properly appointed auditors, such checks could be carried out much more swiftly and economically.