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Rapid Responses: Rapid Responses published:
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clinically appropriate?
- Brian F Walker (17 August 2001)
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I agree!
- Peter Gray (17 August 2001)
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Support for Dr. Mansfield
- Michael G Barley (18 August 2001)
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Clinical Governance in Private Practice?
- Martin McCloskey (19 August 2001)
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Individual Vs Society
- Sanjiv Ahluwalia (19 August 2001)
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Who's to blame?
- Jim Unsworth (19 August 2001)
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Abuse of power
- Richard Whitmore (19 August 2001)
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MMR, Autism and Dr. Mansfield
- F Edward Yazbak (19 August 2001)
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We must make a stand here ..
- L S Lewis (19 August 2001)
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Support
- Amanda Day (19 August 2001)
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Complaint about the Complainant
- Jane Jones (20 August 2001)
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No-one has bothered to interview them...
- Lisa Blakemore-Brown (20 August 2001)
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Re: "Abuse of power" and "Who's to Blame?
- Hilary Butler (20 August 2001)
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A Disturbing Precedent?
- Kevin Carroll (20 August 2001)
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Consider the ethics
- Andrew O'Shaughnessy (20 August 2001)
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Formal Options
- Adrian Midgley (20 August 2001)
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Biggest benefit to society? First do no harm.
- Jackie Fletcher (22 August 2001)
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Governance in Action
- Malcolm Alexander (22 August 2001)
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Other specialties are affected by GMC referral of Dr Mansfield
- Julie Cooke (22 August 2001)
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MMR and GMC
- Michael Innis (22 August 2001)
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Hasn't the GMC enough to do already?
- Keith Baxby (22 August 2001)
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Dr Mansfield: Editorial misses important points
- Alan Weatherup (22 August 2001)
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I concur
- Dyfan Lewis (22 August 2001)
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Just a parents view
- Denise Morris (24 August 2001)
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Conflicting advice
- Rachael Thompson (24 August 2001)
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Who's to blame?(2)
- JIm Unsworth (24 August 2001)
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Unfair treatment of Dr. Mansfield.
- V M Verma (24 August 2001)
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Measles death rate declined by 99.4% before vaccination
- John Lucas (24 August 2001)
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Best for you or best for us?
- Alex Manning (26 August 2001)
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Referral of Dr.Peter Mansfield to the GMC
- K D Bardhan (27 August 2001)
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Abuse of power ? You have NOT looked at evidence..
- L S Lewis (27 August 2001)
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Re: Dr Mansfield: Editorial misses important points
- L S Lewis (27 August 2001)
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Patients entitled to freedom of choice
- Roger M Goss (27 August 2001)
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Implications for psychiatrists
- Kim Hwang (28 August 2001)
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An abuse of power.
- Gregory Gardner (28 August 2001)
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Can you be sure?
- C O Lister (28 August 2001)
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Patient's rights as individuals must be respected
- Richard Morland (29 August 2001)
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Editorial by Dr Majeed
- J K Anand (4 December 2001)
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Professional Autonomy - Drowning not waving
- Moyra Reid (6 December 2001)
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Parental choice for MMR vaccine.
- William D H Carey (7 December 2001)
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Re: Parental choice for MMR vaccine.
- Leslie S Lewis (7 February 2002)
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Referral of Dr Peter Mansfield to the GMC
- William D H Carey (9 February 2002)
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Re: Re: Parental choice for MMR vaccine.
- Paul W Divall (9 February 2002)
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Re: Dr Mansfield: Editorial misses important points
- John Heptonstall (10 February 2002)
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Re: Parental choice & MMR vaccine.
- L S Lewis (10 February 2002)
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Brian F Walker, medical director Hong Kong
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A valid series of points has been made here. One strikes me as particularly interesting; that a GP can be referred for consideration of disciplinary procedures because s/he is providing imappropriate clinical services. This is wonderful. Can we now expect that health authorities will be called to task _and_ disciplined for failing to provide clinically appropriate services? Could we perhaps start with understaffing causing delay or failure to treat? Inadequate funding and consequent rationing? Provision of administrative "support" in lieu of medical services? Provision of unfair pricing policy with refusal to treat based on cost? Appointment of incapable and patently unfit managers with resultant loss of morale and reduced efficacy of services? I think not. Just slam the docs. As usual. Brian Walker |
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Peter Gray, GP Principal Sittingbourne, Kent
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I agree totally with Dr Majeed's reasoning. I too was concerned when I heard about the referral on the news, and felt instinctively that it could not be right, but Dr Majeed has expressed the problem far better than I could. Dr Majeed said that it is "important for doctors and patients to take a stand on this issue" so I would like to stand up and be counted please! |
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Michael G Barley, Retired GP principal n/a
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I agree wholeheartedly with Dr. Majid's article about the referral of Dr. Peter Mansfield to the GMC by the Worcestershire Health Authority, but surely it is more simple than that. Dr. Mansfield's professional conduct and fitness to practise are not in question. I would not have thought the Worcestershire HA were exceeding their powers in complaining to the GMC any more than does anyone else who complains for whatever reason. What I find far more worrying is that the GMC is entertaining this complaint and has even set a date for Dr. Mansfield to be haled before them. People these days complain and sue over increasingly trivial matters; are we now going to see the GMC investigating increasingly trivial and inappropriate complaints? I offer Dr. Mansfield my support and best wishes. (Dr.) M.G. Barley
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Martin McCloskey, GP principal Derry, Northern Ireland
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Majeed states that a health authority worried about the performance of a private practitioner has other options both informal and formal available to it, before referral to the GMC. What formal option is available when the private practitioner has no contractual links with the Health Authority, Trusts, PCGs/Ts, or indeed any part of the NHS? |
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Sanjiv Ahluwalia, GP Burnt Oak, London
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The Royal College of General Practitioners espouse the value of informed patient choice. Every entrant is tested on this principle through the marking of videoes. Just because patients choose an alternative form of therapy to the most desirable demonstrates the application of informed patient choice. For a Health Authority to send Dr Mansfield to the GMC suggests that the value of patient autonomy falls below that of government policy in this regard. This case highlights the need for reform of the governance of Private Healthcare and Practitioners in ensuring the principles of safety and standards, rather than individually trying to make scapegoats out of doctors trying to offer alternatives to government dogma. In tackling this case the GMC must weigh up the rights of the individual to make informed choices against the risk posed to society by individuals refusing interventions perceived to be for the greater good of the public. |
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Jim Unsworth, Consultant Physician Shetland
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The fact that the decision to withold vaccination from infants is made for them complicates the issue, and while I agree with the thrust of the article, there are significant differences (with respect to consent) from the example cited. If the practicioner gives good, accurate, clinical advice and on balance the individual chooses the 'second best' option referral to the GMC is cleary wrong. If the advice given is not accurate and fails to reflect current concensus then their actions must be subject to scrutiny, and referral may be proper. This because the ensueing choice is not informed. If parents choose (as they do) to take their information from the popular press and pressure groups (which may be inaccurate and ill informed) then the clinician has a duty to inform that the decision (not to vaccinate) is not in the child's best interest. The clinician can be critisised if they accept second best treatment for an individual (the child) based on the preconceptions and prejudices of a responsible other (the patent) without challenge. The parent, however has a clear legal responsibility to take decisions which are in the child's best interests. Are the parents of these children failing in their duty and should the criticism and scrutiny be directed at the decisions that they are making which may well be putting their children at avoidable risk? |
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Richard Whitmore, PCG Chairman Worcester City PCG Worcester
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A discussion on a health authority's power and responsibility would be an appropriate topic for debate in a serious medical journal. Majeed's editorial is seriously flawed as it assumes that Worcestershire Health Authority has a position of power in managing its responsibility for a successful public health immunisation campaign. It is precisely because WHA is impotent as a public statutory public body that it has asked the GMC to intervene. The continuing MMR debate dents the confidence of many people, both public and professional, not least because of the 'no smoke without fire' assumptions. Majeed's third and last reference indicates his continuing anxiety despite his initial position statement on the safety of MMR. Patients and the media take heed of these different emphases. There are very real difficulties in maintaining a high level of vaccination cover against diseases that are seen rarely or not at all. Majeed's role as an educationalist, a position of power and responsibility, could provide a forum where these difficulties are debated. The role of medical journals and the media should not be ignored in that debate. Their keenness for headlines containing bad news, however misguided or ill-informed, whilst relegating good news to the middle pages or waste bins, provide a particular challenge for health education campaigns. As Worcester City PCC Chairman I have a clear responsibility for ensuring high levels of MMR vaccinations. I am unable to identify the power I weald in this role, other than to attempt to communicate to patients, health professionals and the media. There is no evidence that separate mumps, measles and rubella vaccinations are safer that combined MMR as they have not been subject to the same level of scrutiny. There is no evidence of a successful voluntary campaign of separate vaccinations for these illnesses. However, if MMR coverage falls as a result of Mansfield's and Desumo's activity children will be more likely to suffer from these illnesses. Some of these children will die as seen in Holland and Dublin. Worcestershire Health Authority is exercising its responsibility correctly by asking the GM to intervene. Whether the GMC feels it has a responsibility for public health remains to be seen. Majeed offers no alternative actions for Worcester Health Authority, despite asserting that there are other options. His article and the BMJ in choosing it as editorial comment do not do justice to the issues. I also despair for the lack of responsibility demonstrated by an educationalist who displays such a superficial understanding of this complex matter. Yours sincerely Dr.Richard Whitmore |
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F Edward Yazbak, Pediatrician TLAutism Research, Falmouth, MA 02540, USA
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MMR, Autism and Dr. Mansfield. Dr. Azeem Majeed’s editorial on Dr. Peter Mansfield’s unfortunate referral to the General Medical Council [BMJ 2001;323:356 (18 August)] was excellent and his support of Dr. Mansfield, whilst he disagrees with his position on the MMR, is commendable. Dr. Mansfield should have never been threatened for providing a safe and proven alternative to children whose parents are adamantly opposed to the triple vaccine. Dr. Majeed is correct: the monovalent vaccines are better than no vaccines at all. The vaccine authorities and most physicians (Dr. Majeed included) believe that the MMR vaccine is safe. Many parents either disagree or are not yet convinced. I am a pediatrician interested in both vaccination and regressive autism. I have interviewed hundreds of parents of children with autism. Many of them strongly believe that their normal children developed symptoms shortly after their MMR vaccination, stopped acquiring new skills, and then regressed. I do not believe the present propaganda campaign will convince those parents (or their friends and relatives) to accept any further MMR vaccinations. These people have witnessed—with their own eyes-- their children’s slide into autism. They have seen their own lives destroyed and have been outraged that no one has ever bothered to interview them. They have not been and will never be impressed by the epidemiological studies that the authorities continuously quote and will continue to demand independent clinical research. Meanwhile vaccination rates will go down and outbreaks will occur.Peter Mansfield will be vindicated and his accusers will be looking for yet another epidemiological study to quote. F. Edward Yazbak, MD, FAAP
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L S Lewis, GP Surgery, Newport, Pembs
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How absolutely right Azeem Majeed is ! I may not agree with what Dr Mansfield may say, but I would defend his right to give separated vaccines to his patients, given their informed consent / choice .. The State overstepped reason, when Dr Pat Troop announced on TV that separate vaccines were 'potentially dangerous' ( which vaccine/medicine isn't ? ). She went on to say that the State would actively discourage their use, and neither licence nor condone. So I have to import them from Switzerland. The State encouraged me to use them for the 25 years of practice before MMR was produced.. Experience enough to judge safety and efficacy ? I have a number of 'conscientious objectors' to vaccination in my practice.. If the proportion of unvaccinated children exceeds 10% in any one year band, then I lose £3000 of income.. What next ? Criminal action against parents who do not have their children vaccinated ?? I believe in effective Immunisation, and in the parental right to make an informed choice.. Forced into a choice between the two, then I choose the latter. Enough already !! Abandon this witch-hunt now ! Dr LS Lewis |
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Amanda Day, full time housewife and mother home
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I support Dr Mansfield totally, as a mother of a 9 yr old son who was diagnosed as Autistic after having MMr. I know if i was to have any more children myself and my husband have already discussed the MMR issue and have said we would opt for single vaccines only.Surley if the department of health want to keep children vaccinated they would go with the parents wishes. I wish Dr Mansfield best of Luck. |
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Jane Jones, Campaign Director National Pure Water Association
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The entrenched, myopic view of Dr McCloskey and his unelected ilk within the health service is arrogant, disrespectful and much despised by the people who pay their salaries. Support for Dr Mansfield's commendable and responsible stance on parental choice reverberates around this country and the world. Running alongside the DoH's MMR propaganda campaign, is a covert bombardment of the British public, (including medical professionals), asserting that "the children's teeth in this area are among the worst in the country." (Guilt is a very serious thing!). Their simplistic remedy? "We urgently need to artificially fluoridate the drinking water." The York Report on water fluoridation, (BMJ, 7 October, 2000), stated that 48% of people in fluoridated areas have dental fluorosis, and 12.5% of these cases are a matter for concern. Significantly, the Report failed to address the psycho-social effects on the victims of moderate to severe dental fluorosis. Psychologists are aware of the negative impact of phyical disfigurement, particularly on children. This frequently results in societal stereotyping and negative self-perception, often leading to developmental and behavioural problems. The long term prospects for these children can be devastating. (See http://www.npwa.freeserve.co.uk/dental_fluorosis.html ). Dental fluorosis is routinely dismissed by public health officials and the British Dental Association as "merely a cosmetic effect . . . a classic public health trade-off . . . the benefits outweigh the risks." These mindless mantras are all too often parroted to justify questionable public health policies. Ultimately, the responsibility for weighing benefits against risks rests with properly informed people. Dr Peter Mansfield is responsibly offering a viable alternative to the "no option, we know best" bullies. Yours truly, Jane Jones. |
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Lisa Blakemore-Brown, Independent Psychologist UK
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Coming from the USA - the same intriguing refusal to look at information in real cases as we have seen in the UK. Obviously if we do not look at individual cases - we don't see the issues. Large scale studies MISS THE POINT. Whether its vaccine damage or false accusations against mother - doesn't it ring bells? |
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Hilary Butler, Freelance Journalist Home
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Dear Sir, Jim Unsworth says that the parent "has a clear legal responsibility to take decisions which are in the child's best interests." His next question implies that he considers parents who chose not to vaccinate their children are not acting in their child's best interests. That is a matter of his personal opinion. That doesn't make it fact. He also considers that information which doesn't come from doctors who support immunisation is not accurate and therefore the "ensuing choice is not informed". How often is medical information, provided by doctors, "informed consent"? In my experience, almost never. How many times does Jim Unsworth give a parent the MMR International Physicians Circular, and the manufacturer's data, and go through with the parents, the meaning and significance of the adverse events listed? Or does he pressure them for an on-the-spot decision on the basis that "everyone who is a good parents just does it."? I'm sure he tells them that if they don't vaccinate, their child might die. But what about the rest? So...., do his parents get given the opportunity to make a thoughtful, considered, unhurried informed choice? As a parent of two children who has had to fend off hospital doctors wanting to have "their way", I have, on numerous occasions, when a procedure or drug has been ordered, refused to sign consent. Doctors have often argued with me - until I have provided THEM with the full medical information on that drug or procedure, to which there is usually a stunned silence. Once there was outright anger that I had intruded into "their" domain. In answer to the question "Why did you not tell me all this?" the reply is usually "You don't need to know that." This appears to be very common. The attitude seems to be "We only want you to know what we think you should know". A parent has a clear moral and legal duty to make decisions taking into account the fact that doctors in general seem to consider "informed consent" to mean unquestioningly doing what they want. It may be that the decision parents make is the opposite to what the doctor wants to do. And it may be that the parent is right for their child. But for a doctor to suggest that vaccination constitutes "the child's best interest", is somewhat bizarre. Richard Whitmore, like Jim Unsworth appears to feel the need to protect his position. I would suggest to him that he does not "weald" (wield) any power at all. He is "employed" by the people of his area, for without them he would not have had a medical practice, or a job. His title would seem to be that of a "public servant". And prior to the use of the MMR, for nearly 25 years, his profession touted single measles and rubella vaccines to parents as fully effective, and the saviour of mankind. He states that single vaccines have not been subjected to the same level of scrutiny as the MMR. Obviously 25 years experience counts for less than 10 years?.... or does something seem a little amiss here? Or were they only any good until the MMR came along? Or is it really a matter of who has control here? All parents do the best they can for their children, but some know far less about good parenting skills than others. And many do not realise how little they know. If Richard Whitmore is really interested in maximum survival of all children from any known cause, he would be better doing two things: 1) Educating parents about the value of long-term breastfeeding, avoidance of all drugs (including paracetamol, and antibiotics - except in life-threatening situations). He could promote the use of Vitamin A in all measles infections whether vaccinated or not, (which is well covered, and supported in the medical literature, even in so called "developed" countries) and he could reinject into society solid concepts of basic preventive medicine - that is, feeding children a proper diet. Further, he could investigate and counsel parents on the avoidance of as many environmental dangers and toxins as possible. He would save more children from many diverse conditions that way, than any vaccination campaign for any disease will ever achieve. And he would reduce the numbers of hospitalisation of children from all causes dramatically. Which would save him a lot of money. 2) And while he is doing that, he could also make sure that all medical practitioners in the Worcester City Hospitals undergo education in all aspects of information sharing, informed consent, and preventable medical error, the latter of which has, in recent years, killed far more children in the United Kingdom that all immunable diseases put together. As a parent, the difficulty I have with the comments of both of these correspondents, is that they seem to be totally unaware of the seeming hypocrisy and inconsistency of their respective arguments and positions as "health advocates". And they also seem to be unaware of the real concerns of the parents in UK, and elsewhere, about the health of their children, and the medical system of today. Sincerely, Hilary Butler. |
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Kevin Carroll, SpR Public Health Kenley, Surrey
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Yet another twist in the MMR story! Like many other contributors of responses so far I do not share Dr Mansfields views with regard to the safety of MMR. However as a parent and a public health professional I am sensitive enough to see that a minority of parents are not similarly reassured about the safety of this vaccine combination but still want their children protected. I think that this whole furore stems from the inability of the Department of Health and the public health community to be able to persuade a minority of the population that MMR is safe. Paradoxically the action taken by Worcestershire Health Authority, with the publicity it has generated is likely to increase demand for single vaccines. I can only wonder at the reasoning that led to the referral of Dr Mansfield to the GMC, was he really putting patients at immediate risk as has been alleged? As Dr Majeed mentions in his editorial, it is indeed a disturbing precedent if we can now expect referral to the GMC for implementing health policies that may conflict with those of the government of the day or the local health authority- but are nonetheless in the best interests of our patients. The issue here is not just the safety or otherwise of MMR it is whether the GMC is to become an enforcer of government public health policy. |
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Andrew O'Shaughnessy, Specialist Registrar in Public Health North Cumbria Health Authority
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Ultimately, Dr Mansfield's actions must be considered within an ethical framework. Much as we may try to direct our practice with definitive rules and regulations, we are all faced daily with decisions bound by their own individual limits. Dr Mansfield's decision is subject, like all others, to scrutiny under the four accepted ethical criteria, namely beneficence, non-maleficence, justice and autonomy. Every ethical consideration eventually falls somewhere into a spectrum contained by these four criteria, and from any standpoint, Dr Mansfield's actions do quite well when placed against them. Ethical decisions cannot always be "right" or "wrong", and although many will find Dr Mansfield guilty of irresponsibility, imagine yourself in the same ethical "dilemma" - what decision would you make? |
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Adrian Midgley, GP Exeter
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"What formal option is available when the private practitioner has no contractual links with the Health Authority, Trusts, PCGs/Ts, or indeed any part of the NHS?" 1. It is not clear that the HA has any constituency here, and I am not convinced that they need any option, therefore. 2. However one option is the BMA Division Ethics Committee, if the behaviour is felt to be unethical. 3. Indeed, that Division may have to convene its committee if there is any complaint that the director of public health has acted unethically here. 4. Distinct from this is the 3 wise men, another option that could hardly be described as informal. |
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Jackie Fletcher, National Co-ordinator/Founder JABS Warrington, Cheshire
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The bottom line is parents are trying to keep their children safe from disease and equally important safe from vaccine damage. Doctors like Dr Mansfield recognise that in the current situation some children would be left unvaccinated if monovalent vaccines were not available. The single measles vaccine has a good safety record in the UK. Introduced in 1967 it was one of the main infant vaccines until it was replaced by the MMR in 1988. The JABS group represents 1800 children believed to have been severely damaged or have died due to MMR vaccine. Some of these children have had their injuries or death acknowleged by awards made under the Government's Vaccine Damage Payment Unit scheme. Many legal cases are going forward and will ultimately be decided in the courts. Whether the DoH's senior medical advisors like it or not there is a huge question mark over the safety of this vaccine. These same advisors have been asked time and again to conduct independent, scientific studies of these children to determine why previously normal, healthy infants and adolescents have developed symptoms in recognised time scales and are subsequently living with long term problems known to the manufacturer. Unfortunately, the DoH officials do not accept that the vaccines caused the children's problems and state that all our information is anecdotal so there is nothing for them to investigate. This kind of patronising response and inaction will ensure that the gulf of distrust that exists between parents and vaccine policy will continue to widen. It is bizarre that officials have stepped in to put Dr Mansfield in the unfortunate position of having to justify protecting children against measles, mumps and rubella whilst the DoH senior advisors remain unaccountable for their own actions. I understand that two of the current suppliers of MMR vaccine hold up-to-date licences for the single measles and mumps vaccines and the only reason that all doctors do not have them at their disposal is that these same policy makers have decided not to order them. They seem hellbent on making it an MMR or nothing situation and woe betide any doctor who doesn't stay in line. JABS has been swamped with telephone calls, letters and e-mails from parents who want to vaccinate but have lost confidence in the MMR and are not reassured by DoH statements. They tell us repeatedly they have heard it all before. It's time for parents to be treated as responsible grown- ups, doctors as professionals and for senior medical advisors to take heed. Reinstate the single dose vaccines immediately and drop the ludicrous case against Dr Mansfield. Jackie Fletcher
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Malcolm Alexander, Clinical Director Orkney Health Board
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Dear Sir Referral of Dr Peter Mansfield to the GMC Far from Worcestershire Health Authority being wrong in taking the decision to refer Dr Mansfield to the GMC I would contend that they are following through on the full implications of Clinical Governance. Each Chief Executive of a Health Authority is ultimately responsible for all clinical activity in their Health Authority area. Exercising this responsibility is relatively straightforward within the public sector, it is altogether different when the clinical activity takes place in the private sector. When a Health Authority is made aware of clinical activity at variance with best practice in the private sector it is still duty bound to investigate and act. When such investigations as are possible uncover shortfalls in care, there are only a limited number of actions available to the Authority. These are: 1. Publicise their concerns. Risking lengthy legal consequences even if they are correct. 2. Develop services locally. These need to be so clearly better that demand dissipates for the private operator. 3. Refer the practitioner to their governing professional body. Worcestershire Health Authority were left with only the third option available to them. The Government, in conjunction with the NHS, had mounted a high level public information campaign making clear the concerns over vaccination with other than the MMR vaccine. Local service development is not an option as patient choice is being exercised in spite of the best practice advice. In light of the public health concerns surrounding this particular topic Worcestershire Health Authority would have been negligent if they had not referred Dr Mansfield to his governing body. All we see in this case is the dynamic of clinical governance coming against that of clinician freedom and patient freewill. Dr Mansfield's case is no different from any practitioner medical or otherwise, who is intent on practice at variance with best practice advice. His case must be tested against these three dynamics. The GMC has as it¡¦s Motto "Protecting patients, guiding Doctors". With it's ability to draw on legal, professional and patient based advice the GMC is ably placed to balance these dynamics and reach a sensible conclusion. Malcolm Alexander |
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Julie Cooke, Consultant Radiologist Jarvis Breast Screening Centre
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I am concerned that the referral to the GMC of Dr Mansfield may have implications for other medical specialties. As a radiologist who spends my whole time working in Breast diagnosis and screening I follow the NHS guidlines for mamographic screening which is to invite women between the age of 50-64 every 3 years as per guidelines. In the private sector a hospital where I work invites women for a well woman check. This will involve a mammogram if they are over 40 and this will be offered every 2 years. Another private hospital offers a major UK company regular 2 yearly breast checks involving a mammogram and a clinical examination. I report the mamograms for this scheme. Does this then contravene the Department of Health guidelines and am I at "risk" for agreeing to report on these X rays? |
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Michael Innis, Director Medisets International Home
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MMR and the GMC Forty years ago Health Authorities enthusiastically advised vaccination of children with Salk vaccine and no doubt saved many from the ravages of Poliomyelitis. For some unfortunates however, the SV-40 contaminant of the vaccine was lethal and resulted in childhood (1) and other malignancies (2). It is too early to be sure the MMR vaccine is harmless in view of the anecdotal reports of Autism following vaccination and the parent’s choice and that of their medical advisers should be respected. Michael Innis References: 1.Innis MD. Oncogenesis and Poliomyelitis Vaccine. Nature 1968; 219: 972-3 2.http:// www.theatlantic.com/issues/2000/02/002 bookchin.htm |
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Keith Baxby, Consultant Urologist Ninewells hospital, Dundee
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Worcestershire Health Authority's action is a disgrace. As part of its recent proposals for overseeing the function of the GMC the government needs to introduce a statutory offence of "Wasting the GMC's time". Obviously, this could not be retrospective, so for now the GMC should advise this health authority to "Go and make love somewhere else". |
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Alan Weatherup, General Practitioner Salisbury Road Surgery, Barry, Vale of Glamorgan
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Dr Azeem Majeed's editorial ignores important issues both in public health terms and in the care of children. First of all on the principle that it is important to have a service for the minority who wish to avoid the MMR vaccine consider these points: For every parent who has come to the conclusion that their child will not be immunised with the MMR vaccine there must be many more parents who are uneasy or very uneasy about the vaccination who are 'sitting on the fence'.A service such as provided by Dr Mansfield may serve to be the prompt that makes these parents decide not to have the MMR vaccine for their children. The mere provision of such a service may heighten doubts about the safety of the mainstream service among parents in a locality increasing the pressure for acceptance of the alternative service: for what I consider to be 'second rate medicine'. At a public health level this service could go along way to reducing community vaccination rates. I will not go into the reasons why single antigen vaccinations might contribute here. On the care of children, Dr Mansfield misses the point with his example of a 75 year old man deciding whether or not to accept warfarin. We are debating here the health care of young children who, unlike an adult, can not speak for themselves or form a considered opinion. Perhaps he could come up with an example of a childhood illness where it would be acceptable to withold potentially lifesaving treatment?? As doctors we have a duty to our child patients and be their advocates. Unlike Dr Mansfield, I will not advocate for my patients 'second class medicine' that will only fuel doubts about the MMR, confuse parents, potentially reduce vaccination rates, and leave children exposed to dangerous infections. |
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Dyfan Lewis, private practitioner Stockholm, Sweden
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I heartily agree with the writer of this article and am relieved at the large number of positive responses to it. I consider Mansfield's action completely ethical although I also believe MMR to be safe. I do not ride a coach and horses over my patients here in Sweden either. |
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Denise Morris, Staff Nurse
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I have read with interest the situation Dr Mansfield finds himself in regarding his willingness to give parents an alternative to the MMR vaccine. As a humble parent I applaud his decision to support a parents right to choose, I would argue that no responsible parent would ever deliberately expose their child to disease especially one which may be prevented by vaccination, but I would also have had concerns about any vaccine where even a small element of doubt was placed upon it's safety. Those with professional experience and probably a great deal more information will no doubt argue it's safety but this does not comfort those parents who believe rightly or wrongly that it is responsible for the damage done to their children. While the MMR vaccine has not applied to my own children, I faced a similar dilemma when they were babies,namely the triple vaccine which included whooping cough, it took a lot of thought and visits from a very patient health visitor to convince me of it's safety, I was not pressurised but given a great deal of literature to read and invited to speak to other parents regarding my fears, thanks to this support I was able to make an informed choice and opted for the triple vaccine. My point is that it has to be the parents informed choice, if they choose not to have the combined MMR vaccine, but nonetheless wish to protect their children from these diseases, should they then be denied the alternative of separate vaccines because it does not meet best practice, if the answer is no and an alternative offered then where is the problem, if on the other hand the answer is yes and the child denied any protection then does this not amount to emotional blackmail, which has no place in a free society. At the end of the day it is the parents choice and responsibility and they have to live with the decision they make. |
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Rachael Thompson, Mother Home
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As a mother of three I am daily subjected to conflicting advice. When my five year old daughter was a baby, it was OK to start solids at three months, by the time my second child was three months old, I was advised not to. My youngest daughter is now six months old, and as advised I avoid peanuts, drink alcohol rarely and only sparingly, I only take paracetamol when my headache is so bad I can barely see my children, and so the list goes on. I spend every moment of my career as a mother trying to do the very best for my children. I force feed them fruit and vegetables, try to avoid junk food and limit their time in front of the television. With all this in mind, how can ANYONE ask me to ignore the rumours and risk ruining my childs whole life by allowing her to be given a vaccine that might not be safe. There is no history of peanut allergy in my family, but I won't even eat a peanut for fear of harming my child. Faced with the actions of a government who is behaving like a dictatorship in so many ways, for instance, the way the petrol price issue was handled, the way that foot and mouth was played down, why should I believe that the motivation of the government is not: a) to save money and b) to make the small stupid people conform to the will of our leaders. The persecution of Dr Mansfield for offering people a choice is disgraceful, dangerous and threatening to our liberty. | |||
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JIm Unsworth, Consultant Physician Gilbert Bain Hospital
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Hilary Butler's reaction demonstrates the strength of feeling on this and related issues. She has made a number of assumptions that bear scrutiny. The thrust of my comment concerns the comparison of professional and personal (or parental) responsibility within the extant legal and ethical frameworks. My practice does not include the administration of or recommendation of any childhood immunisation or vaccination. I do however support full and open discussion about treatment interventions and the provision of factual, concensus based, literature whenever applicable. I do not feel the need to protect my position, which is open and accountable, and have not sought to promote an individual view. I do, however feel the need to protect my children and write as a comsumer. After serious thought and consideration my partner and I consented to the MMR for our children who subsequently received it. We believed, and still do, that the balance of risk was clearly in favour of the immunisation. Just because we're doctors doesn't make that any less valid. |
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V M Verma, Convenor Indian Medical Association, Australia Australia, Delhi.
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Dear Ed, It appears to be blasphemous, that Dr.Peter Mansfield, is being refered to the General Medical Council, for not listening to the Worcestershire Health Authority.GMC referals should be for unethical practices, or medical malpractice.In this instance, by giving children measles, mumps, and rubella vaccines, Dr Mansfield has breached no code of medical ethics.In most of Asia, it is common practice to give measles, mumps, and rubella vaccines, separately, under the WHO's immunisation program, since this program does not cover rubella anyways, and the MMR is considered too expensive. The WHO in India, under the pulse polio program, and in UK is giving polio vaccine seperately, and miss out on opportunities to immunise children against other diseases. Maybe the Worcestershire Health Authority would refer WHO to the GMC...ho, ho ho!!! I hope the GMC, though known for their unfairness, as a Government bureaucracy internationally, will not take this seriously. Dr. Vaishali Mona Verma, Convenor Indian Medical ASsociation, Australia Chapter, c/o Consulate General of India,Curtain Avenue, Eagle Farm, Brisbane, Australia. |
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John Lucas Home
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I support Dr Mansfield in his wish to supply single vaccines. It is obviously just a battle of medical politics that sends out the message to me that GPs are not allowed to think for themselves, but must just follow the orders of the government. Politics must never come before the health of children. I believe the main rationale for measles vaccination is to reduce the death rate, at least this is what the CMO seems to imply in his campaign for the MMR. "Measles kills 1 million worldwide"---Liam Donaldson, Chief Medical Officer However, I found that measles deaths had declined by 99.4% from 1901/2 to when the measles vaccine was introduced in 1968 (1). How do we know vaccination reduced it the last .6% over the factors that reduced it the 99.4%, such as improved diet, and I am astounded that medical doctors don't use vitamin A, as Hilary Butler mentions, or Vitamin C which has been shown to eliminate measles deaths and disability by Dr Archie Kalokerinos MD (2) John Lucas 1. Twentieth Century Mortality CD (England & Wales), Office of National Statistics 2. International Vaccine Newsletter June 1995. Medical Pioneer by Dr Kalokerinos ISBN 0646408526 |
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Alex Manning, General Practitioner Burwell Surgery, Burwell, Cambridgeshire
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Whilst I agree with Azeem Majid that Peter Mansfield's referral to the GMC seems inappropriate, this may prompt more debate around the important issue of whether it is reasonable to legislate for the rights of the community over the rights of the individual as regards MMR vaccination. The argument seems to be that we know that combined MMR is safe and effective (anyone who takes the time to assess the extensive literature should be able to persuade themselves of this fact), and that single MMR vaccinations may reduce adherence to the full course and show no advantage. The community therefore looses out as a result of an individual's decision, by a reduction in herd immunity and an increased chance of an epidemic. The Department of Health therefore feels that single MMR vaccinations should not be offered on the NHS and there is now a question as to whether this is defensible medical practice. Other individual choices (such as aspirin/warfarin in stroke prevention) are allowed as these are not seen to affect the community directly - although there could be seen to be a significant burden for those caring for the increased number of strokes that this would create. The Department of Health banks on the fact that more people would take up the single vaccination option if it were available than refuse all vaccinations with it not being available. Whilst this may seem sensible from a Public Health/community perspective, it sometimes feels difficult to communicate the lack of individual choice in this matter in the consulting room. Surely in this age of "patient centered" medicine, we should trust patients to make decisions for their own children? This would mean the cost of a potential epidemic with each media scare, but give parents the freedom, responsibility and ownership of such a decision. |
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K D Bardhan, Consultant Physician and Gastroenterologist Rotherham General Hospital NHS Trust
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Referral of Dr. Peter Mansfield to the GMC EDITOR: I am not qualified to comment on vaccines but write to applaud Dr. Azeem Majeed on his resolute and eloquent defence of the right to reasonable dissent from official views. (1) Much of the evidence on which modern treatment is based is derived from studies in large, often carefully selected, populations. When such therapy is then applied to similar populations the benefits and risks are predictable. That is the science. Not every individual, however, fits comfortably into convenient algorithms. For them management is influenced by clinical judgement, patient perceptions and preferences, and so on. That is the art of medicine; it goes hand in hand with the science, which most practicing clinicians recognise. Guidelines can be very helpful but at times are treated as rail tracks from which deviation is difficult for fear of criticism, or worse. Approaching my 30th year as a consultant, I get the feeling we are increasingly required to march in step, no matter if the direction is questionable. It is not clear why Dr. Mansfield was referred to the GMC. In the absence of reasonable explanation, there may linger a suspicion that in the current doctor-bashing atmosphere the authorities have tried to pre- empt any risk of being criticised by pointing out someone whose “fault” was being out of step. K.D.Bardhan Consultant Physician and Gastroenterologist Rotherham General Hospital NHS Trust ROTHERHAM South Yorks S60 3NA Tel: 01709-820000 Bleep 058 Sec: 01709-304168 (tel and fax) e-mail: bardhan.sec@rgh-tr.trent.nhs. Uk 1.Majeed A. Editorials. Referral of Dr. Peter Mansfield to the GMC BMJ 2001; 323: 356 |
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L S Lewis, General practitioner Newport Surgery
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This is a response to Richard Whitmore: Richard.. For heaven's sake reconsider your position !! You say:-
Clearly, you heve forgotten the experience of the 35 years prior to
MMR, which is fully evidenced in the Government Publication 'Immunisation
against Infectious Disease'. The extent of evidence and experience is far
larger for M/M/and/R than it is for MMR.. (all of which vaccines I believe
to be substantially safe and effective). Measles and German Measles were
dramatically reduced in the UK population long before MMR was invented
(when the 'given wisdom' was that ONE live vaccine at a time produced best
responses because of interferon and all that : hence the doctrine of 3
weeks between live vaccines ) .. Richard, you are too young to
remember, I suppose.. But you can read.
Alarmist or what ? How many children will die from failure to allow
Measles vaccine legally into the UK? What will we do for children who
react to one element of MMR ?
'MMR vaccine' or Imuunisation against Measles, Mumps, and Rubella ..
a closed mind ? Dr Mansfield's activity is cleary going to RAISE the
level of immunity to Measles, and Mumps, and Rubella if only he be allowed
to get on with it ! Would Richard force MMR on unwilling parents ??
Worcestershire HA has no more jurisdiction than Richard or myself.. I
am free to refer Richard for 'scare-mongering' and failure to respect
parental rights/.. Would he agree?
< Whether the GMC feels it has a responsibility for public health
remains to be seen. >
Let us hope so..
< I also despair for the lack of responsibility demonstrated by an
educationalist who displays such a superficial understanding of this
complex matter.>
Richard.. look to thyself !
Sam Lewis |
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L S Lewis, General Practitioner Newport Surgery
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This is a response to Alan Weatherup Alan, You are right that we must act in the best interests of children, who cannot speak for themselves. But: 1. 'As doctors we have a duty to our child patients and be their advocates.' But until they become Wards of Court they remain wards of their Parents, and not we doctors.. We have an ethical duty to seek valid (parental) consent to any action upon children. 2. 'I will not go into the reasons why single antigen vaccinations might contribute here.' Why not ? They are proven to be safe and effcetive (and available in most advanced countries). 3. 'an example of a childhood illness where it would be acceptable to withold potentially lifesaving treatment??' Dr Mansfield is NOT withholding effective safe vaccination, Alan.. The State is ! In my opinion Dr Mansfield is acting in the best interests of his child patients, with properly obtained parental consent. I do exactly the same (use single vaccinations when the parents agree and cannot be persuaded for MMR). I have pushed UP the vaccination rate in the face of the MMR scare. 4. 'second class medicine' ? only in your unevidenced opinion.. When a child reacts to one of the MMR elements, what will you do ? - I refer you to 'Immunisation against Infectious disease published by HMSO ! With best wishes, For a healthy AND free society! Sam Lewis |
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Roger M Goss, Director Patient Concern
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LETTERS TO THE EDITOR 26 August 2001 Patients entitled to freedom of choice Editor – If the GMC has any moral or historical sense, it will reject the Worcestershire Health Authority’s attack on Dr Mansfield. (1) Some patients refuse ‘life-saving’ amputations and do not necessarily die. Others decline prostate operations because they find the risk of impotence or incontinence, however modest, unacceptable. Some parents understandably fear autism more than rubella, measles or mumps. They prefer single vaccines. They exercise their right to choose. The responsibility of the Department of Health, Health Authorities and individual doctors extends only to ensuring informed consent or refusal of MMR vaccine. Buying shoes used to involve endless foot X rays. We now know that such frequent Xrays can be harmful. Past generations were brought up to believe that a diet high in dairy foods was healthy. Now we are told to restrict our fat intake. Medical history is full of received wisdom subsequently proved false by further research and new evidence. Who knows if this won’t prove the case with the MMR vaccine? Roger M. Goss Director - Patient Concern (1) Majeed A. Referral of Dr Peter Mansfield to the GMC. Worcestershire Health Authority is wrong. BMJ 2001; 323: 356 (18 August) |
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Kim Hwang, Consultant Psychiatrist West Middlesex University Hospital
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Thus far, most of the responses to Dr Azeem Majeed's editorial have come from general practitioners and from parents. However, the editorial also raises some important issues for doctors working in other specialties. For example, in my own field of old age psychiatry, the National Institute of Clinical Excellence (NICE) has published guidelines for the use of anti-dementia drugs (such as Aricept, Exelon and Reminyl) by the NHS. Some patients with dementia will not meet these criteria but could still possibly benefit from treatment. Ineligible patients, or their carers and relatives, may therefore try to obtain the drugs from the private sector. What would be the medico-legal position of any psychiatrist who prescribed anti-dementia drugs to patients not eligible for them, based on the NICE guidelines? Dr Kim Hwang Consultant Psychiatrist |
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Gregory Gardner, Non-Principal GP Swanpool Medical Centre, St. Marks Rd., Tipton DY4 OUB
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Sir, It is pleasing to write a response to a BMJ editorial on an ethical issue which one agrees with. I concur with Azeem Majeed and the majority of the correspondents that the referral of Dr. Mansfield to the GMC is an abuse of power. Three years ago when our oldest child reached the age for MMR vaccination we decided against using this vaccine for ethical reasons. The Rubella component of MMR was derived from experimentation on an aborted foetus. A number of parents with similar views have subsequently contacted me. I have had to import single dose Mumps, Measles and Rubella vaccines for these families from Europe and Japan. It is expensive and time consuming. The current regulations laid down by the Department of Health state that single dose vaccines are only licensed for importation if the child has already begun a course or if there are serious medical concerns about the safety of MMR vaccine for a particular child. This has led some parents into the absurd position of taking their child to France or Ireland to begin a course of single dose vaccines and then completing the course in the UK. When I wrote to the Department of Health to challenge this situation it took them six months to reply and they avoided answering my question about the provision of ethical alternatives. These are concerned, responsible parents who want to have their children vaccinated but have unnecessary obstacles put in their way because of a lack of flexibility at the D.O.H. The state seems to be answerable to nobody but Dr. Mansfield who is clearly seeking to address a strongly felt need and improve vaccination rates is now in trouble. I would like to give him my support. Yours sincerely, Gregory Gardner. |
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C O Lister, Retired
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If one could say quite unequivocally that the MMR vaccine was entirely safe and totally without untoward side effects, then Dr.Mansfield would have a case to answer. It is clear that such unequivocal assurances cannot be given, and in such circumstances parents or doctors who entertain doubts about a particular course of action should have their doubts respected. This referral to the GMC should act as a salutory reminder of the influence of the state on what one used to think was an independent body. Today we are regulated by Government and not by our peers. |
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Richard Morland, Senior Lecturer University of Brighton
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Dear Editor I write to support the views of Majeed, with regard to the referral of Dr Mansfield to the GMC. I am saddened to see a number of doctors confusing Public Health objectives with their responsibilities to individual patients. Within the doctor-patient relationship, the individual patient is owed a duty of care by the doctor. The doctor has no right to inflict treatment on individuals "for the good of the community". The treatment must be for the good of the patient and must respect the patient's views, even if the doctor believes the patient to be wrong. If there is a Public Health need to achieve a high level of immunisation in order to achieve herd immunity, then it is the role of Parliament to enact appropriate legislation to place a legal obligation on parents to have their children immunised. It is Parliament's role to determine the balance between public good and individual's rights. It is quite wrong for the NHS to be used to coerce individuals to undergo treatment that they are afraid may be harmful, particularly when they seem prepared to accept an effective alternative (at their own expense). Doctors working for the NHS must maintain the right to give honest advice and treatment acceptable to the patient. It may be reasonable for the NHS to provide only those treatments that are cost effective, but doctors must be allowed to inform patients of all acceptable treatments irrespective of cost effectiveness. It is vital that the medical profession re-establishes its independence from government. The government and its various agencies have a well deserved reputation for providing biased and self-serving information. (Bristol, BSE, waiting lists, etc.) Doctor bashing will become really serious and could well destroy the profession, if the public come to see doctors as part of the government's misinformation system. Doctors who hold management posts in the NHS need to consider where their duties lie; to the profession and individual patient care, or to the government and the political agenda of the day. If the latter their names need to be removed from the Medical Register. Richard Morland Bsc MBA
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J K Anand, Retired public health physician
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I support Dr Majeed for speaking out for what may be a minority view and I am surprised that he and the BMJ have been criticised for it. JK Anand |
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Moyra Reid, SpR Public Health Medicine Northamptonshire Health Authority, Highfield, Northampton, NN1 5DN
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Recent debates surrounding Dr Peter Mansfield’s referral to the GMC(1) following prescription of single vaccines centre on the issue of professional autonomy and the tension that exists between this and central guidance. On one hand are those who feel that Dr Mansfield has had his professional autonomy (and by extrapolation their own) threatened. Opposing this are arguments that doctors should follow current guidance and best evidence, regardless of their individual views. No doubt both parties have the patients’ best interests at heart, but while the two camps fight it out, the underlying issue of professional autonomy appears to have been overshadowed. This is not simply an academic issue, but is key to current debates and to the way in which medical practice is evolving. Whatever our personal views on this particular case, it should make us question what it means to be a professional, the nature of professional autonomy and whether this is essential to the practice of medicine. The raison d’être of ‘professionals’ is that they possess esoteric knowledge about a particular subject area. Professionals use this information altruistically in the best interests of those who consult them. If this were not the case then patients would be able to diagnose and choose for themselves the nature of their own treatment. In some instances ‘expert patients’ exist, although this is not true for the majority. We live in a period of plentiful information but also of increasing levels of central guidance and governance. I would argue that professional autonomy is essential: Without it how are we to make sense of the information presented to us and apply it in context to patients who may be quite unlike those on whom the information is based? How are we to act as independent advocates and ensure that individual patient’s have input into their care? For these reasons the medical profession needs to reassert its professional autonomy. However, this needs to be undertaken with strong and transparent self-governance. Failure to act may lead to creeping erosion of professional autonomy, with the vacumn left being filled with protocols and guidance intended for the ‘average’ person –a rare species indeed. This would be not only bad for moral among the medical profession, but perhaps worse still for individual patient care. 1 Majeed A. Referral of Dr Peter Mansfield to the GMC. BMJ 2001; 323:356. (18 August.) |
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William D H Carey, Clinical pharmacologist Hammersmith Medicines Research, Central Middlesex Hospital, London NW10 7NS
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Editor- Surely it is a betrayal of the trust placed in doctors if we prescribe treatment which on medical evidence we believe not to be the best available? As far as I am aware, Dr Peter Mansfield [1]has not provided any evidence that the triple MMR vaccine is more dangerous than the single vaccine, if anything the evidence is the other way round. So on what grounds has he made available the single vaccine? Parental choice and belief. When did this policy arise? It seems to me that several issues are being muddied. In the situation where there is no clear advantage of one treatment over another, eg in the case of cancer where one treatment has a higher cure rate but a lower short term survival rate, it right and proper that patients and parents have a say in which treatment to choose. But in a clear cut case, such as treating classical IDDM with insulin, it would be nothing short malpractice for a doctor to prescribe anything but insulin, no matter how much a parent might want some unproven altenative prescribed, as occurred not so long ago. In the latter situation, what is a doctor to do? He or she should refuse to precribe the alternative, having done everything possible to persuade the patient otherwise, and suggest the patient go elsewhere. This brings us to the second area of muddle - distinguishing between a patient, and a child and parental rights. If an adult, in sound mind, wishes to pursue some idiosyncratic treatment, that is their business. But I believe a doctor has some responsibility to a child if the parent is taking a medical decision which is not in a child's best interest. This could include making the child a ward of court. Again, we must not stifle opposing views in medicine, but this is not the same as giving all alternative views equal credence, but only those soundly argued on good science, which brings me to my opening point. If we make decisions based on parental wish, where does that leave evidence based medicine? If a child dies of measles who would not have done so if they had received the triple vaccine, who is going to be liable? The NHS for failing to give the latter vaccine, or Dr Mansfield for giving the single one? One further difficulty in this situation is that in most cases, unlike the IDDM case, the child will be fine, because of herd immunity, and therfore the parent will have a false sense of being vindicated. But the price is lowered herd immunity. Doctors are often accused of being arrogant, but I cannot help think that is it such parents, as well as Dr Mansfield, and who are arrogant in this case. Yours faithfully William D H Carey [1] Referral of Dr Peter Mansfield to the GMC Azeem Majeed BMJ 2001; 323: 356 and subsequent correspondence. Competing interest: Safety of my own children. |
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Leslie S Lewis, GP Principal Newport Surgery, Newport SA42 0TJ
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'Surely it is a betrayal of the trust placed in doctors if we prescribe treatment which on medical evidence we believe not to be the best available?' As a CLINICAL pharmacologist you must surely be aware that the BNF is full of alternative products, most of which are not 'best available'.. 'on what grounds ..Parental choice and belief.. when did this policy arise?' So on what grounds are a wide variety of second-best alternatives available on the NHS ( and even more products privately) ? The answer of course, is precisely in order to meet all the variey of circumstances and individual preferences (and cost constraints sometimes too) that may arise in persuading a patient to accept a treatment.. What would Dr Carey offer to an unvaccinated child with a know hypersensitivity to one component of 'the best available' MMR ? At present the NHS offers NOTHING AT ALL.. (worse than useless). All medicines (or vaccines) should preferably be cheap safe, effective AND tolerable/acceptable to patients. competing interests: a free AND healthy society |
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William D H Carey, Clinical Pharmacologist Hammersmith Medicines Research, Central Middlesex Hospital, London NW10 7NS
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Editor-There are many alternative treatments in the BNF. Examples of different scenarios are: There are alternative drugs provided by different manufactures but where there are not significant differences. The patient and doctor can try different alternatives until the best is found for the patient in terms of response and side effect profile. If a patient has asthma, the doctor should not prescribe a beta-blocker, even if the patient demands it. An alternative would be an ACE inhibitor, but if the patient developed a cough (about 10% of patients), then the doctor should change the drug again, for example to a calcium antagonist. In this case the doctor must be firm about the beta-blocker, but can be flexible about the other 2 drugs used. The doctor's duty is to ensure that the blood pressure is controlled (as blood pressure problems can lead to serious complications), and the patient must be happy that he/she feels well on the treatment. There are different therapeutic strategies where patients can chose. For example, migraine. Migraine can be extremely unpleasant, but does not have any long term effects (with very rare exceptions). Choices are different kinds of drugs and different approaches, namely acute treatment when the headache occurs, or prophylactic treatment. This choice can be left entirely to the patient, with the proviso that the doctor ensures that any treatment is taken correctly and that a drug is not used which would not be suitable for that particular patient. The patient can choose to take no treatment. This, from the doctor's perspective, is acceptable as migraine has no long term complications. In the case of insulin dependent diabetes, insulin is the only treatment, there are no alternatives (as yet). The doctor has to insist that the patient takes insulin (though the patient can chose which regime they take). Of course, the patient can refuse, and die. But the doctor must not agree to another treatment on the grounds of patient/parental choice as that would give the impression to the patient/parent that the two treatments were comparably effective. The question is, therefore, into which scenario does MMR best fit? Clearly it is not the second as the consequences of having measles can be severe, and lead to death. I think it is somewhere between the first and third scenarios, but nearer the third. We have no good evidence that MMR causes autism and bowel disease, we have no good evidence that measles and the single vaccine do not cause autism and bowel disease. There is some evidence that the triple vaccine is better than the single vaccine. In Japan they do not have the triple vaccine and there have been significantly more deaths from measles than here. 'Second-best treatments' is a slightly misleading term. There are alternatives in the BNF as describes above, but they are not second-best which implies that they are significantly worse treatments overall. It would be unethical for a doctor to prescribe them, all things being equal, and they should not be in the BNF. However, for a particular individual one treatment might be second-best. For example, the beta-blocker for the asthmatic would be second-best because although it would improve the blood pressure, it most probably make the asthma worse. The job of the doctor is to use his/her experience and knowledge to select the best treatments, allowing for the specific medical characteristics and views of the patient. A second example of this scenario would be the one you raise, namely the child with the known hypersensitivity. This would be a case for having single vaccines, but that is not the current concern with MMR under discussion. Sometimes, of course doctors do give treatments which we think are not as good as the best on the grounds that something is better than nothing. But only if the difference between alternatives is small. That is the essence of the current debate re MMR. I am sure there are many dodgy treatments in the private system, which is why it needs to be tightly regulated. I have a small child and he has had the MMR. I am shortly to have my second child and I have no hesitation in giving her/him the MMR. Yours sincerely William Carey |
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Paul W Divall, Consultant in Old Age Psychiatry St. Martin's Hospital, Bath, BA2 5RP
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My initial reaction to this debate has been "why not give people choice?". That feeling was reinforced by the remarkably eccentric referral of Dr Mansfield to the GMC. If anything, doctors, who are not giving patients choice, should consider whether they have obtained proper consent - since informed consent requires information about the alternatives. And I thought one of the guiding principles of our Government was choice. (The New Hobsonian Labour party I presume.) Now the Government is effectively blaming parents for failure to vaccinate and thus helping to cause outbreaks of measles. Perhaps if the intransigent Department of Health had made single vaccines readily available those children would have been immune. Why does the government think MMR is so much better that all the alternatives are beyond the pale? I wonder when common sense will prevail in this debate? Yours, concerned and constrained, Paul Divall. |
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John Heptonstall, Director of The Morley Acupuncture Clinic and Complementary Therapy Centre Leeds LS27 8EG
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Sir When doctors consider themselves appropriate 'advocates' for young children such that they are prepared to act contrary to the expressed wishes of the parents acting on behalf of their children, they delude themselves. We are seeing more and more such 'advocacy', perhaps well- meaning but nevertheless misguided, be it through 'morning after pills', support for addictions without parental advic/consent etc. and one wonders how we reached this position - until one reads such a letter on the eBMJ.... Except for those parents who openly relinquish to accept responsibility for their own children, it is essential that society - especially physicians - respect the rights of parents to make decisions for their children as it is they who are best placed/informed and emotionally committed to the well being of the child to make decisions. The MMR debate has exposed Government and the Health Department (as did the BSE/CJD situation) as politically - as opposed to socially and morally - consumed such that obvious public interest is rejected, and prepared to use large sums of public monies in propaganda in support of its debatable views. This is one reason why physicians must first serve their patients, giving due respect to children -hence parental rights to act on behalf of those children - rather than a state which has continually exposed itself as wanting. The UK is rapidly moving towards totalitarianism - both internally and, with the encroaching European superstate and the politico-legal consequences for our historic parliamentary system - so it is imperative that those who believe in human rights, democracy, and the right of children to develop in safe family units stand up for those rights. It is encouraging that so many other respondents support Dr. Mansfield's stance on behalf of those families under his care, especially those who do not take his view of MMR. If doctors put patient care first - remembering the importance of parental advocacy for their children - and parents put their childrens care first, those children will benefit. It's not the doctor who picks up the pieces, but the parents. Every year we see medicines removed from the pharmacopaeia, one never knows what will be the next 'second class' medicine; Dr. Weatherup has a right to his opinion, his patients will gain or lose from that opinion. Other doctors also have a right to an opinion, as do parents who assume responsibility for their children and - witness the many thousands of single antigen vaccines already distributed this past few years - many have taken that responsibilty very seriously. Regards John H. |
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L S Lewis, GP Suregry, Newport, Pembrokeshire, SA42 0TJ
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The Chief Medical Officer, Liam Donaldson, made a TV appearance today on 'BREAKFAST WITH FROST'.. In measured terms he explained to the viewers that 'normally choice is a good thing, but in this case it will cause harm'.. Mr Frost responded that lack of choice (for single vaccines) could be causing more harm.. Are parents to be denied the right to refuse consent, when we doctors feel their choice is ill-considered ? Are we really going to force MMR into unwilling arms ? Dr Donaldson wished that he could meet individually with every parent, and was sure that he would be able to convince them all.. No chance ! I am unable to persuade some parents, despite increasingly lengthy consultations. I wish to be allowed to compromise with those parents who cannot be persuaded, and give their child single vaccines ( just as Dr Mansfield does ). Typically, when I listen, value and respect my patients views, they tend to reciprocate ! I too believe that MMR is at least as safe as any other means of immunising against the three disease. I too believe that MMR has NOT been shown to be associated with bowel disease nor autism, in any scientifically plausible manner. My point is that valid parental consent / refusal must be taken as just that .. < VALID > This debate began when a (private) doctor was reported (by a Health Authority) to the GMC for giving parents an opportunity to choose.. using a vaccine which has many millions of doses on record, whose safety profile is as good as the MMR. But last year it's licence lapsed, and has not been relicensed in the UK .. WHY NOT ? Why are manufacturers of MMR not marketing their MMR product in separated formulations in the UK..? Dr Carey makes the breathtaking statement.. 'Surely it is a betrayal of the trust placed in doctors if we prescribe treatment which on medical evidence we believe not to be the best available?' As a CLINICAL pharmacologist he must surely be aware that the Britain's BNF formulary is full of alternative products, most of which are not 'best available'.. precisely in order to meet all the variey of circumstances and individual preferences (and cost constraints sometimes too) that may arise in persuading a patient to accept a treatment.. What would Dr Carey offer to an unvaccinated child with a known hypersensitivity to one component of 'the best available' MMR ? At present the NHS offers NOTHING AT ALL... All medicines (or vaccines) should preferably be cheap safe, effective AND ACCEPTABLE TO PATIENTS. < The question is, therefore, into which scenario does MMR best fit? > A more pertinent counter-example to Dr Carey's scenarios is DTP (diphtheria/tetanus/pertussis):- DTP triple vaccine is standard in UK child vaccination clinics.. But if a parent refuses consent to pertussis, then after fully informing the patient of the risks, myths, and benefits, we have no problem at all in giving way to their choice, and offer DT only. Despite the known real danger of pertussis outbreak in time of falling confidence we STILL respect parental choice, AND ALLOW SEPARATED VACCINATIONS. Parents do still (thankfully) have the right to withhold consent to vaccination in this country, EVEN IF WE DOCTORS CONSIDER IT A BAD DECISION. 40% of parents express doubts.. Would you allow a doctor to inject your child against your judgement ? Would you inject a child against a parent's valid and sound judgement ? We do not deny pertussis-refusers the second-best option, because the alternative - no vaccination - is worse. The refusal of the UK NHS to allow the parent's choice is actually resulting in large numbers of children not getting vaccinated at all, and compounds the risk. Some very important backs are now against the wall. Is it too late for the sensible compromise position to be permitted ! competing interests: sometimes Health vs. Freedom |
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