Openness: a virtue whose time has come

Despite the upbeat rhetoric of the government, Britain's National Health Service seems to be staggering to the end of the century. The public has been horrified in the past week to discover that many children's hospitals have collected hearts and other organs from children who have died without getting clear consent from parents (p 1518). The government has ordered an inquiry. The Daily Telegraph has started yet another series arguing that elderly people are being failed by the NHS, even to the point of being left to starve. The threnody of the Bristol inquiry into surgical deaths continues (p 1519), and most of the population knows that Britain has the poorest results in Europe for cancer treatment (p 1572).

Journalist Will Hutton argued powerfully in the Observer (5 December, p 30) that the many failures of the NHS “are the consequence of decisionmaking that has not been exposed to genuine public scrutiny.” The NHS, he says, is the least accountable public institution in Britain. Born from a “ghastly marriage of socialism and royalism” it does not treat its patients and users as adults and citizens. “The NHS,” he concludes, “has to be thoroughly opened up to meet the new demands of the age.”

The NHS is not alone in being closed and unaccountable. It may be a feature of many healthcare systems. The Institute of Medicine in the United States has just reported that almost 100 000 Americans may die each year because of medical error (p 1519). The New York Times has run an article on “Breaking down medicine's culture of silence,” which says: “Physicians are taught that it's your job not to make a mistake. It's like a sin. The whole concept of error as a sin, as a moral failing, is deeply ingrained in medicine, and it is very destructive. It means people cannot talk about it, because it is too painful.”

Openness is surely going to be even more important in the new millennium than the old. Openness about the limitations, difficulties, and failings of medicine and healthcare systems; openness about how decisions are made for populations and individuals; openness about rationing; openness of complaints procedures; and openness of the evidence on benefits, costs, and risks and treatments. Politicians prefer closed decision making and obfuscation to transparency and accountability, particularly when money and death are involved, but they must change.

The BMJ is making a small contribution to openness by launching a “netprint server,” where researchers can share their findings in full, for free, and fast (p 1515). We foresee a time when peer review will be transformed from a black box into a scientific discourse conducted entirely in the open on the world wide web.