Debate crystallises dilemma facing many medical disciplines

EDITOR—Tom Heller articulates the dilemma facing doctors in many medical disciplines in his article in the ethical debate on measles, mumps, and rubella (MMR) vaccine, a debate that is being stifled because of the overwhelming evidence base in favour of immunisation.1 He reaches the core of the debate when he refers to the balance to be struck between informed consent and the right of the state to control an infectious disease. He may feel uncomfortable because he is caught between two roles: that of the agent of the state, which doctors are often unwittingly asked to be, and that of protecting the best interest of his patients.

After Alder Hey and Bristol a lot of noise has been made centrally about the need to put patients first and reverse what is seen as the historical imbalance in power between doctors and clients, as Pattison points out in the final paragraph of his contribution to the debate.1 The need for a power differential between experts and clients and for an implicit contract between the parties in terms of who delivers the expertise is currently out of vogue.

If the profession is to be shaken into putting patients first, how does it also put evidence or central government directives first? Doing it surreptitiously by payments for immunisation targets helps no one. Therefore, in its attempt to put patients first the government will presumably now revoke immunisation targets and reincorporate the monies into general practitioners' basic remuneration—still time to include this in the new contractual arrangements.

If not, then it will presumably support giving doctors time to prepare their own leaflets on the available evidence, individualise their patient care, and then state that once informed it is entirely up to parents to decide on the best course of action for their …