Editor's Choice

Reflecting in the swampy lowlands

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7464.0-f (Published 26 August 2004) Cite this as: BMJ 2004;329:0-f
  1. Jane Smith, deputy editor (jsmith{at}bmj.com)

    Holidays are a good time for reflection, and it feels like holiday time in the BMJ office: the air is hot and the office quiet and half empty. So it is fitting that this week's BMJ offers a fair amount of quiet reflection.

    Some of this reflection is internal. Almost four years ago the BMJ set up its own ethics committee, and on page 510 Elizabeth Wager tells its story. We set up the committee, among other things, to help us with difficult cases. Readers might think that much of what editors do—sit and read papers—is a gentle activity, with few risks other than boredom and a sedentary lifestyle. But papers, and their authors, bring with them a whole host of issues. Should authors have to get the consent of the patients they describe or photograph? (Our answer is yes, though several authors accuse us of pedantry and political correctness.) What should we do about a paper describing a scientifically meaningless but potentially harmful intervention where it is not clear whether there was any meaningful informed consent? How do we handle a powerfully written article that describes poor care and worse behaviour by potentially identifiable health professionals? Who should we tell when we discover that a student has plagiarised an article from the studentBMJ? (This week's Career Focus has some good advice on plagiarism (p 86): don't). What do we do when a reviewer raises the possibility that research data might have been made up?

    These events are surprisingly common—which is why we decided that an ethics committee could help us with our thinking and help make our actions and policies more consistent. So, as Wager explains, a large part of the committee's time has been taken up with considering the individual cases referred to it. Cases of research misconduct have proved the most intractable. In several other types of cases, putting our concerns to authors often results in clarification and resolution; in many cases of potential research misconduct it as often produces stonewalling and legal threats.

    With many of these ethical problems we are operating in what Donald Schon, author of Educating the Reflective Practitioner, called the “swampy lowland where situations are confusing ‘messes’ incapable of technical solution.” Ed Peile invokes Schon in his commentary on the outcome of the current interactive case report (p 500). This case (of abnormal liver function) was unusual in many ways—in its presentation, in the way doctors responded, in its shocking effects on the patient and her family. And Peile's conclusion is that “if we reflect honestly on what we do, and why we do it, we may begin to become more coherent and effective in our clinical practice.” He also highlights the fact that many of the rapid responses showed that there was as much to learn from this case about obstructions in the healthcare system as there was about obstructions in the bile duct.


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