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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Smoking should be mentioned as cause of death on death certificates Louise Robinson, John Spencer, Rosie Stacy, Raj Bhopal. 316:doi 10.1136/bmj.316.7144.1606

It is striking that none of those who would encourage us to
write smoking as a cause of death on death certifacates are
doctors who would ever actually write a death certificate.

Death certificates are given to the relatives of the
deceased. In general practice these relatives are often
also my patients and I would hope that they would continue
to be so for many years. If I ever wrote smoking on a death
certificate they would almost invariably view it as
insulting the deceased, blaming the victim, and my
relationship with them, and anyone they complained about it
to, would be damaged.

A few such certificates and I doubt if I would have any
patients left.

Surely it is also medically dubious. A patient dieing of a
myocardial infarction may well have been an overweight,
heavy drinking, smoker who took no exercise and had a high
cholesterol. Am I to write all these risk factors on the
death certificate?

Yours sincerely

Richard Watson

Competing interests: No competing interests

25 May 1998
Richard Watson
General Practitioner
11 Craigallian Avenue, Glasgow, G72 8DQ
Re: Violence begins at home David Hall, Margaret A Lynch. 316:doi 10.1136/bmj.316.7144.1551

The broad definition of violence, which mirrors the health professional's perspective in the Hall and Lynch editorial, concerns me.

While the Family Law varies between countries, many legal concepts still derive in Australia from the UK experience and the consequences of the work of health professionals are ubiquitous in relation to abuse in the Family, particularly with regard to children via government established child protection agencies.

The consequences of the broad definition of violence can lead to a situation whereby the legal framework is able to institute a death sentence to a family. Because of the institution of the category to either partner in a family of being of "an unacceptable risk".

The documentation of this is ubiquitous and specific instances could be cited, however this topic inhabits an area of forbidden knowledge, because of legal prohibition of details by the Family Court of Australia.

A cautionary alarm should be made to ring each time there is a possible misuse of the term violence, because the health professional is making this easier for their legal counterpart. In making "violence" an all inclusive definition it makes it easier in the legal environment for a single of specific violent behaviour to be smeared the full spectrum. This is not a possible conclusion in a scientific or medical diagnosis based on factual evidence and on frequency of occurence.

The health worker may not be aware of the long term consequences. A family partner, gender non-specific, but predominantly the father, is then denied any right of contact with the children for the "life of the child" but nonetheless still maintains full financial child support. The mutual alienation of the child from its natural parent is thus achieved by a mischievous use of notification of child at risk. The long term psychological effects of denied contact for the parties are subject to adult and community health problems and to the meaning of the term family in a future society.

The above problem is a ubiquitous and counselled legal strategy, albeit only one on many, that is a tragedy that in all likelihood raises the label of "abuser" and "unacceptable risk" in a legal framework of balance of probabilities where unsubstantiated allegations and beliefs are paramount. A final result may be the actual death of a family along with any further specific health problems that ensue for the living ghosts of that dead family.

My comment may be viewed as a cautionary tale for all health workers summarised as an new adage.

Misuse of the term violence risks both the parent and the child being thrown out with the bathwater.

Competing interests: No competing interests

25 May 1998
Robert Cordia
Teacher of Science(Physics)
Faculty of Social Sciences, Sydney Institute of Technology,Ultimo, Australia
Re: Admission for depression among men in Scotland, 1980-95: retrospective study Polash M Shajahan, Jonathan T O Cavanagh. 316:doi 10.1136/bmj.316.7143.1496
I have two comments to make on the paper by Shajahan and Cavanagh regarding the admissions for depression among men in Scotland (1). First, there is no mention of the effect of changes in antidepressant prescribing patterns. SSRIs were introduced part way through their study period and this may have affected admission rates particularly if pattern of change were different between the sexes.

Second, some suggest that events which (a) arise independently of one another in the population; (b) occur randomly in time and (c) are fairly rare events for a individual patient are likely to fit a Poisson distribution. Hence it might be better to use Poisson regression for the analysis (2).

1. Shajahan PM, Cavanagh JTO. Admission for depression among men in Scotland 1980-1995: retrospective study. BMJ 1998; 316; 1496-1498.

2. Moore AT, Roland MO. How much variation in referral rates among general practitioners is due to chance? BMJ 1989;298 [25 Feb.]:500-2.

Competing interests: No competing interests

25 May 1998
Julia Hippisley-Cox
Lecturer in General Practice
Nottingham University
Re: Administration of medicines in school: who is responsible? M J Bannon, E M Ross. 316:doi 10.1136/bmj.316.7144.1591

Bannon and Ross presented a balanced view for the way forward to tackle the uncertainties regarding who is responsible for administering medications to children in school. (1) It is perfectly understandable why most teachers have received little or no training in medical matters. To become qualified teachers, most teachers take the Postgraduate Certificate in Education after their first degree. This usually lasts for only one academic year, during which they have to master educational theories, curriculum planning, lesson preparation, classroom management, assessment methods, as well as being involved in curricular activities. If the ethical arguments of Banatvala and Doyal that medical students should say “no” during their electives (2) are correct, they apply even more to teachers. Jamie’s teachers cannot be expected to recognise the early signs of anaphylaxis and to administer subcutaneous adrenaline. The argument that if parents can learn to give medications safely, so should the teachers is not convincing. It is important to appreciate the volume and variety of tasking facing teachers in their day-to-day work.

However, most teachers are keen to learn about medical disorders. There are about 5 inset days (for in-service training) a year for all teachers, and these would provide a golden opportunity to learn about the commonest childhood disorder (e.g. asthma) and the technique of using inhalers. Educational material (i.e. videos and leaflets) should be produced nationally for all schools, preferably by the Health Education Authority, and local health service professionals should provide practical demonstration and answer any queries raised. For the less common and more complicated medical disorders and treatment, it must depend on the availability of teachers with sufficient knowledge, training or experience in medical matters. The school health services must be prepared to provide sufficient support. The question of legal liability and insurance against compensation must be negotiated with the schools and the teachers unions to reassure the teachers that they would be indemnified against any possible compensation claims against them.

If health professionals wish to convince the teaching professionals of the importance of looking after their medical needs in schools, perhaps the health professionals should consider more carefully the educational needs of children in hospital. Do the health professionals routinely supervise children’s academic work whilst in hospital?

(358 words)


1) Bannon MJ, Ross EM. Administration of medicines in school: who
is responsible? BMJ 1998;316:1591-1593

2) Banatvala N, Doyal L. Knowing when to say "no" on the student
elective BMJ 1998;316:1404-1405

Competing interests: No competing interests

25 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
Re: Women lose legal battle over radiotherapy Clare Dyer. 316:doi 10.1136/bmj.316.7143.1477f
Unless medicine sends a strong and apologetic signal that it learns only by trial and error, using animals and humans, and dispels the belief that it is scientific and can cure any disease, there is no way to prevent or escape litigation. Further, precious court time will be wasted.

The people must know that modern medicine is ignorant and is not even in keeping with the scientific standards of the time.

Competing interests: No competing interests

25 May 1998
Jamal Rahman
Re: Children have feelings too Anne McFadyen. 316:doi 10.1136/bmj.316.7144.1616a

I am pleased that your son's penis now looks beautiful and this cosmetic surgery pleases you. A fully functional penis might please your son more.
There are much kinder and thoughtful ways of caring for a tight foreskin. A change in masturbation technique or a dorsal slit is preferable to cutting off a complex part of the penis. The foreskin is a natural part of the penis, capable of giving owner and lover much pleasure.

The child could not retract his foreskin properly. It is usually the haste to force this issue and to probe around under the foreskin in the name of hygiene that causes the problems.

Competing interests: No competing interests

Re: Children have feelings too Anne McFadyen. 316:doi 10.1136/bmj.316.7144.1616a

There are many instances in which I often reflect on the term "minor" as applied to circumcision. What your son has gone through cannot be described as minor, and it is not an uncommon by any means post operative course. I am convinced that the psychological effects last a lot longer than the physical, which as in your case usually heal with good effect. This is a very forgiving organ, thankfully.

Competing interests: No competing interests

24 May 1998
T Chundrigar
Assistant Professor, Surgery, consultant Surgeon
Jinnah Med. Coll. and Meicare Hospital, Karachi
Re: Smoking should be mentioned as cause of death on death certificates Louise Robinson, John Spencer, Rosie Stacy, Raj Bhopal. 316:doi 10.1136/bmj.316.7144.1606

Robinson et al found the initial increase in recording smoking as a cause of death following a change in regulation in 1992 was not sustained., (1) and suggested further investigations for the underlying reasons.

However, it was clear from the outset that the change in policy was unlikely to achieve the original aims intended - namely, to improve the quality and accuracy of statistics of tobacco related deaths. (2) (3) The main reason is that clinicians are not asked to record their clinical observations (e.g. smoking history), but their epidemiological interpretations. It is difficult to assess the relative contributions of external causes, to apply an epidemiological and statistical association to individual deaths, and to conclude one risk factor as being more important than the others. There is also a danger of drawing epidemiological conclusions from data which are themselves based on widely different epidemiological assumptions held amongst clinicians.

Initially, the BMA hoped that the statistics would focus the attention of the doctors, the public, and the politicians on the issue of tobacco related deaths. However, doctors may not feel sufficiently confident to defend smoking as a cause of death in future litigation. Relatives may interpret the clinician’s action as putting blame on the deceased, and it is doubtful bereavement is the most appropriate time for health promotion. Furthermore, much effort and resources would be required to persuade the clinicians to increase the recording rate from an extremely low level in 1992 to a level acceptable for epidemiological purpose. With the recent publication of the Report of the Scientific Committee on Tobacco and Health by the Department of Health, it is doubtful whether the death certification process would be the best way to focus the politician’s attention on the issue. The inclusion of smoking as a cause of death is unlikely to affect the outcome of compensation claims against tobacco companies, as the patients’ medical history of the patients will be fully reviewed by expert witnesses in the event of such litigation.

There are fundamental problems on the quality of death certificate data. One study found that doctors frequently fail to record accurate basic relevant details such as the sites of tumours or the causes for renal failure. (4) Another study found poor concordance between the causes of death recorded on the death certificates and the corresponding autopsy reports. (5) Our efforts should be targeted on these more urgent issues.

(394 words)


1) Robinson L, Spencer J, Stacy R, Bhopal R. Smoking should be mentioned as cause of death on death certificates. BMJ 1998;316:1606 ( 23 May )

2) Peto R, Doll R. Smoking accepted on death certificates. BMJ 1992; 305: 829-830.

3) James DS, Leadbeatter S, Knight B. Smoking accepted on death certificates. BMJ 1992; 305: 830.

4) James DS, Bull AD. Information on death certificates: cause for concern? Journal of Clinical Pathology 1996; 49(3):213-6.

5) Doyle YG, Harrison M, O’Malley F. A study of selected death certificates from three Dublin teaching hospitals. Journal of Public Health Medicine 1990; 12(2): 118-23.

Competing interests: No competing interests

24 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
Re: Effectiveness of treatments for infantile colic: systematic review W J van Geldrop, A Knuistingh Neven, et al. 316:doi 10.1136/bmj.316.7144.1563
Where are the breastfeeding babies?
Q. Who paid for this study?
A. Formula manufacturers?

Breastfeeding, the forgotten art, the forgotten gold brand of milk, the best way to feed a human baby. Huge health benefits for baby which continue all through life, huge health benefits to woman who breastfeeds her children. We forget this at our peril. We continue to sacrifice breastfeeding on the altar of ignorance. So sad, so sad.

Competing interests: No competing interests

24 May 1998
Helen M Woodman
Breastfeeding Counsellor
From home
Re: Violence begins at home David Hall, Margaret A Lynch. 316:doi 10.1136/bmj.316.7144.1551

Hall and Lynch`s editorial concerning violence in the home is an important reminder of the seriousness of this problem and it`s impact on health.

However, to discuss the effects of repeated violence on "adult" victims in this context is misleading. Domestic violence ( usually broadly defined as abuse of a partner or ex-partner ) is not a gender neutral issue. Most victims of domestic violence are women, who experience abuse from male partners or ex-partners, which increases in frequency and severity over time. (1,2). It is women ( and not men) who endure the psychological, social and physical consequences of domestic violence while trying to care for their children as best they can. Similarly, children witnessing domestic violence are injured trying to protect their mother and not a "parent".

1. Mirrlees-Black C, Mayhew P, Percy A. The 1996 British Crime Survey. Home Office Statistical Bulletin 1996;19

2. Alpert EJ. Violence in intimate relationships and the practicing internist. New "disease" or new agenda? Ann Int Med1995;123:774-781

Competing interests: No competing interests

24 May 1998
Jo Richardson
General practitioner/research fellow
East London/Department of General Practice, St Bartholomew`s and the Royal London (not enough space)