Telling stories and listening to them

There's a genre of writing unique to doctors: the tale of the in flight medical incident, where a request goes out for any doctors to make themselves known to the cabin crew. Usually in these stories the passenger doesn't have anything too serious, and our hero (less often heroine) leaves the plane with thanks (more or less effusive), a complimentary bottle of champagne, and hope of a future upgrade.

A pair of articles in this week's BMJ puts these tales into perspective. In flight medical incidents are common — 1 per 11 000 passengers on British Airways flights, according to Nigel Dowdall (p 1336), though 70% are managed entirely by the cabin crew. Yet Tony Goodwin points out that the overall size of the problem, and the risks involved, aren't properly known because there is no central register (p 1338). The Aerospace Medical Association now plans an international voluntary reporting scheme, and doctors' fears about being sued should be allayed by recent legislation in the United States to protect airlines and doctors in “good Samaritan” situations.

Another increasing problem is that posed by “lifestyle medicines.” David Gilbert and colleagues discuss the issues raised by drugs, such as sildenafil and orlistat, that are used for problems that sit on the boundary between illness and lifestyle (p 1341). Such drugs tend to “medicalise” life, challenge traditional approaches to regulating drugs, and threaten the financial sustainability of current health systems.

Indeed, lifestyle drugs raise acutely the issue of rationing—the subject of a qualitative study by Peter Singer and colleagues. They analyse how committees responsible for advising on new technologies in cancer and cardiac care in Ontario go about the business (p 1316). From this they identified a model, which, like a gemstone, has six facets: institutions, people, process, factors, reasons, and appeals. Each facet may be more or less legitimate and fair but each also contributes to the legitimacy and fairness of the whole. The next step, say the authors, is to “harmonise this description of how groups make priority setting decisions with ethical accounts of how they should make such decisions.” Norman Daniels endorses this approach in his editorial (p 1300). Since people will disagree on the principles that should govern priority setting — not everyone will agree to give priority to the worst off, for example — he argues that we need a fair and legitimate process to develop decisions as we face real cases. He also highlights one finding that should provide an immediate lesson for decision makers—the lay participants on the cancer committee, where there were three of them, felt more effective than the single lay member of the cardiac committee.