Intended for healthcare professionals

Rapid response to:


Surgeon acquitted of carrying out female genital mutilation in a prosecution criticised by obstetricians

BMJ 2015; 350 doi: (Published 05 February 2015) Cite this as: BMJ 2015;350:h703

Rapid Response:

Re: Surgeon acquitted of carrying out female genital mutilation in a prosecution criticised by obstetricians

In March of 2014 I welcomed Dr Dhanuson Dharmasena into my basic science laboratory so that he could fulfil his aspiration to do research whilst awaiting trial. My enquiries had confirmed his innocence. During this year we have benefitted from the contributions of this intelligent, honourable, honest, thoroughly decent man. Dr Dharmasena was supported scrupulously by the MPS with the solicitors Radcliffes Le Brasseur and defended by a remarkable woman, Zoe Johnson QC. The prosecuting barrister Kate Bex QC, is to be admired, as she did a searching, forensic job. There is no scope for cynicism:- This doctor was innocent.

In 2012 Dr Dharmasena was confronted with an emergency outside of his experience and acted with professional care. He then discussed the matter with his consultant, they took responsibility for a professional decision and there the matter should have rested. This did not happen.

We do not know what subsequent procedures were enacted or by whom. We all know the outcome: Dr Dharmasena and a relative of the mother were reported to the police for an imagined offense. I do know that the Trust was worrying about accountability to other organisations.

I am a fan of accountability, particularly to my patients and their GPs. I am more enthusiastic about responsibility. Robert Gregory has written a lucid paper [1] which discusses accountability as used by the New Public Management (NPM) movement in order to assert control over the professions. These were considered malign by NPM ideologists. Accountability is not the same as responsibility and, when thus confused, harm can result. Elsewhere [2], Gregory quotes the phrase “careful incompetence” in this context. NPM has been discredited. Clinically productive doctors must take responsibility and this requires them to be trusted. Professionalism should nourish this trust. NPM sabotaged that trust, censuring conscientious clinicians for imagined misconduct. There are examples of dreadful behaviour by a few doctors and nurses. However, obsessive control suffocates and the sick will pay a heavy price.

I gave evidence at the trial as a testimonial witness. However, Kate Bex had some shrewd questions. I faced the proposition that non-compliance with a trust clinical guideline should be part of a criminal case. Regrettably, it took little intellectual effort to muster a substantial body of scientific evidence to trash clinical guidelines in defence of Dr Dharmasena. A limited number of guidelines should be welcome. However, they are fickle and their current plethora is ludicrous [3]. They abound because they have been co-opted as instruments of authority’s control. Using guidelines for punitive purposes is delinquent. Where are the probability analyses of their applicability? What are their adverse effects? What about the exceptions? A conservative estimate, based on Pareto distributions, implies that the needs of 1 in 5 target patients will not be covered. Are we cruel to patients presenting as exceptions? Over-enthusiasm has draped the important, valuable innovation of clinical guidelines in emperor’s clothes. Are we to criminalise those who see through them?

A woman gives birth to her first child. Her relative asks questions motivated by concerns for her. A junior doctor does his level best. The relative and doctor are arraigned for a serious criminal offence and the mother endures a barbaric invasion of her privacy. We should be ashamed. These deplorable events reflect our failure of courage. We have not defended sufficiently the right of the sick to professional care.

The jury took less than 25 minutes to dismiss this case. Was this withering snub a purposeful signal of contempt? If so it was richly deserved.

1. Gregory, R.J., The challenging quest for governmental accountability in New Zealand. Adminstratioin, 2012. 60(2): p. 109 -118.
2. Gregory, R., Political responsibility for bureaucratic incompetence; Tragedy at Cave Creek. Public Administration, 1998. 76: p. 519 - 538.
3. Greenhalgh, T., et al., Evidence based medicine: a movement in crisis? BMJ, 2014. 348: p. g3725.

Competing interests: No competing interests

12 February 2015
James Malone-Lee
Professor of Medicine
University College London Medical School
Hornsey Central Neighbourhood Health Centre, 151 Park Road, London, N8 8JD