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The Art of Medicine

Winston Churchill and the Spirochaetes

29 May, 13 | by Iain Brassington

Did you hear the programme about syphilis on Radio 3 on Sunday?  If not, you can catch up on it here – and I’d thoroughly recommend doing so: it was superb.

One bit in particular caught my attention; it had to do with the use of penicillin to treat the illness during World War II.  (It’s from about 38:40 on the iplayer version.)  Astonishingly, in 1942, more men were out of action in North Africa because of syphilis than because of battlefield wounds.  Obviously, penicillin would be of immense help to both groups; but the problem was that there was not enough of the drug to meet both demands.  Giving it to the wounded obviously had some moral gravity… but so did giving it to the syphilitic: after all, they’d be cured and battle-ready very quickly, whereas the wounded might never be battle-ready again.

You can doubtless see why this might be problematic: more…

Is the NIMH Turning its Back on DSM-V?

9 May, 13 | by Iain Brassington

Thanks to Brian Earp for bringing this release from the US’ National Institute of Mental Health to my attention; it concerns the Institute’s decision to move away from DSM as its diagnostic tool.  DSM has been enormously successful – in terms of having established itself at the centre of psychiatry – but it has been enormously controversial, as well; the NIMH moving away from it is very big news indeed.  Whether the new model that they’re going to be working on will be any better, of course, remains to be seen.

The important bit seems to be this:

NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

One or two things about the statement leap out at me. more…

Conference: Compassion Fatigue: Changing Culture in the NHS

18 Apr, 13 | by Iain Brassington

26-28 June, Woodbrooke Quaker Study Centre, Birmingham

(via Andrew Edgar)

Can the language of compassion capture the moral problems confronted by the NHS, or might it obfuscate and distract us from more subtle and demanding issues?

Through a series of plenary addresses, workshops, panels and shared opportunities for discussion, “Compassion Fatigue” will provide an opportunity to explore the language of compassion, and the impact that it has on the practice of health care provision.

More details below the fold. more…

Gay Conversion “Therapy”: Might the CMF have a point?

5 Feb, 13 | by Iain Brassington

Spoiler alert: Almost certainly not.  But hear me out for a bit.

The Christian Medical Fellowship blog had an article posted yesterday about what it praised as a balanced documentary concerning “sexual orientation change efforts” – gay conversion therapy to you and me – on Radio 4 on Sunday.  Actually, it wasn’t a documentary – it was a short article on Sunday, the station’s religious-affairs-quota-filling hour (go to about 30:50 here), and it’s no more a documentary than is the sports bulletin – and the balance is “BBC balance”, which means giving equal airtime to the fireman and the fire.  But anyway, that’s not what struck me.

Neither am I particularly bothered for the sake of this post about whether or not psychotherapy can make any difference to sexual orientation.  I’ll simply allow, for the sake of the argument, that it can at the very least make a difference to sexual behaviour, and maybe to orientation tout court.

What struck me was a couple of things that Peter Saunders says on his CMF blog post about the use of such “therapies”.  One of the striking things was this: more…


23 Oct, 12 | by Iain Brassington

Seriously!  Theoretical Medicine and Bioethics has published a paper with a hundred and ninety-eight listed authors!

I’ve always been slightly puzzled by multi-authored papers – by just how many people get to add their names to a piece of work.  A friend of mine who is a proper scientist once tried to explain how it works in the sciences to me – about how you need to give credit to the people who ran the experiment, but also to those who did the titration and general donkey-work.  That seems fair enough.  Having said that, I suspect that there’s often a bunch of people who get credits that shouldn’t be there.  (I remember once seeing a CV from a guy that had 45 pages’ worth of publications listed.  Granted, it was double-spaced… but, still: there must have been the thick end of a thousand papers listed; there’s no way on God’s good Earth that he could have played a significant role in all of them.  So why was he entitled to claim them?  Why did he take the credit?  Apparently, it was because, although not all of the papers referred to work he’d done, they did all refer to work done by other people in a lab he ran.)  Anyway… the Steinhauser et al ad infinitum paper, with its 198 authors, isn’t lab-based, so the credit-where-it’s-due argument wouldn’t work.

(Jozsef Kovacs, writing in a paper currently available as a pre-pub in the JME, is also concerned about authorial inflation, and who should get the credit for a given paper, and how to improve things.  It’s definitely worth a look.)

The author list for the Steinhauser paper seems to have been generated at least in part via the membership of a Facebook group (and one that no longer exists, or at least one that is so private that it doesn’t show up on a search).  That’s just silly, and there’s no way that anyone can successfully marshall so many contributors.  That turns a paper into an open letter.  Indeed: the “authors” seem to think that their paper could be treated as such without loss: more…

Modesty, Conscience, and What it Takes to be a Doctor (with a bit of Comedy)

19 Oct, 12 | by Iain Brassington

Two apparently unrelated new and new-ish papers in the JME have caught my eye over the last few days.  One of them is this one: Salilah Saidun’s “Photographing Human Subjects in Biomedical Disciplines: An Islamic Perspective”.  We’ll come to the other in a little while.

There’s a couple of puzzling things about the paper.  One is that I’m not sure what the tone is supposed to be.

It could be a descriptive piece, along the lines of “Look, here’s what Muslims might think about medical photography, and if you’re going to take or use medical photographs, you might want to keep it in mind.”  Of course, it’s by no means certain that all Muslims think alike, or that if (mirabile dictu) they do, it has anything much to do with Islam – but we’ll put that to one side.  Similarly, the fact that some people do think this won’t tell us much about what practical implications there ought to be, beyond keeping it in mind.  It won’t tell us that we ought to adhere to those opinions.  Islamic rules might provide a reason to behave in a certain way; but there might be other reasons to behave in a certain other way – and they might sometimes be more compelling.  I’ll put that to one side, too, though.  As a descriptive paper, it might very well be the sort of thing that’s useful on the wards.

But a descriptive reading won’t explain the passages that appear to have a more normative dimension: more…

William Mager is having a Cochlear Implant.

9 Oct, 12 | by Iain Brassington

And he’s going to blog about the experience.

On Tuesday 6th November at around 7.30am I’ll be in a hospital room while a surgeon uses a marker pen to draw a line behind my ear. Soon after that, I’ll be wheeled into an operating theatre where they’ll make a small incision behind my ear, following the line of marker pen ink.

Once they’ve opened a flap of skin behind my ear, they’re going to drill into my skull, until they reach my inner ear. They’ll then hollow out a small cavity in the flesh beneath the ear flap, where they will insert a piece of technology worth about £10,000. Into the hole in my skull goes a tiny electrode extending all the way into my inner ear, with around 20 or more individual contacts stimulating my cochlear. Hopefully the general anaesthetic will do its job and I won’t feel any of this while it’s happening, because I’ve seen pictures of this procedure and it looks pretty painful.


When I’m switched on six weeks after the operation, I have no idea what will happen. Either I’ll feel a faint buzzing in my skull, or hear consonants for the first time. Either way, the hard work starts after that.


He’s a film-maker in real life: so while you’re waiting for the next post, have a look at some of his films.  This one takes only a couple of minutes to show how there’s really very little that deaf people can’t do… er… so long as the… um… support is… as long as…  Yeah.  Watch it, anyway.

But what if you Don’t Want to be Regulated?

2 Oct, 12 | by Iain Brassington

The Malaysian Parliament has just approved a law about traditional medicine.  The Traditional and Complementary Medicine Act is largely about the regulation of practitioners of TCM – notably, setting up a regulatory Council.  According to section II (5)

The Council shall have the following functions:

(a) to advise the Minister on matters of national policy relating to traditional and complementary medicine practice;

(b) to establish the eligibility requirements for each practice area;

(c) to recognize qualifications conferred by any institutions of higher learning established under any written law in Malaysia or any institutions of higher learning recognized and authorized by any countries outside Malaysia for the purpose of registration under this Act;

(d) to specify the appropriate academic qualifications or recognized skills certificate issued pursuant to the National Skills Development Act 2006 [Act 652] which are or is necessary before a person may apply to be a registered practitioner;

(e) to specify the necessary apprenticeship and training requirements including rules for undergoing apprenticeship, the scope of responsibilities and permitted conduct or activities of apprenticeship, duration of apprenticeship and post-qualification apprenticeship;

(f) to register individuals who will provide traditional and complementary medicine services to the public;

(g) to issue practising certificates to registered practitioners who have satisfied the prescribed conditions and paid the prescribed fees;

(h) to develop codes of professional conduct, rules relating to the professional conduct of registered practitioners, including penalties for breach of such codes or rules;

(i) to develop, undertake, prescribe and mandate any matter relating to or connected with the practice of traditional and complementary medicine or the professionalism of such practice;

(j) to specify, provide for and administer a complaints procedure and process;

(k) to develop rules upon which registered practitioners are to refer their patients to medical practitioners or dental practitioners, as the case may be;

(l) to obtain such relevant information from practitioners, and to provide the same to the Minister;

(m) to carry out such functions as may be specified by this Act; and

(n) to carry out all such other activities as may be directed by the Minister and such direction shall be consistent with the purposes of this Act.

Section IV (21) says that

(1) No person shall practise in any practice area which is not a recognized practice area.

(2) Any person who contravenes subsection (1) commits an offence and shall, on conviction, be liable—

(a) in respect of a first offence, to a fine not exceeding thirty thousand ringgit [approx £6000] or to imprisonment for a term not exceeding two years or to both; and

(b) in respect of a subsequent offence, to a fine not exceeding fifty thousand ringgit [£10 000, or thereabouts] or to imprisonment for a term not exceeding three years or to both.

Is this a good law?  Clearly, it is not a particularly exciting piece of legislation; and there might be problems with it – there’re problems with a lot of laws. more…

Is Bioethics Really a Bully? Really?

11 Sep, 12 | by Iain Brassington

On his blog in The Independent, John Rentoul has a long-running feature called “Questions to which the Answer is No“.  In it, he examines the kind of screaming rhetorical-question headline much beloved of certain middle-market tabloids: “Is this photographic evidence of Nessie?”, “Does coffee cure cancer?”, “Does coffee cause cancer?”, “Does MMR bring down house prices?“* and so on.

Here’s the first in an intermittent parallel series from me: “Questions to which the Answer is Eh?  What are you on about?  No, really: what?“.  For the inaugural post, step forward Dan Sokol, the BMJ”s “ethics man”, who asks in his latest column, “Is Bioethics a Bully?”.  The answer to this is Eh?  What are you on about?  No, really: what?.

(A warning before I start: I’m about to go off on one.  Even by my standards, this is big.  You might want to go and make tea.)

The general thesis of the article is this:

Bioethics, in its current form, has bullying tendencies. Ironically, it often adopts a paternalistic attitude towards clinicians, treating them as an ethically deficient species.  Although bioethics should not shy away from pointing out ethical concerns in medical practice, sometimes forcefully, it must not give way to negativism or, worse still, to a zeal to condemn.  Clinicians are easy targets and, without a command of the fancy theories and language of the accusers, possess few means to respond formally.

Is the thesis true? more…

More on Circumcision in Germany

17 Jul, 12 | by Iain Brassington

Søren Holm sometimes jokes that, if you want your conference well-attended, you should have a paper on the ethics of circumcision.  I don’t know how well-attended the recent IAB satellite on the topic was – the first half clashed with Peter Singer doing his thing, which can’t have helped it, and I couldn’t go to the second because I was giving a paper of my own.

Anyway: though I mentioned the decision of the German court that ritual circumcision constituted assault, I’ve wanted to stay clear of saying more about it.  Partly it’s because I’ve been busy; but there’s another reason: it seemed too potentially toxic.  For example, Jonanthan Sacks’ column about the decision in the Jerusalem Post noted that many attempts to ban circumcision have been motivated by antisemitism; the not-so-subtly made claim is that there’s an undercurrent of antisemitism here.  (An appeal to human rights is, he claims “is the only form in which an assault on Jews can be stated today”.)  Of course, that won’t show that such attempts have to be motivated by antisemitism, or that thinking the court’s decision correct is an indication of latent antisemitism: they don’t, and it isn’t.  Even if it’s true that the only way to launch an assault on Jews is to use the language of human rights, it doesn’t follow that every human-rights claim is an assault on Jews – even when it touches on something that is associated with Judaism.  I didn’t want to open myself to an accusation of antisemitism, so thought it best to keep quiet.

But the debate is rumbling on (it was featured on the Today programme today, for example); and one of the notable things is the poor quality of most of the arguments brought against the decision.  This doesn’t in itself mean that the decision is correct – poor arguments might accidentally bring you to the correct answer – but if the general direction of the poor arguments is the same, and there haven’t been many decent arguments produced that go the same way, then that does raise questions about the conclusion in which they’re headed.  Having said that, there has been one better argument against the decision that I’ve come across; I’ll come to that later.  It’s some of the poor arguments, rather than the position in the service of which they’re advanced, that I have in my sights here. more…

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