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Malignant mesothelioma — the rising epidemic

ence to male authority" seemsto be irrelevant causally in a case where no attempt has been made to inform patients that they are part of an experiment in which all forms of treatment will be withheld. In the end, we have concluded that it will always be difficult to provide adequate safeguards against a whole hospital contracting what we have termed the "Jonestown" syndrome. This appears to have happened recently in the psychiatric section at Townsville's General Hospital, it happened at Chelmsford Hospital in Sydney, and it will happen again if hospitals abnegate their collective responsibility. Fortunately, this is a rare event. As McNeill points out, given the greater sophistication of institutional ethics committees, it is now less likely that a protocol of the Green variety would pass muster. One of Judge Cartwright's recommendations is a plea to improve the teaching of medical ethics in the undergraduate curriculum. This we endorse wholeheartedly. One of us (P.G.) surveyed the content of the ethics courses of all Australasian medical schools in 1987. The picture that emerged ranged from the sublime (the medical schools in Otago and Newcastle)to the perfunctory (those in Western Australia and Queensland), not counting the medical schools of The Flinders University of South Australia and The University of Adelaide, which did not bother to reply. Both the Otago and Newcastle medical schools have recognized that the teaching and discussion of ethical problems in medicine are multidisciplinary and must be integrated into all facets of the curriculum in order: to alert students to the central position of moral issues in decision-making; to acquaint them with the ratiocination that is used in ethical discourse; to uncover and critically to examine the assumptions upon which moral judgements are based; to help students to understand their own value systems and thereby to assist them in identifying and exploring the ethical problems that they encounter; and to provide an introduction to the understanding of ethical theories in historical as well as contemporary terms. We consider it essential that students must learn to question any perceiveddeparture from traditional values in the practice of contemporary medicine and to treat with caution the assumption that all technological advances in medicine necessarily are good and must be pursued vigorously. It is heartening to learn that the medical schools at Otago and Newcastle already are employing suitablyqualified academics in medical law and ethics to provide the teaching that is necessary to present the bases of the behavioural sciences of philosophy, psychology, sociology, law and economics. The conclusion to be drawn from the Auckland experience is the need to have each and every protocol vetted initially by a scientific subcommittee which consists of experts in the relevant field. If a protocol passes rigorous scientific scrutiny, it then is up to the ethics committee to ensure that the protocol conforms to ethical norms and has a suitably-worded consent form which will be explained, in simple language, in circumstances where patients have a free choice and know that a refusal will not affect their treatment. The ethics committee also must retain a degree of supervision and overview over the trial as it progresses and act promptly on any complaint. Nevertheless, such rigorous supervision of a trial by scientific and ethics committees may not provide the panacea. While guarding against the excesses of Auckland, zealots still will have an unfair advantage. Furthermore, the untoward results of an intense pursuit of informed consent only now are beginning to become evident in their effects on medical practice. We fear that the vocal proponents of "patient autonomy" and "total disclosure" will, if successful, create a climate of fear in doctors and patients; both will be reluctant to pursue a treatment regimen which carries a small risk of serious consequences the former from a fear of being sued, the latter simply from fear. It may well be that, in the long run, the lawyers and academics who decry "paternalism" may do more harm than do clinicians who know their patients and make a considered value judgement. One may question whether, after Auckland, anything less than "fully-informed consent" (whatever that may mean) has, as has "clinical freedom", died after being "crushed accidentally". On the positive side, it must be said that Green has shed much light on our understanding of the natural history of the development of cervical cancer. Above all, he and a few others in the 1960scaused many gynaecologists to rethink the need for mandatory hysterectomies and even conization procedures. Now, less than a generation later, most women with carcinoma-in-situ are treated by laser, diathermy or cryosurgery as office procedures. As one of us (M.C.) submitted to the Inquiry (transcript of evidence, Cervical Cancer Inquiry): In retrospect I feel we aremuchthewiser professionally for theexistence of the results of the trial obtained at such a calamitous expense. On a world scale, many thousands of women already have been spared the morbidity associated with hysterectomy. The price that wemust pay for steps on the ladder of experience is, in thisinstance as it hasbeenthroughout history, a matterfor protracted philosophical debate and soul-searching.