Why don’t practices encourage patients to views & REVIEWS enrol on the organ donor register online, asks Des Spence, p 1090 The highs and lows of policy based evidence Personal View David Colquhoun

emember W Bush? For are to offer advice to ministers, “where Leaf him it was simple. If a scientist either the Council consider it expedient storm: told him an inconvenient truth, to do so or they are consulted by the cannabis the messenger was fired, and Minister.” They do not have to wait to be is at the centre of the row over someone more compliant got asked. scientific advice to Rthe job. In every area from global warming Nutt didn’t wait, and he got fired. ministers to the existence of weapons of mass Twitter was ablaze, quickly followed by the destruction he chose to base policy on mainstream media. reason for fantasy and wishful thinking. It seems that This furore arose simply because Nutt including the UK home secretary, Alan Johnson, has said that cannabis was less dangerous than ecstasy with something in common with Bush. When tobacco and alcohol (true) and that more heroin in class A was to make the Advisory Council on the Misuse of people were killed and brain damaged people think that ecstasy was as Drugs (ACMD) said something he didn’t from riding accidents than from ecstasy dangerous as heroin (not true, but like, its chairman, David Nutt, got fired (also true). His Eve Saville lecture, for the precautionary). But it is just as likely (BMJ 2009;339:b4563). Centre for Crime and Justice Studies at that people will conclude that heroin is as In a democracy there is no doubt that King’s College London, seems to have safe as ecstasy. That’s the danger of lying, decisions must be made by politicians. been the immediate problem. There is however good the motives. Sceptical though one may be about nothing in the paper that directly criticises In a sense, we owe Nutt a great debt. politicians, I’m not sure that I’d want the prime minister or the home secretary, His problems have brought to a the to live in a country ruled by scientists. and there is nothing in the rules that says crisis in the relations between science Politicians have wider responsibilities than his academic publications have to be and government. This is only the latest scientists, and they can be voted out if we cleared with the Home Office. case in a long history of politicians basing don’t like the decisions. Why, then, the Don’t worry though, we have a their decisions on ideas that are simply explosion of indignation when Professor democratic system, with an opposition. untrue. That cannot be good for anyone. Nutt got the sack? But the shadow home secretary, Chris The Department of Health has for years In the House of Commons Mr Johnson Grayling, didn’t oppose. On the contrary ignored the evidence about alternative said, “I asked Professor Nutt to resign as he said, “Let me start by reiterating my medicine. It is nothing short of surreal my principal drugs adviser, not because view that the home secretary’s decision on that the House of Commons Science and of the work of the council but because of Friday regarding Professor Nutt’s future Technology Committee is now, in 2009, his failure to recognise that, as chair of was the right one.” holding hearings to assess the evidence ACMD, his role is to advise rather than to Luckily there was a doctor in the House. about whether pills that contain nothing criticise government The Liberal Democrat MP Evan Harris whatsoever can cure diseases. The widely Mr Johnson policy on drugs.” But said, “With every personal attack on David expected change in government is not had it wrong. Mr Johnson had it Nutt, and every piece of cod science likely to help, judging by the support Nutt, unlike, for wrong. Nutt, unlike, [Alan Johnson has] produced, the home given to Mr Johnson by the shadow home example, the for example, the chief secretary deepens the crisis of mistrust secretary. The Tories may not go quite as chief scientific scientific adviser, is not between scientists and the government. far as their MP David Tredinnick, who adviser, is not a a civil servant. He is an The scientific community will not take this asked a parliamentary question about the academic. It is his job lying down—and sources of government need for research into homoeopathic borax civil servant. He to be independent. He advice are likely to dry up.” as a cure for foot and mouth disease. is an academic. is paid nothing for all Harris hit the nail on the head: who on It would be tragic if this sorry affair It is his job to be his hard work on the earth will want to spend years of unpaid were to discourage honest scientists from independent ACMD. He has a day work to produce the best evidence they trying to offer honest advice. I have the job to do as well. It is can and then get abused and fired for their impression that we need a few more his job to criticise whatever he thinks it efforts? Politicians are apt to invoke the doctors in the House. right to criticise. precautionary principle when discussing David Colquhoun is professor of pharmacology, The ACMD was set up by the Misuse illegal drug use, but it isn’t quite as simple University College London [email protected] of Drugs Act 1971[2]. Section 1 of the Act as that. The precautionary principle can Cite this as: BMJ 2009;339:b4564 makes it clear that the duties of the council result in harm to people. Perhaps the See News, p 1047

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review of the week On the concept of trauma

A new book tells the story of how the traumatic victim became culturally respectable, finds Simon Wessely

The Empire of physical state. Fassin and Rechtman point to pose a new law establishing a “presumption Trauma: An Inquiry the “huge difference in society’s attitudes to of good faith,” which would make illegal any into the Condition of ‘trauma neurosis’ in the late nineteenth cen- expression of doubt about the authenticity of Victimhood tury and ‘post traumatic stress disorder’ in the a victim’s testimony in the absence of strong Didier Fassin and late twentieth century,” but, unlike my school contradictory evidence, a direct analogy of the Richard Rechtman pupils, they don’t believe that this is simply due presumption of innocence in criminal trials. Sir (trans Rachel Gomme) to advances in psychiatric diagnostic skills or to John would have failed to understand, let alone Princeton University a more enlightened or compassionate society. endorse, her views, but they are symbolic of Press, 2009, pp 304 Fassin and Rechtman are French, so inevita- the profound change that has occurred in what ISBN bly sentences are long, concepts are complex, it means to be traumatised or to be a victim. 978-0691137537 and Derrida, Foucault, and that old charlatan Having and showing compassion towards £16.95 Lacan make their appearances, but they are those who have suffered is one of the attrac- Rating: **** no intellectual impostors. However, like many tive aspects of human nature, but as Robert French intellectuals they tend to overestimate Hughes argued in Culture of Complaint, elevat- I recently gave a talk at our local school. My the influence of psychoanalysis, in this case ing the status of the victim in our society, let subject: shell shock in the first world war. I on the development of the concepts of shell alone in our legal system, is not without a cost. asked the pupils to name the most famous sol- shock and trauma in the aftermath of the first It is desirable for victims of disaster to com- dier of that war. Some named Wilfred Owen or world war. True, W H R Rivers looked after ment on their experience and for us to consider Siegfried Sassoon (none named or even knew Siegfried Sassoon (albeit briefly), and Freud how we might improve services for them and about the “old boys” of their school whose gave evidence for the defence in the trial of their families. But victims now often become Victoria crosses were honoured on a board in the Viennese neurologist and Nobel laureate involved in questions about how such disasters the hall in which I was speaking). But for them Julius Wagner-Jauregg, accused but acquit- either can or should be prevented. Surviving a the most influential soldier of that conflict was ted of ­brutal treatment of war neurotics. But rail or air crash does not make one an expert neither their own forgotten heroes nor the war ­neither was as influential as historians of on rail or air safety. Furthermore, elevating and poets but a person who never existed: ­Captain ­psychoanalysis or Booker prize winners would occasionally venerating victim status doesn’t . Their views of the first have us believe. The first world war, far from just lead to questionable changes in public world war had been shaped not by ­historians ­revolutionising attitudes to war neurosis, did policy: it may not always have desirable conse- but and . And so almost the opposite and reinforced existing quences for the victims themselves. The risk in when we reached the topic of my talk, the doctrines and prejudices. assuming the role of the victim for a prolonged ­prevailing view was that victims of shell shock A more typical example of the medical period is that the person is in danger of being usually ended up being shot for cowardice. I response to the conflict comes from the career defined, and defining themselves, not by what tried to argue that it was not so simple, but of John Collee. Before the outbreak of war Sir they are and have achieved but solely by what Oh! What a Lovely War and Captain ­Blackadder John was a well known scourge of the new was done to them. were more than a match for my attempt to workers’ compensation acts. From the titles So now psychiatrists, psychologists, and reclaim the Great War for history. of his books—Fraud and its Detection in Accident counsellors have, paradoxically, found them- Of course, much has changed since 1918, Insurance cases (1913) and Malingering and Feign- selves victims of the new politics of trauma. even if we have little to be complacent about ing Sickness (1913)—it is not difficult to guess Just when they had established themselves with when it comes to the contemporary treatment his position. During the war he was appointed the trappings of professional legitimacy (con- of mental breakdown in soldiers or indeed any president of the special medical board set up ferences, journals, accreditation, guidelines, one else. But my audience was wrong in see- to examine soldiers suffering from so called standards, learned societies and the rest) they ing this as a simple journey from ignorance to functional nervous disorders, and after the war face competition and challenges to their exper- enlightenment, because, as Didier Fassin and he became the minister of pensions’ medical tise from the public. Of course, mental health Richard Rechtman elegantly describe in their director. The war had reinforced, rather than professionals never seem far away from either new book, the story is more complex—and changed, his views, as reflected in the conclu- challenge or crisis, which is why the work is so more interesting. The authors, trained in both sions of the 1922 Shell Shock Commission: demanding but also stimulating and never dull. medicine and anthropology, argue that what war neurosis was a problem of character, to be Much the same is true of Empire of Trauma. Like has happened is nothing less than a fundamen- solved by better selection, leadership, training, psychiatry itself, it is not for the faint hearted tal change in what it means to be “traumatised.” morale, and discipline. but is worth it in the end. Look in the index of any standard psychiatric So now let us fast forward to modern day Simon Wessely is director, King’s Centre for Military textbook up to the 1970s and trauma means France. In 2004 Chirac appointed Nicole Health Research, Institute of Psychiatry, King’s College head injury. But nowadays to call a person Guedj as the new minister for the rights of London [email protected] “traumatised” refers to their mental and not victims. One of her first actions was to pro- Cite this as: BMJ 2009;339:b4577

1088 BMJ | 7 NOVEMBER 2009 | Volume 339 VIEWS & REVIEWS review of the week Medical Classics Sound sleep advice De Rerum Natura (The Nature of Things) On the concept of trauma The author Arnold Ben- and schoolmasterish- Lucretius Published circa 50 b c nett was a much loved BETWEEN ness; if to the third, De Rerum Natura is science, including medical science, man, even though Vir- THE LINES into weak gush.” Not in verse. The Roman aristocrat Lucretius (99-55 b c ) was ginia Woolf disparaged Theodore Dalrymple immensely profound, a follower of the Greek philosopher Epicurus of Samos what she thought was perhaps, but true, (341-27 b c ). His narrative poem in six books was an his work’s reactionary often forgotten, and attempt to publicise the Epicurean view of the universe in Rome. The underlying concept is that everything in the realism. When he lay well expressed. world, including human beings, consists of clusters of an dying from typhoid in In “Clothes and infinite number of atoms that move around in an infinite Baker Street in 1931 (it Men” he praises void and in an unpredictable manner. Determinism is not is startling to recall that, smartness and ele- a concept in this philosophy, and neither is immortality. within living memory, gance of dress as These atoms vary in size, density, shape, speed, and people could still die a spiritual achieve- concentration. Ambitious in scope, the comprehensive from typhoid in Baker ment, as a service world view that Lucretius provided seems in some ways Street) straw was strewn not to the self but to modern, in others rather quaint. The aim of the poem was to teach its readers not to fear death, which in Epicurean on the road to lessen others. Of the he philosophy was the main obstacle to tranquillity of mind, the noise of traffic and says: “The fop is not the vital prerequisite for a contented life. thereby ensure his without his use in soci- Lucretius’s and Epicurus’s concept of human beings tranquillity during his Sound sleeping doctors ety. He keeps tailors entails a mind-body division; the senses arise from last days. should take to heart what alert. He may often be different atoms moving through our bodies at varying Coming from a Bennett says: “Sound an ass, but he is also speeds and in varying concentrations. While mind and modest background in an idealist, a searcher body are independently sensate and can become sick sleepers are as odious and can suffer pain independently of each other, they are Staffordshire, he appre- after perfection; and as perfectly healthy born, grow, age, and die together. The mind, made up of ciated the good things persons. Their sympathetic we have none too small, round particles, is located deep within the chest of life that were not to imagination has been many searchers after and forms a “compound nature” with the spirit, which is be taken for granted perfection, and an ass dispersed through the movement of the limbs. in his birthplace. His weakened by nocturnal engaged in that quest The senses and basic human instincts all follow the appreciation was not prosperity” is entitled to some of pattern of the circulating atoms. Smell is vulgar or ostentatious our esteem.” This is caused by streams of particles entering but deeply and sincerely felt: Bennett worth reminding ourselves of, now that the nostrils. Their different shapes affect creatures differently. Vision arises was a thoroughly civilised, tolerant, and we devote so much attention and shop- from images or films that emanate decent man, a character that is by no ping time to buying what will make us from the surface of things. In people means universal in literary circles. look shabby and undignified. with jaundice, seeds of greenish yellow His short essays, of which he wrote a His essay on insomnia repays the short colour streaming out from their bodies prodigious number, are engaging. They time a doctor might spend on it: “This and mingling with their environment are hack work, of course, written purely subject should not be handled lightly, nor cause the patient to see everything for , of which Bennett was above without a kindly regard for the sensibility around them in greenish yellow. averagely fond; but an author’s talent is of the great fellowship of non-sleepers, Another, directly medical theme of the poem is the description of the effects of an epileptic seizure: the often seen to advantage in such work, who as a class appointed to suffer receive victim is “as if struck by lightning” and falls to the ground, and what he knocked off in an hour can far less sympathy than they deserve.” foaming at the mouth, groaning and limbs shuddering, still be read with pleasure and profit 80 Never has the effect of a sleepless night raving, growing rigid, twisting and turning, breathing or 90 years later. Bennett’s qualities as an been better or more succinctly described: irregularly, and tiring out the limbs by thrashing about. essayist, apart from ease and elegance of “The victim of insomnia, having seen the In book 6 Lucretius describes the 5th century b c great style, were genial common sense and a slowness of dawn, arises with every nerve plague of Athens in great (and gory) detail, especially the complete lack of snobbery, intellectual or tattered and the capacity for happiness horrific physical symptoms, which seemed to start in the social, without ever losing a sense of ethi- ruined. His morning is a desolation.” eyes and throat, moving to the chest, and then the mind; patients’ breath was fetid. Mind and body weakened, and cal and aesthetic values (a difficult trick Sound sleeping doctors should (but death approached usually over eight days, accompanied to pull off). mostly won’t) take to heart what Bennett by permanent retching and cramps in the extremities, Here, for example, in “Buying and says: “Sound sleepers are as odious as pain, unquenchable thirst, and disturbed senses. No Reading Books,” is how he divides the perfectly healthy persons. Their sympa- one escaped, whether careless or careful, whether in practice of reading: “I would divide read- thetic imagination has been weakened town or in the country. Habitual burial rites remained ing into three classes—reading for infor- by nocturnal prosperity. They do not unobserved, and each family tried to cremate their own mation, reading for wisdom, reading for understand, and in their arrogance and while the epidemic raged. The book suddenly ends here, but the description is so vivid as to make this sixth book a emotion.” He recommends that we do not self-complacency they do not want to medical classic all by itself. confine ourselves to any one category, understand.” Birte Twisselmann, web editor, bmj.com because “if the reader sticks exclusively Let us not be like that. [email protected] to the first he may tumble into ped- Theodore Dalrymple is a writer and retired doctor Cite this as: BMJ 2009;339:b4562 antry; if to the second, into didacticism Cite this as: BMJ 2009;339:b4523

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It’s better to give

FROM THE For a child, a day meanders; for a teenager, the weeks or are very elderly; neither group are straightforward FRONTLINE roll; in your 20s the months tumble; and after you organ donation candidates. Also, many patients specifi- have children the years whizz by—I recall not a day cally choose to die at home to avoid excessive medical Des Spence of my 30s. We greedily squander time, taking it for intervention—and this runs counter to transplantation. granted. Until the “it’ll never happen to me” inevi- Anyway, how will organs be salvaged in the commu- tably does. Then time is the only valued possession: nity setting? Finally, general practitioners struggle even anything for a few moments more with our loved to discuss where people want to die, so asking, “Oh, ones. I once carried an organ donor card, but it per- and can we have your liver?” seems a non-starter. ished in the part of my wallet full of video shop cards But there seems an obvious solution. Why don’t and business cards from pushy colleagues I had taken practices encourage patients to enrol on the organ only out of politeness. donor register online? Registering takes only about a The UK has a chronic lack of transplant organs, minute, and we could place a computer in the wait- and attempts are being made to increase donation. ing room. At any time of year there will be someone But currently only 60% of relatives agree to requests there, but more so in these darkest of months. Fur- to donate if the patient is not on the organ donation thermore, why not incentivise this activity through register. Proposals for presumed consent schemes have the quality and outcomes framework (QOF), creating faltered, amid resistance and a fear of undermining the one useful outcome in a thousand stupid ones? Then, doctor-patient relationship. So, recently the General if one day our life support machine has to be turned Medical Council floated a new idea: general practi- off, many more of us can offer a stranger that rarest tioners would be required to ask all dying patients of gifts: time. about organ donation. Des Spence is a general practitioner, Glasgow But as the idea drifts by, the guns are coming out. [email protected] Most patients dying at home have metastatic cancer Cite this as: BMJ 2009;339:b4546

An interest in teeth The Bigger Teeth were a major topic here but Maja aimed a lot higher and The years of mentoring were well Picture this week. Our vet let my 12 year succeeded. This June she became worth it for both of us. We respect old son, after persistent maternal the first ever Roma to get a each other. Mary E Black cajoling, sit in on dental surgery Harvard degree. Lots of kids have an interest for our dog. He also showed him I have mentored Maja for some in teeth, but not all will get the puppies on ultrasound and several years, filling in the gaps that come chance to see where that might sick dogs from the shelter. I like from her having no close role lead. For my son nothing is ruled my children to see various career models and limited connections out; he can follow his interests, he options, so they do not blindly with professional networks. I goes to a good school, his family follow the family ant tracks into the introduce her to people, share backs him, he can defer earning a fourth generation of medics. If they opportunities, give feedback on wage. He has a fair shot at success, end up choosing medicine they will her scholarship applications, whatever he chooses. But for have relatives and connections in talk things through. She soaks every child like my son there are most specialties, lining up to test up all suggestions and has cut many, many more children who their resolve, comment on their through the barriers she faced, will not have or who will not see application essays, and give them born outside the club of the much of a choice. They have no the benefit of their experience. educated, the informed, and the professional ant tracks to follow Maja also had an early interest connected. Tomorrow she will or to diverge from. Society is the in teeth, and after completing start her second master’s degree poorer for their exclusion. high school she went on to qualify in health management. What Anyone reading this article has as a dentist. Maja comes from a she offers me is engagement, a skills, contacts, and experience Serbian family with no graduates, good dose of reality and common that could help a marginalised no money, and no connections. sense, and a deep understanding young person succeed. They are Roma, the most of how minority participation and Hippocrates set the ball rolling; I discriminated against minority leadership can develop. These am just enlarging the target. in Europe. Many Roma children days we discuss public health as Mary E Black is a public health physician, get stuck in special education peers, through the different lenses Belgrade, Serbia [email protected] classes or get almost no education, of our ages and backgrounds. Cite this as: BMJ 2009;339:b4526

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