We select the letters for these pages from the rapid responses posted on bmj.com favouring those received within five days of publication of the article to which they letters refer. Letters are thus an early selection of rapid responses on a particular topic. Readers should consult the website for the full list of responses and any authors’ replies, which usually arrive after our selection.

informed consent, this would require more Is prognosis key in donation? resources. The information could be available on Potts (previous letter) highlights an often the NHS spine, although I share concerns misunderstood aspect of organ donation: about awareness of contraindications to that death is not always what it seems, donation. especially to relatives.1 However, I wonder Anne Holmes general practitioner whether his concerns are predominantly Tithebarn Medical Centre, Stockton on Tees TS19 8RH motivated by theological considerations? [email protected]

photos.com Competing interests: None declared. I suspect the key word is prognosis, as Presumed consent accepted by a wide consensus of peers. 1 English V. Is presumed consent the answer to organ The heart may still be beating, but if the shortages? Yes. BMJ 2007;334:1088. (26 May.) First address informed consent prognosis is bleak why not let someone else in organ donation have a chance of a longer life? Richard Bartley physiotherapist Cosmetic genitoplasty English’s arguments in favour of presumed Denbigh Infirmary, Denbigh, Clwyd LL16 3ES consent for organ donation ignore serious [email protected] Surgical solution is becoming Competing interests: None declared. problems with the current system of organ acceptable, as for birth transplantation.1 People who sign organ 1 English V. Is presumed consent the answer to organ donation cards claiming that they will be shortages? Yes. BMJ 2007;334:1088. (26 May.) Liao and Creighton refer to idiosyncratic donating organs “after my death” may not decisions about cosmetic genitoplasty in the realise that organ donors declared dead by absence of local and national guidelines.1 brain based criteria are not dead in the usual Tell public about brain death Having worked as a clinical psychologist sense. Their hearts are beating, their bodies in women’s health for several years, I are warm, and they do not seem to be dead. Until fairly recently, the definition of death have seen patients at various stages on the Family members may be understandably was cardiopulmonary death, not brain labial surgery pathway, and the reasons for reluctant to sign a form authorising what death.1 There is a vast suspicion that doctors referral to me have been varied. they believe to be the killing of their loved will take organs from those who are not Some women have had labial surgery and one by removal of vital organs. “really dead”—this suspicion will seem to request further interventions, thus causing In addition, there has been widespread be confirmed if the heart is still beating and concern to their surgeons. Satisfaction questioning of both the philosophical and there seems to be undue haste to harvest the with surgery has been professed, but it scientific viability of brain death criteria.2 3 organs. has not changed how they feel about their Such questioning of brain death criteria The public needs to be educated on what bodies. These women are faced either with by reputable physicians and philosophers “brain dead” means, the difference between the prospect of more surgery or the stark should not be taken lightly and shows that brain death and a coma, the need for reality that such a solution may not offer presumed consent for a practice that may speed in removal of the organs, and, most everything they had hoped. Other referrals involve doctors killing patients is premature. importantly, the criteria that must be met are to “cover all bases,” check that the Finally, before any notion of presumed to confirm that someone is indeed “dead” patient is in “sound mind,” and rarely can consent can be considered, the issue of before organs will be removed. a serious psychiatric diagnosis be invoked. adequate informed consent to organ Joan McClusky medical writer Unfortunately, some of these patients have donation must be addressed. Without New York, NY 10003, USA [email protected] already been given a date for their surgery adequate informed consent, the current Competing interests: None declared. and think that it can proceed unless the system of voluntary consent for organ 1 English V. Is presumed consent the answer to organ psychologist says otherwise. Thus they are donation is problematic. Any system of shortages? Yes. BMJ 2007;334:1088. (26 May.) unlikely to embrace a psychological rather presumed consent is also problematic. than a surgical solution. Michael Potts professor of philosophy My surgical colleagues seem to be Methodist University, Fayettville, NC 28311-1498, USA Add carrying a card to QOF reluctant to provide such interventions, [email protected] but they respond to psychological distress Competing interests: None declared. Why not make possession of a donor card and can be disempowered by the general 1 English V. Is presumed consent the answer to organ a QOF (quality and outcomes framework) rhetoric of “patient choice.” Surgical shortages? Yes. BMJ 2007;334:1088. (26 May.) 1 2 Potts M, Byrne PA, Nilges RG, eds. Beyond brain death: target? solutions for various concerns about the the case against brain-based criteria for human death. A question about possession of a donor body may be what patients seem to want, Dordrecht: Kluwer, 2000. 3 De Mattei R, ed. Finis vitae: is brain death still life? card is fairly simple but if the practice was but increasing the availability of surgery can Rome: Consiglio Nazionale delle Richerche, 2006. required to discuss donation, and obtain inhibit the visibility of other choices.

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Some clinicians may believe that labial therefore a lesson in the need to construct a MTAS surgery is on the fringes of obstetrics and useful intervention before setting out to test gynaecology. But history repeats itself. it. It is also reminds us of the need to learn Lessons from the disaster We have all seen the rise in caesarean Osler’s century old lesson “Listen to the section rates in the United Kingdom. patient, he’s telling you the diagnosis.” Some lessons must be swiftly learnt from This is reported to have happened Duncan R Petty lecturer practitioner the Medical Training Application Service because of concerns about litigation, but Arnold Zermansky (MTAS) experience.1 The BMA and the another process may be in operation—the University of Leeds, Leeds LS2 9UT [email protected] Academy of Medical Royal Colleges have Competing interests: None declared. sanitisation of a surgical solution to giving been made to look feeble and ineffectual birth. This comes from the widespread 1 Salter C, Holland R, Harvey R, Henwood K. “I haven’t after entering into “partnership” roles with even phoned my doctor yet.” The advice giving role of availability of a surgical solution. Do we not the pharmacist during consultations for medication the Department of Health. The postgraduate already have a snapshot of how things will review with patients aged 80 or more: qualitative deans have been notably silent and have discourse analysis. BMJ 2007;334:1101-4. (26 May.) develop if we do not debate this issue now? 2 Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, behaved as willing accomplices in the Competing interests: None declared. Lipp A, et al. Does home based medication review keep promotion of MTAS. The deaneries have Jacqueline Doyle clinical psychologist, Department of older people out of hospital? The HOMER randomised declined as an independent force in medical controlled trial. BMJ 2005;330:293. Clinical Psychology, Hillingdon Hospital, Uxbridge, Middlesex training and are struggling to fulfil their UB8 3NN [email protected] correct role in providing quality educational 1 Liao LM, Creighton SM. Requests for cosmetic leadership because of over-dependence on genitoplasty: how should healthcare providers respond? Anaemia in developing countries BMJ 2007;334:1090-2. (26 May.) political approval linked to their funding Mass iron treatment is cheaper mechanism. The reputation of UK medical than routine deworming training has taken a damaging hit. Pharmacists in primary care The royal colleges, threatened by loss Gulani et al say that routine administration of power and influence and undermined Study shows wrong people, of intestinal anthelmintic agents results by the emergence of the Postgraduate wrong skills, wrong tools . . . in a marginal increase in haemoglobin Medical Education and Training Board (1.71 g/l).1 What needs to be considered is (PMETB), seem to have been all too easily Salter et al identify some deficiencies in a whether this approach of mass anthelmintic lured into partnership agreements, using small sample of pharmacist consultations.1 therapy is actually economically feasible, a set of desirable motherhood and apple Their results say more about the need for especially in third world countries where pie objectives that were seductively easy consultation skills training and the context iron deficiency anaemia is a major health to sign up to. The trap was then sprung of the pharmacists and patients involved in issue.2 This needs special consideration, and the poorly drafted and unworkable this study than they do about the concept of given the fact that the primary cause operational details released deliberately pharmacist medication review. of anaemia in third world countries is late in the process. The timetable of the The pharmacists involved in this study dietary malnutrition rather than intestinal action plan became a higher priority than were the wrong people because they infestation with helminths.3 the quality of the project itself. Website had no connection with the patient, the A better and more economically feasible design and selection procedures were general practitioner, the local pharmacy, approach to thwart the “epidemic” of unfinished, and consultation on details or the hospital department and therefore anaemia might be mass supplementation was token or non-existent. Bullying tactics lacked credibility. They had the wrong with iron supplements such as oral ferrous created an unstoppable momentum for skills because they scrupulously avoided sulphate.4 The average cost of mebendazole MTAS implementation, regardless of the exploring patients’ ideas and beliefs and treatment (100 mg three times a day for obvious problems piling up and the well persisted in a predetermined agenda that three days) is £15. According to Gulani et based objections of a majority of consultants. patients did not identify with. They had al, this regimen increases haemoglobin by The colleges are protesting that they have the wrong tools because they did not have 1.7 g/l. On the other hand, ferrous sulphate been misrepresented, although manipulated the medical records or any indication for at a dose of 325 mg three times a day will would be more accurate with junior doctors the medicines. They were doing the wrong increase haemoglobin by the same amount feeling disconnected and unsupported until job because people who have just had their in about two weeks and cost £1. it was too late. The government, anxious to medicines reviewed are not likely to benefit Shailendra Kapoor resident physician displace blame elsewhere, insists they were from a further review. And the timing was University of Illinois at Chicago, Chicago, Schaumburg, fully on board. wrong because older people just discharged IL, 60195, USA [email protected] These “partnership” arrangements Competing interests: None declared. from the turmoil of hospital need some have become a damaging form of pseudo time to settle and reflect before someone 1 Gulani A, Nagpal J, Osmond C, Sachdev HP. Effect collaboration. The end result has been a of administration of intestinal anthelmintic drugs intervenes again. on haemoglobin: systematic review of randomised major system crash between the Department This study says little about pharmacists’ controlled trials. BMJ 2007;334:1095-7. (26 May.) of Health and the profession, which is now 2 Cook JD, Reusser ME. Iron fortification: an update. Am J ability to conduct medication reviews. The Clin Nutr 1983;38:648-59. much deeper than the single catastrophe of HOMER study was not a realistic model 3 Tatala S, Svanberg U, Mduma B. Low dietary iron MTAS. for pharmacist medication review.2 The availability is a major cause of anemia: a nutrition John J Turner consultant physician, University Hospital survey in the Lindi District of Tanzania. Am J Clin Nutr Aintree, Liverpool L9 7AL [email protected] discharge note must be reviewed in context 1998;68:171-8. Competing interests: JJT is a consultant and educational of the clinical record and in discussion 4 Mitra AK, Akramuzzaman SM, Fuchs GJ, Rahman MM, Mahalanabis D. Long-term oral supplementation supervisor. with the general practitioner. Only then with iron is not harmful for young children in a poor 1 Godlee F. The future of specialist training. BMJ should the patient be visited. Their paper is community of Bangladesh. J Nutr 1997;127:1451-5. 2007;334:1067-8. (26 May.)

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