Ethics

To the Editor: Perhaps for reasons of space, Tobin et al, in their article on community versus individual benefit,1 have omitted an important public health justification for confidentiality. If patients are fearful that the doctor's obligation to notify the authorities could lead to a loss of privileges (in the case cited, a driver's licence), they may fail to attend for diagnosis and treatment. This understandable anxiety warrants a mention in this debate.

Peter C Arnold · Bernadette M Tobin · Steven R Leeder · Ernest R Somerville

In reply: Arnold makes a good point. We agree with him, and would resist today's increasing tendency, on public health grounds, to make it mandatory for doctors to report a variety of conditions suffered by their patients. In general the community is well served if doctors have the discretion to decide, in any particular case, whether the public interest in maintaining a patient's confidentiality is outweighed by the public interest in breaching that confidentiality in order to protect innocent third parties.

Peter C Arnold · Bernadette M Tobin MA PhD · Steven R Leeder PhD FRACP FFPHM · Ernest R Somerville MB BS FRACP FRCP

To the Editor: End-of-life issues: Case 11 illustrates an increasingly common scenario confronting physicians caring for older patients. The case example of a nursing home resident with stroke, dementia and the onset of pneumonia highlights the importance of encouraging patients to prepare for future medical decision-making. This can be done through the use of enduring guardianship, medical powers-of-attorney or advance care directives ("living wills"). Documenting these matters allows people to appoint others to make healthcare decisions on their behalf, and to indicate what treatment they would want in various clinical circumstances, should they no longer be competent to do so. If "Mrs W" had appointed an enduring guardian to deal with issues of healthcare and medical consent, or had indicated in an advance care directive what her wishes would be if she were to become seriously ill, the decision-making process may well have been clearer. The other issue this scenario raises is the need to check whether Mrs W's daughter could have made medical decisions for her mother. In New South Wales, if the daughter had been in a caring role for her mother before nursing-home placement, she could be considered the "person responsible" (similar to the old concept of "next of kin"). Under the Guardianship Act 1987 (NSW), the "person responsible" is able to act as a substitute decision-maker for healthcare and medical treatment. While it would clearly still be good, sensible medical practice to involve other family members in discussion about Mrs W's future, it would ultimately be the daughter, as the "person responsible", who would be able to make those decisions.

Susan E Kurrle

In reply: We agree with Kurrle about the importance of encouraging patients to prepare for future medical decision-making. The strategies she suggests are practical and useful. However, we believe that the difficulties confronting physicians in caring for older patients require us to go further and to rethink what represents excellent care at the end of life. Today, death from acute illness has largely been superseded by death from chronic illness, and the latter generally follows one of three main trajectories: cancer, organ system failure or dementia/frailty.1 Our systems of care for people who are near the end of life need to reflect the ways in which elderly people actually decline and die. If we wish to promise elderly people what a decent society should be able to promise them (accurate diagnoses, excellent control of symptoms, the absence of any gaps in care and of any "surprises" in their condition and its treatment, clarity about the role of their family in caring for them, a way of dying that accords with their hopes, and, most importantly, help to live the remaining part of their lives "to the full"), we need to rethink the care provided during hospitalisation of older people at the end of their lives.1

Susan E Kurrle · Bernadette M Tobin MA PhD · Ian D Cameron FACRM FAFRM PhD

Ethics and putting the patient first are the primary considerations in deciding what is acceptable advertising of medical services by doctors Type "cosmetic surgery" into your Internet search engine and several hundred thousand sites will appear. All enthuse about the benefits and increasing popularity of their techniques. They identify and detail medical practitioners qualified to work their miracles on the human body. Few negatives are to be found in such promotional material, and much of the hype is not dissimilar to that used to market other lifestyle products. This is but part of the global rise of the entrepreneurial approach to healthcare. Cosmetic surgery is in demand because of the changing culture and attitude of patients. For some in today's world there is a need to satisfy a desire for what, in times gone by, would be unrealistic expectations — changes to their bodies to enhance their appearance — at least in their own eyes. If we take the definition used by the New South Wales Committee of Inquiry into Cosmetic Surgery, "cosmetic surgery" is any cosmetic procedure "performed to reshape normal structures of the body or to adorn part of the body, with the aim of improving the consumer's appearance and self-esteem". It "is initiated by the consumer, not medical need", and "excludes reconstructive surgery".1 This lies outside the traditional boundaries of medicine, which saw the profession dedicated to saving lives, healing and promoting health.2 Cosmetic surgery is not rebatable under Medicare, nor covered by health insurance. There are relatively few referrals. However, it does provide a service for which consumers are prepared to pay. Traditionally, the medical profession has prohibited advertising in its codes of ethics. The traditional view is that doctors should develop a reputation for excellence based on a reputation among their peers, rather than by the advertising of their services directly to the public. This minimises the opportunity for patients to be misled by claims of superiority of a technique or individual. Particularly in Australia and the United Kingdom, general practitioners have long been "gatekeepers" to specialist services. This role has helped maintain quality care for patients and has probably helped to contain overall costs in the healthcare system. But with the demise of paternalism, both in society and in the professions, this way of doing things has attracted increasing criticism. Undoubtedly, this forms part of the rationale for applying trade practice law to the health sector and to advertising by doctors, and to the interpretation of such law by the Australian Competition and Consumer Commission. Under federal law in Australia the Trade Practices Act 1974 (Cwlth) now permits advertising, unless it is likely to mislead or deceive. Direct advertising by doctors to the public is now lawful. The article by Ring in this issue of the Journal (page 597)3 asks if ethical standards are a casualty in the promotion of cosmetic surgery, and shows that this specialty is being seen as part of the beauty industry rather than a procedure for meeting health needs. The promotional strategies used do not sit well within the medical environment. The beauty industry promotes a body image that draws on vanity rather than on health. It creates expectations linked to perpetual youth, which can feed insecurities in people of both sexes, and contributes to a youth culture which treats with contempt the results of the ageing process.2 On the other hand, people who wish to change their image are now being informed that there are treatments available. The World Medical Association Declaration on the Rights of the Patient says that, "The patient has the right to self-determination, to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decision".4 Should not patient autonomy include the freedom of adults to purchase these treatments, as long as the advertising surrounding them remains within the ethical boundaries of truthfulness? Where should the boundaries lie between medicine as traditionally defined, and lifestyle-modification medicine? The Australian Medical Association (AMA) Code of Ethics encourages doctors to promote the health and well-being of their patients and prohibits doctors from behaving in their own self-interest. It also says that doctors have "a responsibility to their patients to recommend only those diagnostic procedures necessary to assist in the care of patients and only that therapy necessary for their well being".5 Many patients would say that changing their image through cosmetic surgery is for their well-being, as it would improve their quality of life. It is a personal decision based on personal perceptions. If we consider that cosmetic surgery is part of medicine, then the advertising and promotion of such procedures must adhere to the ethical guidelines of the medical profession. The AMA believes that, as a general principle, advertisements must be honest, must not exploit patients' vulnerability or lack of medical knowledge, and should provide only factual information. Any advertisement for a doctor's services should present information that is reasonably necessary for making an informed decision about the appropriateness and availability of the medical services offered.6 In recognition of the need for a middle ground between the traditional ban on advertising and the current deregulated environment, the Medical Practitioners Board of Victoria has produced draft guidelines which will provide clear guidance for doctors who wish to advertise their services. A summary of the guidelines is presented in the Box.7 Summary of the Medical Practitioners Board of Victoria's draft guidelines for medical advertising7* Ban the use of "before and after" photography, which is common in advertisements for cosmetic surgery. Limit advertising to a factual statement of services offered. Warn against the creation of "unwarranted or unrealistic" patient expectations of treatment. Continue the ban on the use of patient testimonials. Prohibit advertising which encourages inappropriate use of medical services and contains information or language which could cause fear or distress or make people believe their health may suffer from not using a medical service. * Reproduced with permission. Whether we agree with changes in contemporary views which have allowed doctors to enter the free market of advertised services, or prefer the traditional culture, the one interwoven thread which must run unbroken through the fabric of medical practice is that of standards of ethical practice and the primacy of the patient.

Trevor J Mudge MB BS, FRACOG · Dorothy A Dashwood BEd, GradDipAdmin

Within the past five years, medical practitioners have seen major changes to the ways in which they are entitled to promote their services in Australia. The current approach was formalised as a result of the State-by-State deregulation of advertising by doctors through concerted action by the Australian Competition and Consumer Commission (ACCC), which did so in order to enable equal opportunity to all businesses in compliance with the National Competition Policy.1,2 Box 1 outlines the current conditions for medical advertising. In 1998, the then Head of the NSW Health Care Complaints Commission (HCCC) sounded a cautionary note about the risks to the medical profession from a shift to "competitive principles", and the potential effects of this in compromising the traditional medical ethics that have guided the behaviour of members of the profession "since Hippocrates".1 Concerns about implications for the profession have also been expressed by the Australian Medical Association (AMA), with one of the key points in its current position statement on advertising and endorsement being that: "The promotion of a doctor's medical services as if the provision of such services were no more than a commercial product or activity is likely to undermine public confidence in the medical profession."4 Evidence that some practitioners of cosmetic surgery were in the vanguard of the profession in promoting their services in this way was presented to the New South Wales Inquiry into Cosmetic Surgery conducted in 1999 by the NSW HCCC. The Committee of that Inquiry concluded that a number of the promotional practices "may be in breach of professional standards and fair trading laws".5 Two years on, the ways in which a subset of plastic and other cosmetic surgeons continue to promote their practice2,6 require the medical profession to consider, fair trading laws aside, some important questions about the implications of such commercial strategies for both the cosmetic surgery sector, and for the profession as a whole. It should be noted that the term "cosmetic surgery", as used in this article, is in accordance with its definition by the NSW Committee of Inquiry into Cosmetic Surgery. Key points of that definition are listed in Box 2. Are ethical standards a casualty in the promotion of cosmetic surgery?Doctors strive to prolong life, and have earned some of the credit for the fact that we are living in a society that is ageing healthily as our life expectancy continues to grow. It is therefore somewhat anomalous that the public face of cosmetic surgery includes promotions which play on the insecurities associated with the superficial consequences of ageing. Specifically, there is considerable evidence that the highly profitable tactic of targeting the appearance of ageing as an undesirable quality is being exploited by some medical practitioners, using methods similar to the beauty industry's approach of stigmatising this normal bodily process. The allegation that doctors have made a substantial contribution to the reconstruction of ageing for profit is, of course, not new.7,8 By 1990, in America, Naomi Wolf (in her book The beauty myth7) had described a key marketing strategy for cosmetic surgery — namely, classifying ageing as ugly, and ugliness as a disease for which cosmetic surgery practitioners had the most effective treatment.7 She also questioned whether such exploitation of women's insecurities about their appearance was "subject to the ethics of the genuine medical profession".7 These are now matters that also need to be examined in the Australian context. This can be done on the basis of examples of anti-ageing strategies drawn from Australian media and attributed to Australian medical practitioners. The following examples fall into two categories: textual references, and the use of enhanced and idealised images that could be construed as misleading. The majority of the examples come from recent issues of Australian Cosmetic Surgery Magazine.9 This is a quarterly publication distributed through newsagents since 1998 (by which time, it should be noted, advertising by doctors had been deregulated in the three most populous States in response to the requirements of the ACCC10). Key aspects of this magazine are that: Many of the articles are identified as being authored by, or substantively based on interviews with, named medical practitioner contributors. Many of the contributors also have an advertisement within the magazine, either on the same page as one of those articles, or in another part of the magazine. The contributors are introduced in an illustrated list at the front of the magazine.9 It is relevant to note that, while there are substantial and often publicly aired areas of professional conflict between different categories of surgeons who practise cosmetic surgery,5,11 they use similar promotional strategies within the covers of Australian Cosmetic Surgery Magazine.9 Text messagesTypically, negative comments about the appearance of ageing have focused on aspects of the face and skin (usually, but not always, in reference to women). Box 3 shows examples of the ways in which some doctors have characterised normal bodily changes as undesirable changes in appearance. In each of the articles from which the quotes were drawn, the doctor offered cosmetic solutions to the targeted features. Enhanced and idealised imagesSince the linking of questionable anti-ageing images and cosmetic surgery was raised in Australia in 1998,12 quite a lot has happened, and nothing much has changed. Examples of "ideal" and enhanced images used in magazines were presented to the 1999 NSW Inquiry into Cosmetic Surgery.5 The key elements of the images that were presented included a number of tactics that are standard practice in the beauty industry. They have, however, been specifically criticised as being neither appropriate nor acceptable promotional strategies for medical practitioners. The NSW Inquiry, for example, concluded that advertising practices that "may be in breach of professional standards and fair trading laws" included: "use of models, implying the model has had the procedure or that the procedure can achieve the results (with or without a disclaimer)"; and " 'before-and-after' photographs that have been enhanced, or are different in size, colour or pose, or give a misleading impression of long-term effects of a treatment".5 One of the outcomes of the Inquiry was the recommendation for development of a guide by the ACCC and the HCCC "on the application of fair trading laws to the promotion of health services".5 When the guide was published, both of the above practices were specifically targeted as potentially misleading.3 It is therefore highly significant that, over a year after the publication of the guide, many of the same, or very similar, kinds of photographs were still being used. Examples of such illustrations can be seen in magazine advertisements and in a more neutral and widely accessible form of commercial media, the Yellow Pages telephone directories. Some advertisements for cosmetic surgery, for example, include photographs of youthful and idealised female features, or enhanced "after" pictures. These images provide a graphic demonstration of the gulf between the promotion of cosmetic surgery and the promotion of other areas of medical practice at this time. Where does cosmetic surgery belong?"Anti-ageing" is one of the most powerful contemporary marketing devices used by the beauty industry. Essentially, it involves exploiting the insecurities wrought by the appearance of ageing, and is a part of the broader strategy of promoting idealised or enhanced standards of appearance as an incentive for buying cosmetic products and services.7 It has a long-established history of targeting women, and, more recently, men, and functions under the socially accepted banner of caveat emptor. The issue here, however, is not whether such tactics are a good or a bad thing or to make any such moral judgements. It is the question of their place within the practice of medicine, as conventionally defined; that is, as "the science or practice of the diagnosis and treatment of illness and injury and the preservation of health".13 Concerns about the place of cosmetic surgery have, in fact, been raised by some of its practitioners. For example, the NSW Inquiry into Cosmetic Surgery cited the Australian Society of Plastic Surgeons (ASPS) as expressing "concern about the promotion of an attitude that cosmetic surgery is just another beauty product".5 A member of the ASPS placed the blame for this attitude on "women's magazines, regrettably, and the media generally".5 However, as the examples cited in this article suggest, "the media" may only be part of the problem, and it is noteworthy that, at the same Inquiry, a cosmetic surgeon described his area of practice in the following terms: "You have to recognise that cosmetic surgery is the nearest thing you're going to get to retail medicine — or retail surgery. You're not treating sick people, we're not treating people who need to have pathology addressed. This is the surgical or medical end of the beauty industry".14 Certainly, there is evidence that the ASPS is right in its reported perception of how the media is currently constructing cosmetic surgery. Recent editions of the magazines Good Medicine and the Australian Women's Weekly (AWW), for example, both classified anti-ageing features involving cosmetic surgery solutions in the "beauty" and "fashion and beauty" sections of their respective contents pages.15,16 Each of the ensuing feature stories expanded on the legitimacy of that location. The introductory text to the Good Medicine article, "Lift your spirits", stated that: "Sophisticated medical technology is making cosmetic surgery an increasingly popular beauty option for many thousands of Australians who want to give themselves a much-needed boost of confidence."17 AWW's story, "Stop the clock", presented a range of "cosmetic fixes", stating in its introduction: "Even the most effective anti-ageing creams can only do so much — that's why an increasing number of women are turning to cosmetic surgeons and dermatologists for high-tech treatments."18 Statements such as these suggest that "anti-ageing" cosmetic surgery and allied procedures are being socially classified as a beauty want rather than a health need. This classification also applies more broadly to the practice of cosmetic surgery as a whole, and is, in fact, consistent with the definition of cosmetic surgery given earlier in this article as the basis for the NSW Inquiry into Cosmetic Surgery.5 At this early phase of deregulated advertising by doctors, the nature of cosmetic surgery, and the perhaps consequent way in which some of its practitioners have adopted commercial strategies from the beauty industry, has clearly opened up some interesting areas of debate for the medical profession as a whole. Should current promotions of cosmetic surgery be a focus of professional concern?First of all, there is the issue of cosmetic surgery itself, and the extent to which some ways of promoting this burgeoning area of medical practice meld with accepted visions of what being a doctor is all about. Do such visions include the application of medical technology, techniques and procedures to consumer needs which have been defined as "non-medical",5 and with what may be seen as some of the sophistry of commercial advertising techniques? More specifically, does the profession see the latter aspects of such applications as simply an extension of core business for doctors, or a worrying expansion into a grey area of mixed allegiances and hazy ethical boundaries that need to be examined? What are the implications of commercially structured promotional strategies for the tradition of "Trust me, I'm a doctor"?It could, more broadly, be argued that the way in which cosmetic surgery is being promoted by some practitioners in Australia today makes it an important test case for how the medical profession and the community want to see the future direction of the profession develop. The AMA's concerns, cited at the beginning of this article, about the potential for such promotional strategies to "undermine public confidence in the medical profession"4 need to be taken seriously. Would the continuing and potentially expanding use of such strategies presage a decline in the role of trust within a doctor–patient/client/consumer relationship? And would any such decline be of concern to the medical profession, or just be seen as a natural and acceptable consequence of a progression towards the more commercialised practice of medicine? 1: Advertising: what doctors can and can not — and should and should not — do* The National Competition Policy requires that "strict controls on advertising" have to be eased "where anticompetitive effects do not have countervailing public benefits". However, the subsequent changes in the laws do not result in a "free for all where anything goes". Advertising and other promotional activity must comply with: the rules of the Commonwealth Trade Practices Act 1974, which prohibits a range of misleading, deceptive and unconscionable conduct, and misrepresentations; the relevant State and Territory Fair Trading Acts; and "any specific medical and health practitioner regulations that remain". Some equivocation applies, however, with regard to the distinction that the Trade Practices Act draws between misleading content and "puffery or self-evident exaggeration". While there is a reluctance at the legal level to elevate puffery "to the status of potentially misleading conduct", it is recommended that – in the case of complex areas such as medical and health care – puffery "should be avoided or used with extreme caution". This echoes a broader caveat laid down for practitioners: that consumers "are best protected when they are fully informed and when medical and health professionals maintain professional and ethical standards". * Drawn from a 2000 guide to the Trade Practices Act 1974 (Cwlth) for health and medical professionals.3 2: Current parameters of cosmetic surgery Cosmetic surgery: is any cosmetic procedure "performed to reshape normal structures of the body or to adorn parts of the body, with the aim of improving the consumer's appearance and self-esteem"; "is initiated by the consumer, not medical need"; and "excludes reconstructive surgery which is . . . [generally] performed to improve functions, but may also be done to approximate a normal appearance".5 3: Quotes from cosmetic and plastic surgeons* ". . . lower face and neck . . . is the area where the by-product of ageing is most obvious with defects such as 'turkey neck', double chin, jowl fat and platysma bands. This area is most susceptible to gravity pull and is usually regarded as the ageing area . . ." ". . . as a natural part of the ageing process, most people develop deposits of fat underneath the eye and on the eyelid which make them appear older than they are . . ." [included for its curious logic]. ". . . as we age, the globe of the eye tends to descend and fall backwards due to gravity and subcutaneous fat fades away. This causes the eyelids and folds around the eyes to become crepey [sic] and wrinkled giving an untidy and withered appearance . . ." * From publicly available magazines published in 2000 and 2001.

Anne L Ring PhD, GradDipHlthEd

The Department of Rural Health, University of Melbourne, has developed a framework for conducting research in partnership with Indigenous communities. The framework addresses past inappropriate research practices, incorporates cultural understandings, and outlines culturally appropriate protocols. The four parts of the framework are a committee to initiate, direct and oversee all research projects; a Koorie Team to guide research; a set of research guidelines; and a policy for the department. The framework has been used to develop strong relations with Koorie communities and conduct various health projects.

Rick Henderson GradCertAppSc · David S Simmons MD, FRACP · Lisa Bourke MSc, PhD · Janice Muir

To the Editor: It is possible to diminish bias, especially in litigation concerning general practitioners.1 First, request all the defendant's clinical notes about the patient, not merely the records of the incident. Then, before reading the allegations or the history following the incident, read the entire history of the patient's contacts with the doctor or the practice: frequency of attendances, nature of complaints, details of history and examination, referrals for tests or second opinions — all give insight into the nature of that patient–doctor relationship. Reading the notes from the beginning allows the expert to approach, anterospectively, the consultation(s) at which things went awry. If the relevant consultation cannot be identified, the expert has to correlate the patient's story, as presented by the solicitor, with the doctor's records. As he or she progresses through the records, the expert can assess whether or not the doctor's recorded acts accorded with responsible practice. Unrecorded omissions can also be identified, based on what is written in the records: why didn't the doctor ask about X, examine for Y, request a test for Z or refer to a specialist? Of course, these things might have been done, but not recorded. One would hope that barristers for both parties would frame their questions based on a similarly anterospective approach, and that judges would focus their attention and that of a jury (if there is one) on the appropriateness of process rather than on the unfortunate outcome. I cannot conclude without mentioning one solicitor's claim that the doctor had failed to use a retrospectoscope. Competing interests: P C A, at the request of both plaintiffs and defendants, provides expert opinions for the courts. Hugh TB, Tracy GD. Hindsight bias in medicolegal expert reports. Med J Aust 2002; 176: 277-278. <eMJA Full text> <PubMed> (Received 19 Mar 2002, accepted 11 Apr 2002)

Peter C Arnold

To the Editor: I read with interest the recent article by Hugh and Tracy on hindsight bias in medicolegal expert reports.1 As they themselves admit, "the very seeking of an expert opinion usually indicates that there has been an adverse outcome". In my experience, the unfortunate outcome can usually be predicted within reading the first few paragraphs of the brief. I do not think withholding information on outcome would prevent the occasional use of the "retrospectoscope". I wondered whether the views of the authors might have been slightly biased on the basis of the particular cases they had reviewed as Chairmen of the Australian Cases Committee of the Medical Defence Union. Did these cases range across all specialties and subspecialties? The problem of hindsight bias is, in my view, greater when there are no clearly accepted guidelines for diagnosis and management, or where the case is unusual and falls outside the exposure of experienced clinicians. They mention clinical practice guidelines as a way to improve the objectivity of experts, but then seem to exclude them on the basis of the expense and time involved in their development. In cardiology, there are now internationally accepted guidelines developed by the American College of Cardiology and the American Heart Association for the diagnosis and management of all common clinical situations.2 These are regularly updated and have been sometimes modified for Australian use by the Quality of Health Care Committee of the National Health and Medical Research Council (NHMRC) or the Cardiac Society of Australia and New Zealand.3 These guidelines provide an important baseline for any expert opinion in this specialty. More universal clinical guidelines will educate reviewers. It will reduce the problems of hindsight and the overzealous expert. It will also allow the expert to be tested by the well-prepared barrister. Human nature being fallible, it will not eliminate personal bias. Hugh TB, Tracy GD. Hindsight bias in medicolegal expert reports. Med J Aust 2002; 176: 277-278. <eMJA full text> <PubMed> American College of Cardiology/American Heart Association guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. Circulation 2001; 104: 2996-3007. <PubMed> Clinical exercise stress testing. Safety and performance guidelines. The Cardiac Society of Australia and New Zealand. Med J Aust 1996; 164: 282-284. <PubMed> (Received 19 Mar 2002, accepted 11 Apr 2002)

John B Hickie

In reply: We agree with Arnold that, ideally, expert witnesses should attempt to assess management decisions before acquainting themselves with the outcome and allegations in negligence cases. In practice, we suspect this is rarely done. In any case, the mere seeking of an expert opinion conveys the information that there has been an adverse outcome and, as we noted, there is evidence that, even if experts attempt to guard against it, hindsight bias is unavoidable in such circumstances. The central problem is that the expert is, as it were, looking back down one fork in the pathway of events, whereas the treating doctor was looking forwards at many possible and often uncertain forks.1 Hickie's statement "in my experience the unfortunate outcome can usually be predicted within reading the first few paragraphs of the brief" epitomises the very problem we address. Such retrospective snap judgements are characteristic of hindsight bias and are often accompanied by the telltale phrase, known to be a marker for hindsight bias,1 "it should have been obvious". We are unable to understand Hickie's statement that our "views . . . might have been slightly biased on the basis of . . . cases . . . reviewed as Chairmen of the Australian Cases Committee of the Medical Defence Union". The Committee contained representatives from the major specialties, including two consultant physicians, and the cases ranged over all specialties and subspecialties. Experts from subspecialties, including cardiology, were co-opted when appropriate. We agree with Hickie that clinical practice guidelines are useful. We did not recommend that they be excluded, but we did draw attention to their difficulties and limitations. We acknowledge the admirable work done by the American College of Cardiology in developing an impressive range of guidelines, but our view remains unaltered that they are costly in terms of time and effort to produce, cannot cover all clinical contingencies, and have limitations when applied to negligence cases. The guidelines for heart failure referred to by Hickie took more than three years to prepare, involved numerous committee members and no fewer than 26 reviewers, and were not subsequently updated for six years. Relatively few guidelines have been modified for Australian use and some are obviously deficient. For example, the current National Health and Medical Research Council (NHMRC) guidelines relating to the common problem of chest pain2 are six years old, and have been criticised on the grounds that they have not been rigorously tested to ensure clinical usefulness and do not include appropriate management strategies for patients with non-cardiac chest pain.3 We adhere to our view that these problems make it likely that clinical practice guidelines will have a limited role in negligence cases. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner MS, editor. Human error in medicine. New Jersey: Lawrence Erlbaum, 1994; 255-310. Working party of the NHMRC Standing Committee on quality of care and health outcomes. Clinical practice guidelines: diagnosis and management of unstable angina. Canberra: National Health and Medical Research Council, 1996. Eslick GD, Talley NJ. Non-cardiac chest pain: squeezing the life out of the Australian healthcare system? Med J Aust 2000; 173: 233-234. <PubMed> (Received 9 Apr 2002, accepted 11 Apr 2002)

Thomas B Hugh · G Douglas Tracy

To the Editor: Consensus exists that the provision of medical advice must be based on the correct interpretation of the evidence base. It is logical to assume that consideration should also apply to the provision of medical opinion in cases of medical litigation. The recent article on Sharp v Port Kembla RSL Club1 raises concerns which require wider debate. It is not our purpose to discuss legal niceties nor to contest the epidemiological evidence of an increased incidence, in active smokers, of cancers at several sites, including the head and neck. Rather, we wish to concentrate on a central conclusion in the report, namely the assertion that ". . . a relationship between exposure to ETS [environmental tobacco smoke] and an increased risk of head and neck cancer . . . is supported by the available epidemiology". The larger2 of the two studies quoted showed a crude odds ratio of 2.4 (95% CI, 0.9–6.8). This result is statistically non-significant. The authors also claimed a dose response between "moderate" and "heavy" exposure of 1.8 (95% CI, 0.5–7.3) and 4.3 (95% CI, 0.8–23.5) for non-smokers and 2.5 (95% CI, 0.9–6.9) and 5.3 (95% CI, 1.8–16.1) for smokers. Statistical interpretation of these results leads to a conclusion of no evidence of an increased risk compared with people who were "never" exposed to ETS. Leaving aside our considerable reservations regarding the overall design and analysis of this case–control study, the data as presented are at best suggestive. Significant doubt must remain regarding the role of ETS in head and neck cancer. That being so, two disturbing issues emerge which merit further debate. Firstly, there is an ethical issue as to whether the requirements for the correct interpretation of the evidence base for medical opinion should be any different in the clinic or the courtroom. Secondly, the judgment in this case highlights a dilemma in clinical practice. A clinician is not expected to practise according to non-significant differences in outcome. But, in the event of litigation, will the courts decide, as in this case, that bigger is better?

Allan O Langlands FRACR, FRACS · Val J Gebski BA, MStat

In reply: Our article1 outlined evidence presented to the Supreme Court of New South Wales. The paucity of epidemiological evidence concerning an association between exposure to environmental tobacco smoke (ETS) and laryngeal cancer (two studies available) was offset by biological plausibility concerning the carcinogenicity of tobacco smoke. To that extent, the epidemiological evidence in question "supported" a clear inference of causality from other data. The views offered by Langlands and Gebski do not alter this consideration, and are otherwise without merit for several reasons. To restrict the inference reasonably drawn from epidemiological data to whether or not statistical significance is achieved is inadequate. To offer an overall conclusion other than one based on all the data (in this instance, both studies) is unsound. To publish imputations concerning a specific study in a context denying right of reply by the authors concerned is unfortunate. To identify an ethical problem predicated only on a perceived discontinuity between evidence accepted by a court and evidence accepted by the medico-scientific community is spurious. The Court in Sharp v Port Kembla RSL Club was provided with vigorous criticism of the epidemiological data. Most of the eight weeks of court time was occupied by a painstaking analysis of this and other causative issues. The Court then made a determination consistent with the medico-scientific evidence. Stewart BW, Semmler PCB. Sharp v Port Kembla RSL Club: establishing causation of laryngeal cancer by environmental tobacco smoke. Med J Aust 2002: 176; 113-116. (Received 18 Mar 2002, accepted 21 Mar 2002) South East Sydney Public Health Unit, Randwick, NSW. Bernard W Stewart, PhD, FRACP, Head, Cancer Control Program, and Professor, UNSW School of Paediatrics. Sir James Martin Chambers, Sydney, NSW. Peter C B Semmler, MA, QC, Senior Counsel. Correspondence: Professor B W Stewart, South East Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. stewartbATsesahs.nsw.gov.au AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address.

Bernard W Stewart · Peter C B Semmler

To the Editor: I read with interest the accounts of de Costa, Walton, and Flynn and Atkinson dealing with the Professional Standards Committee (PSC) of the NSW Medical Board and the behaviour of the Health Care Complaints Commission (HCCC).1-3 I would like to add a few comments arising from my personal experience of appearing before the PSC. The PSC is supposed to be non-adversarial. The Medical Practice Act 1992 (NSW) states that the doctor under investigation and the HCCC are not to be represented by a solicitor or barrister, but could be assisted by one. In my case, I soon realised that the HCCC Hearings Officer opposing me was dauntingly competent in court craft. She was, in fact, a very experienced solicitor who had for a long time been in practice outside Australia but was not registered as a solicitor in New South Wales. As a result of my application to the Supreme Court, this malpractice was stopped by Justices Dunford and O'Keefe.4, 5 Note that Justice O'Keefe ruled that a person qualified in law could represent the HCCC in PSC hearings, provided the person had never been registered as a legal practitioner. I would like to pose three questions. Firstly, why was it left to me, someone inexperienced in legal processes, to call a halt to this inequity? Secondly, why did the Medical Board countenance this malpractice, when it was manifestly in breach of the Medical Practice Act and most unfair to the medical practitioners whose welfare is its responsibility? And thirdly, why did legal representatives of the medical defence organisations continue to permit this obvious imposition on the doctors whom they had been paid to defend? In my case, evidence obtained in confidence from peer reviewers has been published in the journal of the Health Care Complaints Commission, even though the action against me has not yet come to hearing. The HCCC's practice of publishing such information prior to hearings has been sanctioned by the Medical Tribunal.6 It is my belief that the HCCC has brought the NSW medical regulatory bodies into disrepute by its malpractices, its disrespect for the wishes of Parliament and its lack of a long-term perspective.

Richard F Gorman MBBS DO FRACO

To the Editor: I am a general practitioner who has specialised solely in the field of cosmetic medicine since 1988. I have been the subject of an investigation by the Health Care Complaints Commission (HCCC) and a resultant Professional Standards Committee (PSC) hearing, in which peer reviewers with significant conflicts of interest were used. The process was triggered by a complaint from a patient who had developed blisters and superficial crusting after facial laser hair removal treatment. This is a recognised complication that the patient was aware of when giving consent for the procedure. The HCCC briefed a dermatologist, Dr "X", to comment on the treatment of which the patient had complained. The HCCC further instructed Dr X: "Your report need not be confined to the above questions [relating to such treatment] but should include any other matters you consider relevant and significant." I was referred to the PSC primarily on matters unrelated to the treatment that had led to the patient's complaint. Before the PSC hearing I submitted various documents to the HCCC: (a) a copy of a newspaper advertisement for laser hair removal in which Dr X had stated "Trust only a dermatologist to recommend a safe and reliable method of managing unwanted hair" and "Prospective clients should closely check the qualifications of their laser practitioner and look for the letters FACD"; (b) a report from another dermatologist stating that Dr X "does have a history of a negative attitude to general practitioners who specialise in lasers. He has been seen on television on several occasions espousing this view."; (c) expert reports from two dermatologists expressing views contrary to the opinions of Dr X that had triggered my PSC referral; and (d) statutory evidence from a patient treated in his practice that Dr X's own clinical practice was contrary to that which he had advised the HCCC I should have followed. The NSW Medical Board appointed as a PSC representative at my hearing a dermatologist who was a co-advertiser for laser hair removal with Dr X. The dermatologist in question was later removed (with difficulty) on objection. The PSC systematically disregarded expert evidence I had presented in favour of evidence presented by the HCCC. I have been told that this is a common occurrence. I sincerely hope that the NSW Government Inquiry into the HCCC, to be released in 2002, will address the abuse of this system by biased reviewers. However, justice cannot be guaranteed when the HCCC and NSW Medical Board both effectively collude to prosecute these cases. PSC hearings should be administered by an independent body.

Geoffrey K Heber MB BS DipRACOG MBA

To the Editor: The Acts constituting the NSW Medical Board and Health Care Complaints Commission (HCCC) unfortunately permit inequitable joint functioning of these agencies. The provision that the complainant may appeal an unsatisfactory decision of a Medical Board's Professional Standards Committee (PSC) to the Medical Tribunal is misleading.1 The HCCC chooses its peer reviewer in any matter, investigates, recommends that the Board take action (or not), prosecutes matters at a hearing (or not) and is the only complainant allowed to appeal.2 Clearly, the skills, methods, and decisions of the HCCC and the Board must be beyond reproach. The HCCC selects peer reviewers to consult during the investigation of a complaint.3 They are paid to report on documents and to appear as witnesses before any committee or tribunal of inquiry — either before an in camera PSC of the Board or at a Medical Tribunal, chaired by a judge in open court. Peer review reports, which are legally privileged and generally inscrutable, may be selectively biased. My own involvement (as a complainant disallowed appellant standing from the PSC, and as an occasional consultant to a complainant and to the defence in other, separate psychiatric complaint matters) has led me to conclude that some peer review reports are inconsistent with minimal professional requirements or even duplicitous. Blind faith in a system comprising these two statutory bodies and an anonymous peer reviewer is inappropriate. The NSW Administrative Decisions Tribunal (ADT) has judged disclosure of the membership lists of HCCC peer review panels to be in the public interest. In 1999, the ADT inquired into the selection of the list of psychiatrist peer reviewers when dealing with an application for disclosure based on the Freedom of Information Act 1989 (NSW).4 The list proved to have evolved over an unknown period, through unknown differing methods (such as recommendations from unidentifiable practitioners or staff), for unknown precipitating reasons, and at unknown times. There was no general awareness within Medical Colleges or other medical associations of the selection process or of the members who may be thus empowered. This, when we know that, as a profession, we cannot be uniformly sensible, ethical or emotionally stable. The HCCC and the NSW Medical Board are thus vulnerable to corrupt influence. The NSW Parliamentary Committee on the HCCC has sought submissions from the public and has been conducting an inquiry since November 2001 to determine necessary improvements to the functioning of the HCCC. I believe professional bodies need to take a resolute lead, declare their intentions, identify their roles, consult with their members and heed their responses. Ideally, each will clarify its policies and procedures for regulation and will demand proper functioning from the agencies with statutory responsibilities.

Eleanor Dawson

In reply: A Medical Board's role is to protect the public by ensuring that appropriate standards of conduct and practice are maintained by registered medical practitioners. In New South Wales, the NSW Medical Board administers the disciplinary provisions under the Medical Practice Act 1992 (NSW). Included in this legislation is the Medical Tribunal/Professional Standards Committee (PSC) model that has been the subject of comment in recent correspondence. It is important to note that the Medical Board, the Health Care Complaints Commission (HCCC), the Medical Tribunal and PSCs are all independent bodies in their own right. The Medical Board welcomes constructive comment on the system and its administration. It meets regularly with the major parties (HCCC, United Medical Protection, and the Australian Medical Association [AMA] as the doctors' professional body) to discuss the workings of the disciplinary system, to identify problems and shortcomings, and to develop solutions. Inevitably, there will be aspects of the process that participants do not like — who enjoys being taken to court, in any circumstances? As in all legal and quasi-legal processes, the parties are unlikely to uniformly praise the impartiality or quality of witnesses, experts, and the judiciary. Processes are in place to minimise the possibility of conflict of interest, or the perception of bias. On the rare occasion when a panellist is challenged, a conservative approach is generally taken, and a replacement found. Heber raises concerns about an inquiry extending beyond the parameters of the original patient complaint. In a protective jurisdiction, it would be quite wrong to limit a case to what the complainant had been able to articulate. Not infrequently, a patient's unhappiness is focused on what, from a medical perspective, is relatively minor, while seriously poor conduct or practice is not recognised as such. The legislation specifically envisages an "inquiry", which, subject to natural justice requirements, may go beyond the original complaint. To deny this would be inconsistent with the protective nature of the jurisdiction. The issues raised by Dawson and Gorman concentrate on procedures adopted by the HCCC regarding peer review and representation before hearings. The Board understands that the HCCC has a detailed policy document, prepared in consultation with stakeholders including the AMA and United Medical Protection, regarding the selection and utilisation of peer reviewers and expert witnesses. The Board is also aware of wider concerns in the legal system regarding the use of "hired guns" as distinct from impartial peers or experts, and when concerns have been brought to its attention suggesting even a perception of bias it has taken steps to address them. The Board and members appointed to sit on PSCs and Medical Tribunals take their roles very seriously, and do so with a sense of professional responsibility, while acknowledging the difficulty of sitting in judgement on their peers. Criticisms are carefully considered and practices changed where appropriate. At all times, the Board must ensure that it acts fairly and in accordance with its charter of public protection.

Brian C McCaughan MB BS FRACS

Malpractice litigation is now a substantial cost in the provision of healthcare. Despite new attitudes of Australian courts towards medical evidence, expert reports remain the cornerstone of most medical negligence cases. There is evidence that hindsight bias, which may cause the expert to simplify, trivialise and criticise retrospectively the decisions of the treating doctor, is inevitable when the expert knows there has been an adverse outcome. If possible, outcome information should be withheld from experts providing reports. If outcome information is not withheld, courts should be made aware of the probability of hindsight bias.

Thomas B Hugh FRCS, FRACS · G Douglas Tracy AO, FRCS, FRACS, FACS

Australian law embodies a "communitarian" conception of the doctor's responsibility to respect the confidentiality of the doctor–patient relationship. This implies that respect for confidentiality sits alongside two other responsibilities: proper care for the patient's general wellbeing and proper attention to the safety of the community. Most jurisdictions now require drivers to advise their local driver-licensing authority of any permanent or long-term injury or illness that affects their ability to drive safely. Some jurisdictions require doctors to inform the driver-licensing authority about patients whose medical condition may impair their driving to the extent that they are likely to endanger the public. If you can not persuade a patient to inform the driver- licensing authority of the need for an assessment of his or her ability to drive safely, then you should inform the relevant authorities yourself.

Bernadette M Tobin MA, PhD · Stephen R Leeder PhD, FRACP, FFPHM · Ernest R Somerville MB BS, FRACP, FRCP

Mistakes in medicine, particularly when patients have suffered harm as a result, are of ethical concern as breaching a fundamental injunction in medicine: "first do not harm". To minimise the chances of a recurrence, an effective response to harm must take into account both the concerns of patients who have been harmed and the concerns of doctors who may fear extreme outcomes if a mistake is admitted. There is an apparent conflict between a need to respond to errors non-punitively, on the one hand, and ethical and legal requirements for accountability and compensation for anyone harmed, on the other. There is also confusion between arguments for a "blame-free" culture in the healthcare system and the need to attribute responsibility in some cases. Important elements in an ethical response to mistakes include disclosure to the patient and family; taking appropriate clinical steps to mitigate any harm that may result from a mistake; identifying the process leading to harm; and responding in an appropriate and humane manner to minimise the likelihood of any recurrence.

Paul M McNeill MA, LLB, PhD · Merrilyn Walton BA, MSW

Rapid and radical change in almost every facet of society has brought in its wake community anxiety, suspicion and hostility. Current examples in Australia include the impact of globalisation, the introduction of the goods and services tax, and the actions of the banks in phasing out local branches. Even the health industry faces increased levels of public scrutiny and criticism. A recent example has been the aged-care institutions, charged with providing suboptimal facilities and services.1 Hospitals, too, both in the private and public sector, have received embarrassing media attention — the organ-harvesting scandal in the United Kingdom being but one example.2 Surprisingly, while such public pressure has resulted in many large companies formulating corporate codes of ethics, few hospitals, with the exception of some with religious affiliations, have adopted such codes. This may be due in part to many hospital staff having their own professional codes of ethical behaviour. However, a hospital is more than the sum of its professional staff, and decision-making at a corporate level raises ethical issues. For example, ethical issues need to be taken into account in the allocation of scarce financial resources and the sometimes fierce interdepartmental battles for funding. The size of many hospital budgets brings them into the ambit of "big business" and, as such, boards must be sensitive to the bottom line of financial accountability. Currently, there is increasing pressure on all businesses, large and small, to establish their activities on a sustainable basis, incorporating "triple-bottom-line" accountability — decision-making must take into account not only financial outcomes but also human rights and the impact on the environment.3 Only when all these issues are addressed, it is argued, can legitimate and responsible decisions be made. The question might be asked, why bother with a code of ethics when hospitals are governed by highly prescriptive laws and regulations covering just about every aspect of their activities — from occupational health and safety to environmental protection to paternity leave — and where the threat of litigation hangs heavily over the system? The simple answer is that, to maintain and develop a reputation with customers and the community and create credibility and trust in a "brand" or image, any organisation must these days go beyond pure legal compliance with regulations and avoidance of litigation. This requires a willingness to communicate the values under which the organisation will operate, and to be judged against those values. This is particularly important for community service organisations such as hospitals and even medical practices. In a code of ethics, a hospital is stating the values to which it is committed and which, in seeking to achieve its objectives, it will never violate. In short, the end never justifies the means. Codes of conduct have been in use in the Australian medical world for many years (eg, the Central Sydney Area Health Service has had a code of conduct in operation since the early 1990s),4 and A statement of ethical principles for those who shape and give health care has been developed by the Tavistock Group (a group comprised mostly of UK and US healthcare professionals and ethicists).5 However, a recent initiative by the Austin and Repatriation Medical Centre (ARMC), a major metropolitan teaching hospital in Melbourne, is believed to be the first code of ethics adopted by a major non-religious public hospital in Australia. Codes of ethics and codes of conduct are often assumed to be synonymous, whereas they perform quite different, but complementary, roles. To quote Lagan: 6,7 A code of ethics sits alongside a code of conduct and together they provide the ground rules for day-to-day behaviour as well as guiding how decisions might be made in unanticipated situations. Typically a code of ethics spells out an organisation's values and principles; it both reflects and shapes the organisation's culture. It makes transparent the values framework by which management will manage the business and its employees and the core values that will underpin company policies. [On the other hand] a code of conduct is about what types of behaviour are acceptable in the workplace. It outlines the rules and measurements by which employees will be held accountable in observing the stated corporate values and principles. Like all tertiary teaching hospitals engaged in research, ARMC conforms with the ethical requirements of the National Health and Medical Research Council. It also has a Patient Care Ethics Committee that deals with such issues as patient autonomy, and limitation-of-treatment policies. In 1995, a decision was made by the then Liberal State Government that the ARMC would be privatised. This naturally caused considerable concern. A major factor in this concern was whether the new "owners" of the hospital would adhere to the hospital's perceived high level of ethical concern and care for its patients. These ethical standards were nowhere codified. Therefore, a committee that included professional staff from the hospital — doctors, nurses and allied health professionals — together with community representatives set about developing a corporate code of ethics, to which some 200 staff members subsequently contributed. The plan was to present the code to the prospective purchasers of the hospital and seek their acceptance of it. In the event, the decision to privatise the ARMC was reversed, but the code had aroused so much interest that the ARMC Board decided to adopt it. While staff contributions to the development of the ARMC Code of Ethics were substantial, its continued relevance depends on effective promulgation or it risks going the way of many similar well-meant projects. Firstly, the code must be displayed within the hospital in such a way that staff, patients and visitors are constantly reminded of its ethical standards. One American hospital, which has a code of ethics, has achieved this by placing framed copies of the code in critical positions, such as reception, outpatients, emergency and other departments. Secondly, staff intake programs must include a session on the importance of the code. Finally, publicity in the community is vital. Above all, a code of ethics must be a living document, and genuinely form the basis for the value system on which every person in the hospital operates, and is seen to operate — from the boardroom to the bedside to the boiler room. The challenge to every incorporated body in the medical field, big or small, is to formulate a code of ethics that demonstrates its adherence to fundamental human values in the face of rapidly changing circumstances. Reconciling the ethics of responsible financial accountability and best-practice medical care has, in recent times, caused difficulties for hospital boards. Hence, the need for a code of ethics which covers both business and medical practice, and whose standards are higher than the minimum required by law. It is not an easy task and will become even more difficult in the future, but, in the long run, it will save hospitals and the practice of medicine many potential difficulties and enhance their status in the community. It is particularly important that such a code be regularly updated to reflect, among other things, emerging ethical issues in patient care and treatment in end-of-life situations and in the rapidly developing fields of life science, such as gene technology. Corporate code of ethics The Austin & Repatriation Medical Centre (ARMC) has adopted this Corporate Code of Ethics as an expression of its commitment to the community that it will apply the highest ethical standards to all its activities Values The Austin & Repatriation Medical Centre upholds the following values as being self evident and having both intrinsic worth and universal application: The inherent dignity of each and every human being The autonomy of the individual The exercise of care and compassion The practice of justice, fairness, honesty and integrity The proper stewardship of resources The advancement of knowledge and learning The striving for excellence Principles These values will be guided by the following principles: 1. All individuals of whatever culture, class or belief will be treated with respect, including and especially those who are intellectually or physically impaired or disabled, incompetent or deceased. 2. All individuals, especially patients, have the right to make or be involved in decisions which affect their lives, and where applicable this right extends to include consultation with those who are close to the patients concerned. 3. The primary concern of the hospital will be the provision of compassionate care and treatment to its patients with every effort made to relieve suffering. 4. The principle of justice will be observed in the avoidance of all discriminatory practices and the provision of equal opportunity. 5. Organisational activity, including administration, will be conducted in a fair, open and collaborative manner. 6. Responsibility and accountability will be exercised in all decisions and actions at every level to ensure that the best use of resources is achieved. 7. The importance of research and teaching in every clinical discipline will be recognised and every effort made to ensure that all research is conducted at the highest scientific and ethical standards. 8. The hospital acknowledges that it shares both a natural and a cultural environment with a wider community and affirms its commitment to respect and nurture those environments. 9. The pursuit of excellence will be encouraged not only in clinical practice but in every field of activity with the aim of improving standards of service to the community. Practices In accordance with "best practice" policy of the hospital, the principles enunciated in this Corporate Code of Ethics will be implemented as follows. Principle 1. Respect The conduct of all staff will reflect a respect for the uniqueness of every individual regardless of disability, impairment or incompetence. Such respect will be accorded to patients not only when they are living but also when they are deceased. "End of life" decisions will be made with due regard to the patient's known wishes, the responses of the next of kin and the relevant hospital policies. Principle 2. Autonomy Patient participation in decisions relevant to their condition will be regarded as both important and valued. They will be provided with information relevant to their condition openly and honestly, encouraged to ask questions and, where clinically viable, given time to reflect and consult before responding. Whenever possible, information will be made available both orally and in written form and in the patient's customary language. Clinicians will explain clearly to patients the difference between procedures which are accepted practices and those which are related to research. In the latter case, ARMC research ethics policies will be strictly observed. Principle 3. Compassion Every effort will be made to relieve patients of unnecessary suffering as speedily and effectively as possible. Special efforts will be made to identify and respond to unarticulated fears and anxieties. Where possible the needs of next of kin and others closely related to the patient will be addressed with care and concern. Principle 4. Justice The hospital recognises that this principle applies to dealings with staff and "stakeholders" as well as with patients. All patients will be afforded best possible treatment and care appropriate to their medical condition. There will be no discrimination based on race, culture, religion, sex or position in society. Treatment will be determined according to need, likely benefit, and the responsible use of resources. Legislation related to discrimination, harassment and equal opportunity will be observed both in the spirit and the letter of the law. Grievance issues will be addressed speedily and fairly. Principle 5. Collaboration Mutuality of respect will be encouraged between those engaged in clinical treatment and patient care. The sharing of information and decision making will be practised in the best interest of the patients. Unnecessary duplication of examinations, investigations and patient interviews will be avoided. External agencies and individuals including ministers of religion who contribute to the patient's welfare will be afforded respect and assistance. Before any innovative or experimental procedures are undertaken they will be discussed with other health professionals engaged in the patient's care. Principle 6. Accountability Clear guidelines of responsibility for the care of patients will be established. Health care professionals will be encouraged to express concerns without fear of recrimination. The allocation of human, financial and technical resources will be in accord with the hospital's policies and the responsible spending of public monies. There will be a continuing review of resource allocation in the light of subsequent outcomes. Principle 7. Research and teaching All professions represented at the hospital will be encouraged to engage in high quality research both in clinical practice and academic study. All research conducted within or under the auspices of the hospital will be subjected to scrutiny as to its scientific value and validity and according to the high ethical standards which the hospital holds. As a teaching hospital it will endeavour to provide students of relevant disciplines with opportunities for clinical study at the highest standard. The hospital will encourage and support the conduct of forums, seminars and other methods of education designed to assist staff and the wider community to a better understanding and practice of health related issues. Principle 8. Environment The hospital acknowledges that it shares a common natural environment with the surrounding community and will ensure that any potential threat to this environment emanating from the hospital will be speedily and effectively identified and addressed. The hospital will support community initiatives for the preservation and enhancement of the natural environment. Recognising the multicultural character of the social environment in which it operates, the hospital will encourage community involvement in its activities. Principle 9. Excellence The hospital will promote the pursuit of excellence at every level of its activities. Continuous quality improvement programs will be regarded as fundamental to this process. The hospital will recognise and appropriately reward outstanding achievements on the part of individuals and departments. The hospital will strive for world leadership in its clinical, research, teaching and administrative practices.

Max M J Griffiths MBE, BA, BCom, BD · Ian T Dunlop MA(Cantab), FAICD, FAIMM

"Culture" can be understood as the way in which people make sense of the world by deploying shared meanings, attitudes, assumptions and values. Doctors will frequently encounter patients whose lives are guided by ethical systems and values that are different from their own. Individuals may differ in their beliefs about decision-making, regardless of their cultural background. Doctors should be willing to examine and test their own moral systems and cultural assumptions and be open to alternative traditions and beliefs. Engaging with other cultures does not imply that all cultural norms should be accepted uncritically, as there may not always be room for compromise. Failure to engage with issues of culture can erode the trust on which the doctor–patient relationship depends. Tensions can only be resolved through rigorous attention to a person's story.

Rob Irvine BA (Hons), PhD · John McPhee BCom(Hons)(LegStud) · Ian Kerridge MPhil, FRACP, FRCPA

To the Editor: In his recent Commentary on hastening death in terminally ill patients,1 Hunt may not have fully appreciated a very cogent point made in the research by Douglas and colleagues.2 The surgeons surveyed clearly reported the intent of their prescribing. This is contrary to Hunt's assertion that "Intention is inherently subjective . . . complex [and] ambiguous". Some surgeons gave a dose appropriate to the symptoms, others deliberately increased the dose beyond direct symptomatic control, and a few deliberately ended life, at times with no explicit request. As Douglas points out, the dose of a medication given will be an important clue in this. Good clinical practice is about minimum effective dose (MED), not maximum administrable dose (MAD). This is the case for all patients, whether they are near the end of life or not. Hunt also states that "The duty of doctors is to strive to satisfy the wishes and interests of their patients and their patients' loved ones".1 This is a disturbing comment if left unqualified. There is a broader accountability for doctors to the community through the registration process, quality assurance and continuing education, and the criminal code. If the article by Douglas et al highlights nothing else, it should be clear that there are certain members of the medical profession who believe that they are above the law and have control over the life and death of their patients, with no external review.2 It is frightening that such paternalism still exists. Unfortunately, the Dutch experience of tolerating euthanasia does not appear to have decreased unilateral decision-making on the part of some doctors.3,4 If the premise that the interests of the patients' loved ones is a consideration in the duty of care,1 then we are risking the loss of patient autonomy in an unprecedented way. As a practising clinician, the majority of requests that I receive to hasten death are from relatives, not patients. These relatives ask that they be put out of their own misery by ending the patient's life prematurely. To do something to a patient for a third party, however concerned or distressed, is an unacceptable action for clinicians. For the profession to credibly engage in the debate about end-of-life care, we must accept that we are part of the community and hence governed by its laws. There are reference points external to the profession by which we will be judged.

David C Currow

In reply: The survey by Douglas et al1 indicated that, under the current criminal code, about one in three Australian general surgeons are at risk of prosecution for murder because of the way they treat their dying patients. It is likely that many other Australian doctors are similarly at risk of prosecution. This is a serious problem that raises important questions: Why are so many doctors breaking the law? Should these practices be kept covert or brought out into the open for audit and discussion? Is the law serving the needs and interests of dying patients, those who care for them, and the wider community? Rather than argue that doctors are above the law, I have argued that the practice of medicine should be congruent with the law.2 Laws have been established and refined over time so doctors can help their patients (eg, with procedures and the administration of drugs) in ways that are illegal for others. An integral part of the medical role involves the negotiation of life–death decisions. I believe murder laws should be refined to reflect the reality that some terminally ill patients want death as a release from suffering and seek the help of their doctor to provide this. Just as there are differences between rape and making love, I see obvious differences between common murder and the hastening of death that doctors provide for terminally ill patients out of compassion, mercy, and respect for their wishes. Unfortunately, the ethics of current practices are difficult to elucidate because the existing law makes investigations problematic. The current crude law does not reflect community values — Morgan Gallup polls indicate about 80% of Australians are in favour of allowing voluntary euthanasia in certain circumstances.3 As Currow observes, these widely held values are sometimes expressed by the relatives of dying patients. In my experience, however, these relatives are usually advocating for the patient's wishes and interests, rather than undermining patient autonomy. I support the established hospice tenet that "the family is the unit of care" and there is a duty to address the concerns not only of patients but also of their loved ones. I think it is only a matter of time before politicians introduce the reforms that render the legal framework for terminal care more congruent with community values, the wishes of patients and their families, and current medical practices. These reforms should enable research, audit and the better regulation of end-of-life care.

Roger W Hunt BM BS, GDPH, FAChPM

A New South Wales Supreme Court jury has decided that environmental tobacco smoke (ETS) can cause or materially contribute to the development of laryngeal cancer. Evidence presented that ETS may cause or materially contribute to laryngeal cancer included the molecular genetics of tobacco-smoke-induced carcinogenesis, and two relevant epidemiological studies. The plaintiff's exposure to ETS was established indirectly, on the basis of occupational history involving work as a bar attendant in licensed premises. The jury's decision seems likely to encourage other "passive smoking" cases, and may result in measures to reduce occupational exposure to ETS.

Bernard W Stewart PhD, FRACP · Peter C B Semmler MA, QC

Medical practitioners and the pharmaceutical industry serve interests that sometimes overlap and sometimes conflict. There is strong evidence that associations between industry and doctors influence the behaviour of the latter in relation to both clinical decision making and the conduct of research. In view of the risk of compromising relationships with patients and the integrity of the research process, doctors must exercise care in their dealings with industry. The basic principles underlying the conduct of doctors with respect to pharmaceutical companies should be openness and transparency. Clearly articulated procedures should be developed to deal with specific issues such as travel subsidies, receipt of gifts, sponsorship of conferences and continuing education activities, and dualities of interest arising in clinical and research settings.

Paul A Komesaroff MA, PhD, FRACP · Ian H Kerridge MPhil, FRACP, FRCPA